Abstract 10240: Lower May Not Be Better: Systolic Blood Pressure and Risk of Major Adverse Limb Events in Patients With Symptomatic Peripheral Artery Disease After Revascularization: Insights From Voyager Pad

Introduction: Blood pressure (BP) trials have established optimal targets for major adverse cardiovascular event (MACE) prevention; however, less intensive BP control (also called permissive hypertension) is sometimes utilized to minimize end organ damage in specific settings such as acute stroke and acute kidney injury. An analysis from ALLHAT found that systolic blood pressure (SBP) <120mmHg was associated with a 26% higher rate of major adverse limb events (MALE) in peripheral artery disease (PAD). Whether this association is present in patients with PAD after lower extremity revascularization (LER) is not well described. Methods: VOYAGER PAD randomized patients with symptomatic PAD after LER to rivaroxaban or placebo. The primary composite endpoint was time to first event of MACE or MALE. BP measurements were obtained at baseline, 1, 3, and every 6 months after enrollment. Associations between average SBP at 1 month after LER and incident MACE and MALE through follow up were evaluated. Splines were estimated in proportional hazard models with adjustment for treatment assignment. Results: SBP measurements at 1 month were available in 6,248 patients. Median (IQR) SBP in mmHg was (126, 114-139). The relationship between SBP after LER and future risk of MACE (Figure, Panel A) shows an apparent increased risk at SBP <90mmHg. The relationship of SBP and MALE appeared linear (Figure, Panel B) with a lower risk at higher SBP and greater risk with SBP below ~120mmHg. For every 5mmHg decrease in SBP there was an associated 7% increase in risk of MALE (HR 1.07, 95% CI 1.05-1.10, p <0.0001). The pattern appeared consistent regardless of index revascularization type (surgical vs endovascular). Conclusion: Patients with PAD are at heightened risk of MALE due to obstructive conduit artery disease. There is an inverse relationship between SBP and MALE after LER. Further investigation into optimal BP targets in patients with PAD are warranted.