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Systolic BP levels below guideline targets may decrease CVD, mortality risk
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The lowering of systolic BP levels below recommended goals is linked to the reduced risk for CVD and all-cause mortality, according to a systematic review and network meta-analysis in JAMA Cardiology.
“These findings support more intensive [systolic] BP control among adults with hypertension and suggest the need for revising the current clinical guidelines for management of hypertension,” Joshua D. Bundy, MPH, a doctoral candidate in the department of epidemiology at Tulane University School of Public Health and Tropical Medicine in New Orleans, and colleagues wrote.
Trial meta-analysis
Researchers analyzed data from 144,220 patients from 42 separate trials whose mean achieved systolic BP varied from 114 mm Hg to 171 mm Hg, including patients assigned to an antihypertensive medication independent of other treatments, a control or a treatment target for 6 months or more. Outcomes were defined as stroke, CVD mortality, CHD, all-cause mortality and major CVD events such as HF, stroke, CHD and CVD deaths.
Achieved systolic BP levels were linearly associated with the risk for stroke, major CVD, CHD, CVD mortality and all-cause mortality. Patients with a mean achieved systolic BP between 120 mm Hg and 124 mm Hg had the lowest risk for CHD, major CVD, all-cause mortality and CVD mortality. Those who achieved systolic BP less than 120 mm Hg had the lowest risk for stroke.
Regarding major CVD, risk was lower for those with mean achieved systolic BP of 120 mm Hg to 124 mm Hg compared with patients who had a systolic BP of 130 mm Hg to 134 mm Hg (HR = 0.71; 95% CI, 0.6-0.83), 140 mm Hg to 144 mm Hg (HR = 0.58; 95% CI, 0.48-0.72), 150 mm Hg to 154 mm Hg (HR = 0.46; 95% CI, 0.34-0.63) and 160 mm Hg or more (HR = 0.36; 95% CI, 0.26-0.51).
For all-cause mortality, risk was lower in patients who achieved a systolic BP between 120 mm Hg and 124 mm Hg vs. those who achieved a BP between 130 mm Hg and 134 mm Hg (HR = 0.73; 95% CI, 0.58-0.93), 140 mm Hg and 144 mm Hg (HR = 0.59; 95% CI, 0.45-0.77), 150 mm Hg and 154 mm Hg (HR = 0.51; 95% CI, 0.36-0.71) and 160 mm Hg and above (0.47; 95% CI, 0.32-0.67).
“The findings from SPRINT and our network meta-analysis suggest that a more intensive treatment target than currently recommended (eg, [systolic] BP of 120-124 mm Hg) provides additional benefits for prevention of CVD complications and all-cause mortality,” Bundy and colleagues wrote.
Study implications
“These are nontrivial findings,” Clyde W. Yancy, MD, MSc, vice dean for diversity and inclusion, chief of cardiology in the department of medicine, Magerstadt professor and professor of medicine and medical social sciences at Northwestern University Feinberg School of Medicine, and Robert O. Bonow, MD, MS, Max and Lilly Goldberg distinguished professor of cardiology and professor of medicine at Northwestern University Feinberg School of Medicine, wrote in a related editorial. “We should not ignore the potential for harm attributed to lowering [BP] too aggressively, particularly in the elderly, but those harms have not yet emerged to be more important than the benefits. Taken together, these data create a strong imperative to revisit how we treat hypertension.” – by Darlene Dobkowski
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopFranz H. Messerli MD, FACC, <br> <i>Cardiology Today</i> Editorial Board Member <br>University of Bern, Switzerland <br>Mount Sinai Icahn School of Medicine, New York <br>Jagiellonian University Krakow, Poland<br> Chirag Bavishi MD, MPH,<br> Department of Cardiology, Mount Sinai St. Luke’s and West Hospitals
In the thorough network meta-analysis of Bundy et al, randomized groups with a mean achieved systolic BP of 120 mm Hg to 124 mm Hg had lower CVD and all-cause mortality outcomes compared to other groups. Unfortunately, the conclusion supporting a "more intensive" BP control is solely based on evaluation of efficacy outcomes, and safety outcomes are conspicuously missing in this dataset. Safety, however, is a seminal issue with these exceedingly low BP target levels.
In fact, as most clinicians would agree, the lower the on-treatment BP levels, the more important safety issues become. In a recent meta-analysis, we evaluated both efficacy and safety outcomes of various BP targets (Bavishi C, et al. J Am Coll Cardiol. 2017;doi: 10.1016/j.jacc.2016.10.077). Similar to Bundy et al, systolic BP targets of < 120 mm Hg and < 130 mm Hg were ranked as providing optimal efficacy outcomes. However, when data were analyzed for safety, systolic BP targets of < 140 mm Hg and < 150 mm Hg were found to be the safest. We concluded that systolic BP levels of < 130 mm Hg provided optimal balance between safety and efficacy for all endpoints.
The accompanying editorial of the network meta-analysis of Bundy et al by Drs. Yancy and Bonow carries the headline “New blood pressure-lowering targets — Finding clarity,” and states that these findings provide “provocative evidence that lower is better and likely so in all cohorts with hypertension.” As long as ironclad safety data on these target BP levels have not been put forward, such broad generalization is not acceptable.
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