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Lower BP targets may not benefit some patients at high CV risk
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In individuals at high CV risk, very low BP appears to be associated with increased risk for CV outcomes, although not stroke, researchers wrote in The Lancet.
“Guidelines recommend a target [BP] of less than [140 mm Hg systolic/90 mm Hg diastolic] to reduce [CV] events. However, [CV] outcomes including stroke and [HF] are more sensitive to systolic [BP] reduction than are other outcomes, such as coronary events,” Michael Böhm, MD, of Saarland University in Germany, and colleagues wrote. “Risk is also higher for some [CV] events at low [systolic] BP, resulting in a J-curve of the risk–[systolic] BP relationship, which exists for coronary disease events but not for stroke in hypertensive patients and in patients with stable [CAD].”
The researchers analyzed data from the ONTARGET and TRANSCEND trials, looking at the associations of baseline, time-updated and mean achieved systolic BP and diastolic BP with a composite of CV outcomes including CV death, MI, stroke and hospital admission for HF, and each of those outcomes individually.
Participants aged at least 55 years and those without symptomatic HF or a history of CAD, peripheral artery disease, stroke, transient ischemic attack or diabetes were included in the studies.
ONTARGET participants (n = 25,127), who were tolerant to ACE inhibitors, were randomly assigned to ramipril (n = 8,407), telmisartan (n = 8,386) or a combination (n = 8,334). TRANSCEND participants (n = 5,810), who were intolerant to ACE inhibitors, were randomly assigned to telmisartan (n = 2,903) or placebo (n = 2,907).
Baseline systolic BP > 140 mm Hg was associated with a greater incidence of all outcomes compared with BP of 120 mm Hg to 140 mm Hg.
Baseline diastolic BP of < 70 mm Hg was associated with the highest risk for most outcomes compared with all categories of > 70 mm Hg.
Systolic BP
In participants with low systolic BP on treatment (< 120 mm Hg), there was an increased risk for the composite CV outcome (HR = 1.14; 95% CI, 1.03-1.26), CV death (HR = 1.29; 95% CI, 1.12-1.49) and all-cause mortality (HR = 1.28; 95% CI, 1.15-1.42) vs. treatment of systolic BP of 120 mm Hg to 140 mm Hg.
No associations were found between MI, stroke or hospital admission for HF and achieved systolic BP during treatment.
Compared with baseline or time-updated systolic BP, mean achieved systolic BP was the best predictor of outcomes, according to the researchers. Mean achieved BP of 130 mm Hg was associated with lower risk for outcomes. Mean achieved systolic BP of 110 mm Hg to 120 mm Hg increased risk for composite outcome, CV death and all-cause death except stroke.
Diastolic BP
A low mean diastolic BP (< 70 mm Hg) during treatment was associated with an increased risk for composite outcomes (HR = 1.31, 95% CI, 1.2-1.42), MI (HR = 1.55; 95% CI, 1.33-1.8), hospital admission for HF (HR = 1.59; 95% CI, 1.36-1.86) and all-cause death (HR = 1.16; 95% CI, 1.06-1.28) vs. diastolic BP of 70 mm Hg to 80 mm Hg.
“Taken together, these data indicate that achieved [BP] values have diverse benefit for different outcomes and this probably differs according to baseline risk in hypertensive patients,” the researchers wrote. “Consequently, people with a particular risk for a specific outcome — eg, stroke, might benefit from lower [BP] than those who are more prone to develop [MI] or [CV] death — the challenge, however, is how to predict who is most likely to develop each of these events.” – by Cassie Homer
Disclosure: The study was funded by Boehringer Ingelheim. The researchers report no relevant financial disclosures.
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