Regardless of baseline BP, reduction beneficial for primary, secondary CVD prevention
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The CV benefits of BP lowering, for both primary and secondary prevention, were found to be proportional to the intensity of the reduction regardless of baseline BP, researchers reported.
According to the BPLTTC meta-analysis presented at the virtual European Society of Cardiology Congress, for every 5 mm Hg decrease in baseline systolic BP, patients experienced a risk reduction of 10% for major CV events, 13% for stroke, 14% for HF, 7% for ischemic heart disease and 5% for CV death.
“The decision to prescribe blood pressure-lowering medication should not be based simply on a prior diagnosis of cardiovascular disease or an individual's current blood pressure,” Kazem Rahimi, FRCP, DM, MSc, FESC, associate professor of cardiovascular medicine at the University of Oxford, U.K., said during a presentation. “Rather, antihypertensive medications are better considered as risk-modifying treatments for prevention of incident or recurrent cardiovascular events, regardless of blood pressure itself at baseline.”
For this analysis, investigators included trials of BP-lowering medications that had at least 1,000 person-years of follow-up and individual participant data. The final assessment included 348,854 patients across 48 randomized controlled trials. The primary outcome was major adverse CV events including nonfatal stroke, fatal or nonfatal MI or ischemic heart disease or HF leading to death or hospitalization.
Patients were grouped according to CVD history (primary prevention vs. secondary prevention) and stratified by baseline systolic BP.
For both groups, regardless of baseline BP (less than 120 to more than 170), researchers observed a decline in the occurrence of major CV events, concurrent with each 5 mm Hg drop in systolic BP (HR for primary prevention = 0.91; 95% CI, 0.89-0.94; HR for secondary prevention = 0.89; 95% CI, 0.86-0.92).
The researchers also found each 5 mm Hg reduction in systolic BP was associated with reductions in risk for stroke (HR = 0.87; 95% CI, 0.84-0.90), ischemic heart disease (HR = 0.93; 95% CI, 0.90-0.96), HR (HR = 0.86; 95% CI, 0.82-0.91) and CV death (HR = 0.95; 95% CI, 0.91-0.99), consistent between the primary and secondary prevention populations.
In a discussion following the presentation, Johannes B. Reitsma, MD, PhD, associate professor in the department of epidemiology and the Julius Center Research Program Methodology at the Julius Center for Health Sciences and Primary Care, said the researchers “showed that the relative treatment effect is constant across all these levels of systolic, blood pressure at baseline. An important subgroup that they had was cardiovascular disease at baseline. They were able to show in large groups that they didn't modify the relative treatment effect. Of course, background incidence was different across these groups, but the relative treatment effect of blood pressure lowering was constant.
“I would like more insight into variation of estimates across studies because if there is heterogeneity in the results of different trials, it does affect the strength of recommendations,” Reitsma said. “We need to be aware of whether this was constant across all the trials or if there where exceptions. I would like to see more focus on absolute difference in treatment effect, as this is the most relevant scale for shared decision-making when it comes to treatment decision.”
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Rahimi K, et al. Hot Line III. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).
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