A new study suggests that lowering blood pressure with antihypertensive drugs reduces future cardiovascular events, even in people with normal or slightly elevated blood pressure.
In a meta-analysis of individual patients in 48 antihypertensive treatment studies with a total of 348,854 participants, a set amount of blood pressure reduction was associated with the same relative risk of future cardiovascular events over the entire range of baseline pressure. It was shown to be associated with a decrease in 115 mm Hg systole with or without heart disease.
Dr. Kasem Rahimi
“This challenges the widely held view that hypotension is only for people with a history of hypertension or cardiovascular disease.” [CVD]Said Dr. Kasem Rahimi, MD, from Oxford University in the UK theheart.org | Medscape Cardiology.
New data from Clinician’s collaboration on low blood pressure treatment (BPLTTC), Was announced at Virtual Cardiovascular Society (ESC) 2020 Conference August 31st.
Rahimi is now High blood pressure Guidelines recommend an overall rating Cardiovascular risk —But only after the blood pressure reaches a certain threshold.
“It assumes that a wide range of people are not eligible because their blood pressure is below that threshold,” Rahimi said. “But our results show that considering taking antihypertensive drugs only when blood pressure is above a certain threshold (such as 140 mm Hg) is not a valid approach.” Studies suggest that these thresholds are inadequate.”
Rahimi says that decisions about whether to treat with antihypertensive drugs should instead be made by assessing each individual’s overall cardiovascular risk. “People at high risk have a greater absolute benefit in lowering blood pressure. In this way, a wider range of people will be treated.”
He added that some people have a higher cardiovascular risk but have normal or slightly elevated blood pressure. “The current guidelines do not qualify them for antihypertensive drug treatments, but our data suggest they should be candidates for such treatments.”
Moreover, the opposite may be true, Rahimi said. “Patients may have blood pressures above current treatment thresholds, but the overall risk of cardiovascular disease is so low that the relative benefits of antihypertensive treatment are low.”
Main impact on clinical practice
Rahimi believes these results will have a major impact on clinical practice worldwide. “We should not make decisions about antihypertensive treatment based on a single number, and the population should not be dichotomized based on a single threshold,” he says.
For meta-analysis, researchers divided participants in 48 studies into 7 subgroups based on systolic blood pressure at study entry (120, 120-129, 130-139, 140- 149, 150-159, 160-169, 170 or more mm Hg).
With an average 4-year follow-up, a 5 mm Hg reduction in systolic blood pressure reduced the relative risk of major cardiovascular events by approximately 10%. Risk of stroke, Ischemic heart disease, heart failure, And CVD mortality were reduced by 13%, 7%, 14%, and 5%, respectively.
Neither the presence of CVD nor the blood pressure level at the start of the study affected the therapeutic effect.
|
Effects on major CV events for each 5 mm Hg reduction in systolic blood pressure |
|
|
Baseline systolic blood pressure (mm Hg) |
Hazard ratio of CVD event |
|
For previous CVD (n = 160,271) |
|
|
<120 |
0.82 |
|
120 ~ 129 |
0.86 |
|
130-139 |
0.99 |
|
140-149 |
0.89 |
|
150-159 |
0.89 |
|
160-169 |
0.83 |
|
> 170 |
0.90 |
|
No previous CVD (n = 188,583) |
|
|
<120 |
0.80 |
|
120 ~ 129 |
0.96 |
|
130-139 |
0.90 |
|
140-149 |
0.95 |
|
150-159 |
0.88 |
|
160-169 |
0.88 |
|
> 170 |
0.89 |
Yet, “the fact that the relative effects are similar to everyone does not mean that everyone should be treated,” Rahimi said. “This decision depends on the likelihood of an individual developing cardiovascular disease in the future. There are several risk calculators that health professionals can use. Other factors to consider are the likelihood of side effects and the cost of treatment. “
Rahimi points out that lipid-lowering is already the first approach to assessing overall cardiovascular risk. “Cholesterol alone doesn’t make a treatment decision,” he said. “There are differences between the two areas, but in general our general message is that the hypertension field must follow what is already accepted in the cholesterol field.”
He says no studies have previously examined this problem in the area of blood pressure reduction.
” Sprint He was a very prominent study and the number was too small to make a decision in this population, as many individuals had systolic blood pressure below 130 mm Hg. Events for people with systolic levels below 130 mm Hg — there was statistical power to investigate this in detail. “
Asked how the change to this approach would affect the number of patients being treated, Rahimi said it does not necessarily increase the number of patients treated. “
Comments on research theheart.org | Medscape Cardiology, Michael A. Weber, MD (Professor, SUNY Downstate School of Medicine, New York City), said the data from this BPLTTC meta-analysis extend the findings from previous meta-analyses that showed the cardiovascular benefits of hypotension. Drug for patients with systolic blood pressure of 130 mm Hg. “Today, these benefits appear to occur when systolic blood pressure is as low as 120 mm Hg.”
Weber said results from this analysis in patients with a previous cardiovascular history might have been expected. However, the new finding of outcome benefit in patients without previous cardiovascular history treated with 120 mm Hg systole is not currently considered a good candidate for treatment, even by current relatively aggressive criteria. Extends discovery to important groups of individuals ACC/AHA Hypertension Guidelines In the United States.
“Of course,” Weber added. “These new findings should be mitigated by recognizing that they came from a meta-analysis rather than a strong randomized clinical trial.
During the post-data discussion at the ESC Hotline, Co-Chair of the session, Dr. Derderick Grobbie, MD, Medical Epidemiology Professor at Utrecht University Medical Center in The Netherlands, said: Although hypertension may be less diagnostically important, treatment of blood pressure is becoming more important as a modifier of baseline risk, even in the presence of relatively low initial blood pressure. I think it’s an important message. “
Dr. Johannes Reitzma, MD, University of Utrecht Medical Center, described the BPLTTC analysis as a “very rich data source”, allowing more flexibility to explore different subgroups.
He said he would like to gain more insight into the variability of the individual studies involved and to focus more on the analysis of absolute benefits and side effects.
The meta-analysis was funded by the British Heart Foundation, National Institutes of Health Oxford Biomedical Research Center, Oxford Martin School, UK Research and Innovation. Rahimi does not disclose the financial relationship involved.
European Society of Cardiology (ESC) Conference 2020: Hotline 9. Announced August 31, 2020.
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