Risk factors and predictors of coronary arterial lesions in Japanese hypertensive patients

Carotid Ultrasound Screening for Coronary Heart Disease: Results Based on a meta-analysis of 18 Studies and 44,861 Subjects

Background

Carotid artery ultrasound is a possible screening test for future coronary heart disease (CHD) events to select individuals for preventive treatment.

Objectives

To assess the screening performance of carotid artery intima-media thickness (IMT) and carotid plaque in the identification of individuals with CHD.

Methods

meta-analysis of case-control and cohort studies, reporting carotid IMT or plaque in individuals with and without CHD. Screening performance (detection rates [DRs] for specified false-positive rates [FPRs]) was assessed from the relative Gaussian distributions of IMT among individuals with and without CHD and from the proportion of affected and unaffected individuals with plaque.

Results

Eighteen studies, involving 2920 individuals with CHD (mean age range 46–73 years) and 41,941 without (aged 44–73 years) were included in the meta-analysis. For plaque the DR was 62% for an FPR of 30%; likelihood ratio (2.1 [95% CI 1.6–2.4]). For IMT, the DR was 65% for the same 30% FPR (IMT cut-off ≥0.82 mm); likelihood ratio 2.2 (1.9–2.5). The results were similar in case-control and cohort studies.

Conclusion

Neither carotid plaque nor IMT has a CHD screening performance that is sufficiently discriminatory between affected and unaffected individuals to be a worthwhile screening test.

The adverse prognostic significance of the metabolic syndrome with and without hypertension in patients who underwent complete coronary revascularization

OBJECTIVES

The metabolic syndrome is associated with high risk for long-term coronary artery disease mortality. However, few studies have examined the prognostic importance of the metabolic syndrome with and without hypertension.

METHODS

The data of 1133 nondiabetic patients who underwent complete revascularization were analyzed. The patients were categorized by the presence of the metabolic syndrome using the modified American Heart Association/National Heart, Lung, and Blood Institute statement and by the presence of hypertension. All patients were divided into four groups: neither the metabolic syndrome nor hypertension (group 1); the metabolic syndrome without hypertension (group 2); hypertension without the metabolic syndrome (group 3); and both the metabolic syndrome and hypertension (group 4). Cox proportional hazards were used in adjusted analyses for all-cause and cardiac mortality, as well as for the composite incidence of fatal and nonfatal stroke.

RESULTS

The progress of 276 (24.4%) patients in group 1, 413 (36.5%) in group 2, 105 (9.3%) in group 3, and 339 (29.9%) in group 4 was analyzed. The mean follow-up was 10.4 +/- 3.4 years. Patients in group 4 had a higher risk of all-cause mortality (hazard ratio 1.78, P = 0.004). In addition, patients in groups 2 and 4 had a higher risk of cardiac mortality (group 2: hazard ratio 2.84, P = 0.04, group 4: hazard ratio 3.91, P = 0.001) and stroke (group 2: hazard ratio 2.46, P = 0.03, group 4: hazard ratio 2.09, P = 0.03).

CONCLUSION

The metabolic syndrome both with and without hypertension is associated with increased risk of cardiac mortality and stroke incidence in patients who underwent complete coronary revascularization.

A calcium-channel blocker, benidipine, improves forearm reactive hyperemia in patients with essential hypertension

The pathophysiological role of endothelial cells is important in the mechanism of progression of atherosclerosis and improvement of endothelial function may be important for cardiovascular morbidity. Calcium antagonists are reported to have protective effects on the endothelium in vitro and in vivo. In this clinical study, we investigated the effect of calcium antagonist, benidipine, on endothelial function in the patients with essential hypertension, which causes endothelial dysfunction. Twenty-five patients with hypertension without other risk factors for atherosclerosis were treated with monotherapy (8 mg benidipine, n=25) for 8 weeks. Blood pressure was reduced significantly. Endothelial function was evaluated using forearm blood flow by strain-gauge plethysmography after 8 weeks of treatment. Changes in vasodilator response to reactive hyperemia were significantly improved (p<0.01), while the response to nitroglycerin was not changed, suggesting the improvement of endothelial function. Moreover, we focused on hepatocyte growth factor (HGF), which is a novel angiogenic growth factor with an anti-apoptotic action on endothelial cells, and evaluated involvement of HGF in improvement of endothelial function. Serum HGF concentration in subjects treated with benidipine was significantly elevated at 8 weeks (p<0.05). Overall, these results demonstrated that benidipine improved endothelial dysfunction in patients with hypertension. Interestingly, an increase in serum HGF concentration by benidipine might contribute to the improvement of endothelial dysfunction.

Nifedipine retard was as effective as angiotensin converting enzyme inhibitors in preventing cardiac events in high-risk hypertensive patients with diabetes and coronary artery disease: the Japan Multicenter Investigation for Cardiovascular Diseases-B (JMIC-B) subgroup analysis

We stratified findings from the Japan Multicenter Investigation for Cardiovascular Diseases-B according to whether or not the patients had diabetes and compared the incidence of cardiac events occurring over a 3-year period between treatment with nifedipine retard and angiotensin converting enzyme (ACE) inhibitor. The primary endpoint was the overall incidence of cardiac events (cardiac death or sudden death, myocardial infarction, hospitalization for angina pectoris or heart failure, serious arrhythmia, and coronary interventions), and the secondary endpoints were a composite of other events (cerebrovascular accidents, worsening of renal dysfunction, non-cardiovascular events, and total mortality). The results showed no significant difference in the incidence of the primary endpoint between the nifedipine group (n=199) and the ACE inhibitor group (n=173) in diabetic patients: 15.08% vs. 15.03%, relative risk 1.06, p=0.838. Also in nondiabetic patients, no significant difference was observed between the former (n=629) and the latter (n=649): 13.67% vs. 12.33%, relative risk 1.04, p=0.792. Similar results were obtained for the incidence of the secondary endpoints: in diabetic patients, 5.03% vs. 5.20%, relative risk 0.89, p=0.799; in nondiabetic patients, 2.70% vs. 2.47%, relative risk 1.07, p=0.842. Achieved blood pressure levels were 138/76 and 136/77 mmHg in the nifedipine group and 140/78 and 138/79 mmHg in the ACE inhibitor group in diabetic and nondiabetic patients, respectively. This study showed that nifedipine retard was as effective as ACE inhibitors in reducing the incidence of cardiac events in extremely high-risk hypertensive patients with complications of diabetes and coronary artery disease.

Effect of nifedipine on endothelial function in normotensive smokers: potential contribution of increase in circulating hepatocyte growth factor

Calcium antagonists are reported to have protective effects on the endothelium in vitro and in vivo. Especially, nifedipine, among many calcium antagonists, was shown to improve endothelial dysfunction in patients with hypertension. However, no report has determined whether the improvement of endothelial dysfunction by nifedipine is due to direct effects or indirect effects such as its hypotensive effect. Thus, in this study, we evaluated the direct effects of nifedipine on smoking-induced endothelial dysfunction, since cigarette smoking itself is a major factor in damage of endothelial cells, as well as hypertension. We examined whether nifedipine improves endothelial function in 10 normotensive smokers without any risk factors for atherosclerosis. The subjects were treated with 20 mg nifedipine monotherapy (n = 10) or placebo (n = 10) for 4 weeks. Nifedipine did not affect blood pressure and heart rate of normotensive smokers. We measured forearm blood flow (FBF) by strain-gauge plethysmography after 2 and 4 weeks of treatment. Changes in vasodilator response to reactive hyperaemia were significantly improved in nifedipine-treated subjects (P < 0.05), while there was no significant change in FBP response in control subjects. Response to nitroglycerin was not changed in either group. Moreover, to evaluate the mechanisms of the direct effects of nifedipine on the endothelium, we focused on hepatocyte growth factor (HGF), which is a novel angiogenic growth factor with an antiapoptotic action on endothelial cells. Interestingly, serum HGF concentration in smokers treated with nifedipine was significantly elevated both at 2 and 4 weeks (P < 0.05). Overall, these results demonstrated direct effects of nifedipine in the improvement of endothelial dysfunction in normotensive smokers. The increase in serum HGF concentration by nifedipine might contribute to the improvement of endothelial dysfunction.

Interaction between Amlodipine and Simvastatin in Patients with Hypercholesterolemia and Hypertension

3-Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors are often prescribed in association with antihypertensive agents, including calcium antagonists. Simvastatin is an HMG-CoA reductase inhibitor that is metabolized by the cytochrome P450 (CYP) 3A4. The calcium antagonist amlodipine is also metabolized by CYP3A4. The purpose of this study was to investigate drug interactions between amlodipine and simvastatin. Eight patients with hypercholesterolemia and hypertension were enrolled. They were given 4 weeks of oral simvastatin (5 mg/day), followed by 4 weeks of oral amlodipine (5 mg/day) co-administered with simvastatin (5 mg/day). Combined treatment with simvastatin and amlodipine increased the peak concentration (C(max)) of HMG-CoA reductase inhibitors from 9.6 +/- 3.7 ng/ml to 13.7 +/- 4.7 ng/ml (p < 0.05) and the area under the concentration-time curve (AUC) from 34.3 +/- 16.5 ng h/ml to 43.9 +/- 16.6 ng h/ml (p < 0.05) without affecting the cholesterol-lowering effect of simvastatin. This study is the first to determine prospectively the pharmacokinetic and pharmacodynamic interaction between amlodipine and simvastatin.

Effect of Transdermal Hormone Replacement Therapy on Carotid Artery Wall Thickness and Levels of Vascular Inflammatory Markers in Postmenopausal Women

Carotid intima-media thickness (IMT) and vascular inflammatory markers have been shown to be involved in atherosclerosis. This study was designed to investigate the effect of transdermal hormone replacement therapy (HRT) on carotid IMT and vascular inflammatory markers in postmenopausal women and to explore the interrelationship between the change in carotid IMT and the changes in vascular inflammatory markers. Thirty-five postmenopausal women (mean age 57.0+/-7.7 years) received transdermal HRT (continuous 17beta-estradiol patch [36 microg/day] plus cyclic oral medroxyprogesterone acetate [2.5 mg/day, for 12 days/ month]) for 12 months, and 32 controls (mean age 58.0+/-7.5 years) did not. Carotid IMT, assessed by ultrasound, and circulating vascular inflammatory markers, i.e., C-reactive protein (CRP), intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, E-selectin, monocyte chemoattractant protein (MCP)-1, and matrix metalloproteinase (MMP)-9 were measured before and after 12 months of treatment. In the HRT group, carotid IMT decreased significantly (p<0.01), from 0.71+/-0.13 mm to 0.65+/-0.12 mm, and the ICAM-1, VCAM-1, E-selectin, and MCP-1 levels decreased significantly (p<0.01 for all), but the CRP and MMP-9 levels remained unchanged. Carotid IMT and vascular inflammatory markers were unchanged in the control group. In the HRT group, the change in carotid IMT was significantly correlated with the change in serum E-selectin (r=0.38, p<0.05), but not with the changes in other vascular inflammatory markers. These results suggest that transdermal HRT reduced carotid artery wall thickness, and that the reduction may have been induced by an antiatherosclerotic effect combined with the direct effect of estrogen and decreased levels of estrogen-induced E-selectin.

Smoking is Associated with Silent Cerebrovascular Disease in a High-Risk Japanese Community-Dwelling Population

We aimed to investigate the relationships between smoking and silent cerebrovascular damage. We performed brain MRI to evaluate silent cerebral infarct (SCI) and periventricular hyperintensity (PVH), and carotid-ultrasonography to investigate carotid atherosclerotic plaque in 170 high-risk community-dwelling subjects (mean age: 67.2 years; men: 28.7%) who met more than 3 of the following 9 criteria: 1) high blood pressure (BP); 2) hypercholesterolemia; 3) left ventricular hypertrophy; 4) high hemoglobin A1c; 5) proteinuria; 6) high waist-to-hip ratio; 7) smoking > or =30 cigarettes/day; 8) heavy alcohol intake; 9) family history of stroke. The subjects with SCI (SCI group) were older (70 years vs. 66 years, p=0.004) and had higher systolic BP (SBP) (160 vs. 148 mmHg, p <0.001) and higher carotid plaque score (2.3 vs. 1.5/person, p <0.05) than those without SCI. Among the variables, smoking status (r =0.34, p <0.001), SBP (r =0.28, p <0.001), male gender (r =0.29, p <0.001), left ventricular mass index (r =0.25, p =0.001), and serum creatinine (r =0.20, p =0.006) were significantly correlated with the number of SCIs. Among smokers, the number of SCIs was significantly higher in current smokers than in past smokers (1.9+/-2.2 vs. 0.5+/-0.8, p <0.01). In multiple regression analysis, smoking status (beta =0.183, p =0.045) and SBP (beta =0.196, p =0.011) were independent determinants of the increased number of SCIs. In conclusion, smoking status was an independent determinant of multiple SCIs in a high-risk Japanese community-dwelling population.

Elevation of serum C-reactive protein levels is associated with obesity in boys

This study aimed to reveal the relationships among C-reactive protein (CRP), obesity, blood pressure (BP), and serum lipids in children. Eighty-six obese and 58 non-obese boys aged an average of 11.2 years were examined. Serum CRP levels were measured by high sensitivity latex turbidimetric immunoassay and subjects with CRP levels below 0.3 mg/dl were adopted. Comparisons of serum CRP levels, BP, and serum lipids levels between age-matched obese and non-obese groups were performed. A comparison of serum CRP levels among the percentage of relative weight quartiles and the relationships among percentage of relative weight, BP, and serum lipids in CRP quartiles were analyzed. The relationships between CRP and other parameters were analyzed by simple and stepwise multiple regressions. Obese children had significantly higher high-sensitivity CRP (hs-CRP) levels than their non-obese counterparts. The mean hs-CRP level was 5.5-fold higher in the top quartile of the percentage of relative weight than in the bottom quartile. In the top quartile of CRP, the percentage of relative weight, systolic BP, diastolic BP, pulse pressure, and low density/high density lipoprotein-cholesterol (LDL-C/HDL-C) were significantly higher than in the bottom quartile. The percentage of relative weight, BP, LDL-C, and apolipoprotein B (ApoB) showed positive correlations and HDL-C showed a negative correlation with log CRP by simple regression. Stepwise multiple regression analysis indicated that only the percentage of relative weight was strongly related to CRP. In conclusion, this study revealed a significant relationship between CRP and obesity in children. Obese children tended to have high CRP levels, BP elevation, and slight dyslipidemia. These results support the findings that CRP is one of the useful indices of childhood obesity that would affect the progression to future atherosclerotic disease. We consider that a strategy of preventing obesity from childhood would contribute to a drop in the future incidence of metabolic syndromes.

Smoking raises the risk of total and ischemic strokes in hypertensive men

To examine the relation between cigarette smoking and risk of stroke and coronary heart disease among Japanese, we conducted a 14-year prospective study of 3,626 men aged 40-69, initially free from history of stroke and coronary heart disease. We identified 257 strokes (75 hemorrhagic and 173 ischemic strokes) and 100 coronary heart disease events. When we adjusted for age and other cardiovascular risk factors, a significant excess risk among current smokers of > 20 cigarettes/day vs. never-smokers was found for total stroke (relative risk (RR) = 1.6 (95% confidence interval (CI), 1.1-2.4)). The excess risk of total stroke was particularly evident among hypertensives (RR = 2.3 (1.2-4.4)). The multivariate RR of ischemic stroke was 1.6 (1.0-2.5) for total subjects, and 2.2 (1.0-5.0) among hypertensives. Significant excess risks among current smokers of > 20 cigarettes/day vs. never-smokers were also found for coronary heart disease (RR = 4.6 (1.6-12.9)) and total cardiovascular disease (1.9 (1.3-2.7)). The estimated proportion of the events attributable to current smoking was 30 (95% CI, 11-44)% for total stroke and 34 (5-54)% for coronary heart disease. In conclusion, current smoking of > 20 cigarettes per day increased the risk of both total stroke and ischemic stroke among Japanese middle-aged men, and particularly among middle-aged hypertensive men.

Activation of Protein Kinase C and Nicotinamide Adenine Dinucleotide Phosphate Oxidase in Leukocytes of Spontaneously Hypertensive Rats

The involvement of oxidative stress in polymorphonuclear leukocytes (PMN) in the pathogenesis of hypertension remains to be elucidated. We analyzed the generation of reactive oxygen species (ROS) by the circulating and peritoneally infiltrating PMN from spontaneously hypertensive rats (SHR) and Wistar Kyoto rats (WKY). Flow cytometric analysis revealed that ROS generation by PMN from SHR was higher than that from WKY before (at 6 weeks of age) and after (at 16 weeks of age) the onset of hypertension. In vivo, ROS generation by PMN from SHR, but not that by PMN from WKY, was significantly suppressed by 10-week treatment with 50 mg/kg/day carvedilol, and this treatment did not affect blood pressure. Western blotting analysis revealed that protein kinase C alpha (PKCalpha), but not PKCbetaI or betaII, was activated more strongly in PMN from SHR than in PMN from WKY. Furthermore, expression of p47phox of nicotinamide adenine dinucleotide phosphate oxidase, but not of p67phox, in PMN from SHR was higher than that in PMN from WKY. These results suggest that ROS generation by PMN is principally enhanced in SHR through activation of PKCalpha and p47phox.

Forearm hyperemia is a better marker than carotid intima-media thickness or ankle-brachial index for coronary artery disease in Japanese males under 65

Forearm hyperemia, carotid intima-media thickness (IMT), and ankle-brachial pressure index (ABI) are subclinical markers associated with coronary artery disease (CAD). However, it is not known which marker is most highly correlated with CAD. We therefore compared these three parameters in the same patients under 65 years of age. In 40 males with documented CAD (mean age, 53 years), we measured forearm hyperemia by plethysmography, carotid IMT by B-mode ultrasound, and ABI by Doppler ultrasonography. Microalbuminuria, serum lipids, glucose and C-reactive protein (CRP) were also measured. Thirteen normal males served as controls (mean age, 49 years). Compared with normal subjects, CAD patients had lower hyperemia (42 vs. 92%; p < 0.001) and greater carotid IMT (0.81 vs. 0.67 mm; p < 0.01), but ABI was similar. The sensitivity of forearm hyperemia (72%) was higher than that of carotid IMT (22%) or ABI (3%) (abnormal criteria: forearm hyperemia < 60%, carotid IMT 21.0 mm, and ABI < 0.9). The patients had higher serum low-density lipoprotein (LDL) cholesterol, glucose and CRP, and lower high-density lipoprotein (HDL) cholesterol than the controls. Albuminuria was present in 49% of patients. Subclinical markers were further analyzed by age (35-54 vs. 55-64 years). The sensitivity of carotid IMT was lower in the younger patients (4% vs. 33%), while that of forearm hyperemia (69% vs. 75%) and albuminuria (47% vs. 52%) did not change with age. While carotid ultrasound was useful in older patients ( > or = 55 years), forearm hyperemia and microalbuminuria were sensitive markers irrespective of age. ABI was not useful in the Japanese men with CAD under age 65.

Impact of multiple risk factor clustering on the elevation of blood pressure

A family history of hypertension, obesity, diabetes mellitus, hypercholesterolemia, and hypertriglyceridemia have all been associated with risk of hypertension. We retrospectively conducted a longitudinal study in a large screened cohort to explore the effect of the clustering of these five risk factors on the elevation of blood pressure (BP) in normotensive subjects at baseline. The study group comprised 4,857 normotensive subjects not treated with antihypertensive drugs (systolic BP < 140 mmHg, diastolic BP < 90 mmHg, 3,111 men and 1,746 women) who were followed up from 1997 to 1999. By 1999, 360 subjects had BP at the hypertensive level (systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg). The incidence of subjects whose BP became hypertensive was 37 per 1,000 person-years. After adjusting for age, sex, systolic BP and other clinical factors, multiple logistic analysis showed that the relative risk of BP elevation was 1.49 (95% Cl: 1.09 to 2.05) in subjects with one risk factor; 1.65 (95% Cl: 1.15 to 2.27) in those with two risk factors; 1.42 (95% Cl: 0.91 to 2.32) in those with three; and 4.86 (95% Cl: 2.58 to 9.16) in those with four or more when compared with subjects with no risk factors. Multiple regression analysis showed that the number of risk factors was positively correlated with an increase in BP from 1997 to 1999; the regression coefficient was 0.51 (p = 0.001) for increase in systolic BP, and 0.31 (p = 0.008) for increase in diastolic BP after adjusting for age and sex. In conclusion, clustering of risk factors significantly predicted the development of hypertension.

The relationship between changes in normal-range systolic blood pressure and cognitive function in middle-aged healthy women

Little is known about the effect of normal-range blood pressure (BP) on cognitive function. In previous studies investigating the relationship between BP and cognitive function in elderly subjects, underlying cerebrovascular damage has complicated the interpretation of results. To reveal the relationship between BP levels that were within an absolutely normal range and cognitive function, we examined cognitive function in normotensive, healthy middle-aged women. BP levels were measured on three separate occasions at 1-month intervals, and the subjects exhibiting normotension (< 140/90 mmHg) throughout the evaluation period were recruited as normotensive subjects. Cognitive function was assessed using subtests of the Wechsler Adult Intelligence Scale-Revised. The study demonstrated that, among the subtests examined, the scores on the Digit Symbol Test, an index of psychomotor performance, had a significant correlation with normotensive-range systolic blood pressure (SBP) (r=-0.51, p<0.05); this relation was negative-that is, higher but still normal-range SBP levels were associated with impaired Digit Symbol Test scores. In addition, the relationship adjusted by age and educational level was also significant (partial correlation = -0.56, p<0.05). In contrast, diastolic BP was not related to the Digit Symbol Test (r = -0.33, p = 0.13). Furthermore, the Digit Symbol Test was not influenced by blood glucose or serum cholesterol levels. These findings suggested that, even within the normotensive range, lower levels of SBP might be protective against impairment of psychomotor speed in middle-aged women.

Association of cardiovascular risk factors and endothelial dysfunction in japanese hypertensive patients: implications for early atherosclerosis

Although hypertension, hyperlipidemia, diabetes and smoking are known risk factors of atherosclerosis in Caucasians, their relative contributions to early atherosclerosis among Japanese are unknown. Decrease in flow-mediated dilation (FMD) of the brachial artery is a useful marker of endothelial dysfunction and early atherosclerosis. To evaluate the relative contribution of hypertension to early atherogenesis, we determined FMD, as well as plasma levels of tissue-type plasminogen activator (t-PA; a sensitive index of endothelial damage) and tumor necrosis factor (TNF)-a and interleukin (IL)-6 (established markers of inflammation) in normotensive and hypertensive patients under treatment. FMD was significantly reduced as the number of risk factors increased, suggesting that accumulations of risk factors were related to endothelial dysfunction. FMD was reduced in hypertensives (9.9 +/- 5.8 (SD) %) compared to normotensives (14.6 +/- 7.6, p<0.01) despite good blood pressure control (139 +/- 20/80 +/- 14 mmHg in hypertensives). Nitroglycerine-induced endothelium-independent vasodilation was not altered in hypertensives (16.0 +/- 6.3%) as compared to normotensives (16.7 +/- 5.8). Plasma t-PA, TNF-alpha, and IL-6 levels were increased in hypertensives despite good blood pressure control. Thus, hypertension alone is a high risk for early atherosclerosis. Persistent endothelial damage and moderate inflammation may increase the risk of early atherosclerosis synergistically under the presence of hypertension in Japanese.

Reverse J-curve relation between diastolic blood pressure and severity of coronary artery lesion in hypertensive patients with angina pectoris

The existence of the J-curve in hypertension treatment remains controversial. The major question is whether the increase in mortality from coronary disease is induced by the lowering of blood pressure (BP) or by the severity of underlying coronary artery disease. We recruited patients with a history of hypertension (systolic BP (SBP) >160 mmHg and/or diastolic BP (DBP) >90 mmHg) and a diagnosis of angina pectoris with angiographically confirmed coronary artery lesion. The relationship among the treated levels of SBP and DBP, the severity of coronary artery lesion, and the clinical consequences were investigated. Among the 234 enrolled patients, 115 experienced further events, 19 of which were serious. There were no significant differences in the average BP of patients with and those without events, but the coronary severity indices (CSI) were significantly greater in patients with events. As a function of DBP from < or = 74 to 105 < or = mmHg, there was a positive association with the incidence of serious events, and a reversed J-curve in CSI with a nadir at 95-104 mmHg. A similar relationship was observed in SBP, but a potentially unfavorable outcome was suggested in the lowest SBP range of < or = 124 mmHg. In conclusion, there was no J-curve for DBP in hypertensive patients with angina pectoris; rather, the lower the DBP, the better was the prognosis. Interestingly, the severity of coronary lesion is in a reversed J-curve relation with DBP, suggesting that high BP plays a critical role in serious events in hypertensive patients with moderate coronary artery lesions.