Antihypertensive medication confers lower CV event rates regardless of CVD, BP history
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Medications that lower BP reduced CV event rates regardless of prior CVD or baseline BP, according to a meta-analysis published in The Lancet.
The analysis included 344,716 participants from 48 randomized clinical trials.
“Our findings are of great importance to the debate concerning blood pressure treatment. This new and best available evidence tells us that decisions to prescribe blood pressure medication should not be based simply on a prior diagnosis of cardiovascular disease or an individual’s blood pressure level. Instead, medication should be viewed as an effective tool for preventing cardiovascular disease in people at increased risk for developing heart disease or stroke. Clinical guidelines should be changed to reflect these findings,” Kazem Rahimi, FRCP, DM, MSc, FESC, professor of cardiovascular medicine and population health at the University of Oxford, said in a press release.
The researchers determined that a 5 mm Hg reduction in systolic BP lowered the relative risk for CV events by almost 10% regardless of previous diagnosis of CVD.
According to the researchers, the findings suggest that medication for lowering BP is effective for primary and secondary prevention of major CVD events at BP levels that do not require treatment.
In the analysis, during a median follow-up of 4.15 years, 12.3% of the participants had at least one major CV event: 4% with stroke, 5.6% with ischemic heart disease and 2.4% with HF.
According to the researchers, 8.4% of participants died during follow-up and 3.4% died from CVD.
Among participants who did not have previous CVD at baseline, the incidence rate for developing a major CV event was 31.9 per 1,000 person-years (95% CI, 31.3-32.5) in the comparator group and 25.9 per 1,000 person-years (95% CI, 25.4-26.4) in the intervention group.
Among the cohort with prior CVD at baseline, the incidence rate for developing a major CV event was 39.7 per 1,000 person-years (95% CI, 39-40.5) in the comparator group and 36 per 1,000 person-years (95% CI, 35.3-36.7) in the intervention group, according to the researchers.
The researchers found that for each 5% reduction in systolic BP, there was an 11% reduced risk for major CV events in people with prior CVD (adjusted HR = 0.89; 95% CI, 0.86-0.92) and a 9% reduced risk in people without prior CVD (aHR = 0.91; 95% CI, 0.89-0.94).
“It is important that people are considered for blood pressure-lowering treatment based on their cardiovascular risk, rather than focusing on blood pressure itself as a qualifying factor for or target of treatment,” Zeinab Bidel, MSc, statistical programmer and epidemiologist at the University of Oxford, said in the release. “We must provide well-rounded guidelines to lower risks for cardiovascular disease that include exercise, nutrition, smoking cessation and — where appropriate — medication.”
Perspective
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Wanpen Vongpatanasin, MD
In this study, reducing systolic BP by 5 mm Hg was shown to cut major CV event rates by 10%. This beneficial effect of antihypertensive drug treatment is independent of baseline BP. Whether baseline BP started at 120 mm Hg or 130 mm Hg, the effects are very similar across the board.
It is not completely surprising as a previous meta-analysis from the same research group (Ettehad D, et al. Lancet. 2016;doi:10.1016/S0140-6736(15)01225-8) showed similar effects (ie, 10 mm Hg reduction in systolic BP resulted in 20% relative risk reduction in CVD events). However, the previous meta-analysis was conducted by gathering summary data from published studies. In this meta-analysis, the researchers used individual data, which are more precise.
The authors raise a thought-provoking point that BP-lowering drugs should be considered as a CVD preventive strategy the same way we gave statins to patients with the aim to reduce CV risks rather than to lower BP or cholesterol itself.
Although the concept is appealing, the risk assessment tool is still far from perfect for all populations across age, sex and socioeconomic status. Patients understand and relate to BP more and are able to use the number as a way to motivate themselves and their providers reach a certain goal. At least this study underscores the important role of pharmacologic treatment of elevated BP at lower thresholds than what many people perceive as high BP.
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