Lowering blood pressure below latest recommendations reduces risk of cardiovascular disease and death

Blood pressure should be lowered below 130 mmHg in patients at high risk for cardiovascular disease and stroke regardless of their starting blood pressure, and all high-risk patients should be offered blood pressure-lowering drugs, according to the largest meta-analysis on the subject published online December 23, 2015 in The Lancet.

The researchers determined that, overall, a 10 mmHg reduction in systolic blood pressure reduces the risk of major cardiovascular disease events by 20%, coronary heart disease by 17%, stroke by 27%, heart failure by 28%, and all-cause mortality by 13%.

“The size of these proportional reductions was broadly consistent across several major high-risk groups of patients, suggesting that blood pressure lowering provides broadly generalisable benefits,” the authors wrote.

Accordingly, they called for an urgent revision of recent blood pressure-lowering guidelines—such as those from National Institute for Health and Care Excellence (NICE) and the European Society of Hypertension—that have relaxed blood pressure targets from 130/85 mmHg to 140/90 mmHg, and for the elderly to even higher targets of 150/90 mmHg.

They also recommended a shift from rigid blood pressure targets to individualized risk-based targets, even when blood pressure is below 130 mmHg before treatment.

In this systematic review, researchers analyzed the findings of 123 large-scale randomized trials that compared different blood pressure targets. Trials ranged from January 1966 to July 2015 and included more than 600,000 participants.

Treatment with any of the main classes of blood pressure-lowering drugs significantly reduced the risk of major cardiovascular events, stroke, heart failure, and death proportional to the extent that blood pressure was lowered, the researchers found.

Importantly, these reductions in disease were similar across a wide range of high-risk patients, including those with a history of cardiovascular disease, heart failure, diabetes, and kidney disease, regardless of whether their starting blood pressure was already low (less than 130 mmHg).

“Our findings clearly show that treating blood pressure to a lower level than currently recommended could greatly reduce the incidence of cardiovascular disease and potentially save millions of lives if the treatment was widely implemented,” said the study’s corresponding author Kazem Rahimi, DM, Associate Professor of Cardiovascular Medicine at The George Institute for Global Health, University of Oxford, in Oxford, UK.

Dr. Rahimi added, “The results provide strong support for reducing systolic blood pressure to less than 130 mmHg, and blood pressure-lowering drugs should be offered to all patients at high risk of having a heart attack or stroke, whatever their reason for being at risk.”

All classes of antihypertensive drugs were similarly effective in preventing vascular outcomes, the researchers found, but some classes were modestly more effective than others for specific outcomes:

• β-blockers seemed worse than other classes for the prevention of major cardiovascular disease, stroke, renal failure, and all-cause mortality.
• Calcium channel blockers seemed better than other classes for stroke.
• Diuretics were better than other classes for heart failure prevention.

“The prevalence of uncontrolled hypertension is elevated worldwide, particularly in patients with hypertension who are at high risk of cardiovascular complications,” wrote Stéphane Laurent, MD, PhD, and Pierre Boutouyrie, MD, PhD, from the Department of Pharmacology at Paris Descartes University, Paris, France, in an accompanying commentary in The Lancet. “Because energetic lowering of blood pressure seems safe and beneficial to patients, there is no reason not to apply it to high-risk patients.”