Reducing systolic blood pressure to levels below the recommended targets can significantly reduce the risk of cardiovascular disease (CVD) and all-cause mortality, according to research published in JAMA Cardiology.
Data from recent clinical trials have suggested that lowering blood pressure reduces CVD and premature deaths, but the optimal target for reduction of systolic blood pressure is uncertain. Therefore, investigators conducted a systematic review and meta-analysis to assess the association of mean achieved systolic blood pressure levels with the risk of CVD and mortality in adults with hypertension who were treated with antihypertensive therapy. The analysis included 42 clinical trials (144,220 patients), with random allocation to an antihypertensive medication, control, or treatment target.
Overall, the researchers observed linear associations between mean achieved systolic blood pressure and CVD risk, with the lowest risk at 120 to 124 mm Hg.
Participants with a mean achieved systolic blood pressure of 120 to 124 mm Hg had a hazard ratio (HR) for major CVD of 0.71, compared with those who had mean levels of 130 to 134 mm Hg (HR, 0.58), compared with those with mean levels of 140 to 144 mm Hg (HR, 0.46), compared with those with mean levels of 150 to 154 mm Hg (HR, 0.36), compared with those with mean levels of 160 mm Hg or more.
In addition, individuals with a mean achieved systolic blood pressure of 120 to 124 mm Hg had an HR for all-cause mortality of 0.73, compared with those with mean levels of 130 to 134 mm Hg (HR, 0.59), compared with those with mean levels of 140 to 144 mm Hg (HR, 0.51), compared with those with mean levels of 150 to 154 mm Hg (HR, 0.47), compared with those with mean levels of 160 mm Hg or more.
In an accompanying editorial, Clyde W. Yancy, MD, MSc, and Robert O. Bonow, MD, MS, from the Feinberg School of Medicine at Northwestern University in Chicago, offered 5 steps to update the approach of hypertension treatment:
- Confirm hypertension diagnosis with home blood pressure readings or with ambulatory blood pressure monitoring.
- Determine CVD risk using an available risk assessment tool.
- The target goal for treating blood pressure should be less than 130 mm Hg in those with higher CVD risk.
- Nonpharmacological approaches are an appropriate first step for those at lower risk or those with difficulty tolerating antihypertensive therapy.
- Remain aware of the risks of aggressive blood pressure lowering and polypharmacy.
“Medicine is practiced on a patient-level basis, and individualized treatments based on a shared decision-making model should drive patient-level interventions; this is especially the case for those at higher risk for CVD and for those who are most vulnerable,” Drs Yancy and Bonow wrote.
“But the population health benefits of lower blood pressure targets, much lower than we have previously recognized, are real,” they continued. “If we can avoid harm, lives will be saved, productivity extended and suffering from the consequences of hypertension will be reduced.”
- Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: A systematic review and network meta-analysis. JAMA Cardiol. 2017. doi:10.1001/jamacardio.2017.1421
- Yancy CW, Bonow RO. New blood pressure-lowering targets—finding clarity. JAMA Cardiol. 2017. doi:10/1001/jamacardio.2017.1422