Management of arterial hypertension in patients with peripheral arterial disease

Abstract

Hypertension is a major risk factor for peripheral arterial atherosclerotic disease (PAD). Hypertension deteriorates arterial wall function and the morphology of all layers of arteries. Endothelial cell injury enhances permeability and promotes migration of cholesterol and monocytes into the vessel wall. Increased blood pressure (BP) through hyperplasia of smooth muscle cells initiates remodeling of the arterial wall that increases peripheral resistance. Further, hypertension, particularly in patients with dyslipidemia, provokes atherosclerosis in different vascular territories, including the lower legs. Guidelines recommend treatment of hypertension in patients with PAD to reach the target BP of <130/80 mmHg. However, systolic BP (SBP) <120 mmHg may worsen oxygen delivery to the diseased leg and is related to a higher rate of cardiovascular (CV) events. Therefore, there is a J-shape relationship between SBP and the rate of primary outcomes. Any class of antihypertensive drugs, including beta-blockers, can be used for the treatment of hypertension in patients with PAD. Angiotensin converting enzyme (ACE) inhibitors may have some additional benefit over other antihypertensive drugs including improvement of perfusion of the diseased leg and are recommended even in patients with critical limb ischemia. In conclusion: hypertensive patients with PAD are at increased risk for CV events and treatment of raised BP is indicated, but SBP <120 mmHg and DBP <70 mmHg may contribute to adverse limb outcomes and other CV events. Consequently, PAD patients may require a different BP target than those without PAD.