Physicians' Academy for Cardiovascular Education

Intensive SBP reduction associated with lower CVD and all-cause mortality risk

Systolic Blood Pressure Reduction and Risk of Cardiovascular Disease and Mortality A Systematic Review and Network Meta-analysis

Bundy JD, Li C, Stuchlik P, et al. - JAMA Cardiol. 2017; published online ahead of print

Background

Due to the J-shaped association reported between achieved blood pressure (BP) and risk of coronary heart disease (CHD), cardiovascular disease (CVD) and all-cause mortality, there is uncertainty regarding the optimal treatment targets for hypertensive patients [1,2]. Similarly, the relevant clinical practice guidelines are inconsistent, when recommending BP targets [3-5].

In this network meta-analysis of 42 randomized clinical trials (published before December 15, 2015) including 144 220 patients, the association of different levels of systolic BP (SBP) reduction with the risk of major CVD, stroke, CHD, CVD mortality, and all-cause mortality was evaluated.

Main results

Randomized groups with a mean achieved SBP of 120 to 124 mm Hg had the following HRs for major CVD:

Randomized groups with a mean achieved SBP of 120 to 124 mmHg had the following HRs for stroke:

A similar but weaker association between mean achieved SBP and CHD was observed.

Randomized groups with a mean achieved SBP of 120 to 124 mmHg had the following HRs for all-cause mortality:

Randomized groups with a mean achieved SBP of 120 to 124 mmHg had the following HRs for CVD mortality:

In the sensitivity analysis, the lowest-risk group for stroke was the group with an SBP of 120 to 124 mmHg, and the lowest-risk group for CVD mortality was the group with an SBP of less than 120 mmHg.

In the main analyses, the lowest-risk group for stroke was the group with an SBP of less than 120 mmHg, and the lowest-risk group for CVD mortality was the group with an SBP of 120 to 124 mmHg.

Conclusion

In a network meta-analysis of randomized clinical trials, treating patients to reduce SBP below currently recommended targets was associated with a significantly reduced risk of CVD and all-cause mortality. These findings support a more intensive SBP control in patients with hypertension.

Editorial comment

In their editorial article [6] Yancy and Bonow comment that the meta-analysis by Bundy et al provide ‘’provocative evidence that lower is better and likely so in all cohorts with hypertension.’’ Based on the data they propose a 5-steps approach for the treatment of hypertension:

  • Confirm the diagnosis and evaluate secondary causes.
  • Determine the overall risk for CVD.
  • In those at higher CVD risk the target SBP goal should be less than 130 mmHg.
  • For those at lower risk the treatment goal should be less than 150 mmHg.
  • Keep in mind the risks of aggressive blood pressure lowering and polypharmacy.

The authors conclude: ‘’But for now, we should transition from the interrogative question of what treatment target is appropriate to the declarative statement that lower, preferably less than 130 mmHg, if safely attainable, is better.’’

References

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Find this article online at JAMA