Blood pressure targets in people with cardiovascular disease

Review question

We assessed whether lower blood pressure goals are better than standard blood pressure goals for people with high blood pressure who also have heart or vascular problems.

Background

Many people with heart or vascular problems also have high blood pressure. Some clinical guidelines recommend a lower blood pressure goal (135/85 mmHg or lower) for people with previous heart or vascular problems than for with those without (≤ 140 to 160 mmHg systolic and ≤ 90 to 100 mmHg diastolic are standard blood pressure goals). It is unclear whether lower goals lead to overall health benefits.

Search date

We searched for evidence up to February 2018.

Study characteristics

For this updated review, we included six trials with 9484 participants who were followed-up from one year to 4.7 years. We analyzed data to detect differences between lower and standard blood pressure goals in terms of numbers of deaths and numbers of serious adverse events (leading to hospital admission).

Key results

We found no differences in total numbers of deaths, heart or vascular deaths, total heart problems, or vascular problems, nor in total serious harms, between lower and standard blood pressure goal approaches. Based on very little information, we found more dropouts resulting from drug-related harms in the lower blood pressure target group and no overall health benefit among people in the lower target group.

Quality of the evidence

The best available evidence does not support lower blood pressure goals over standard goals in people with elevated blood pressure and heart or vascular problems. More new trials are needed to examine this question. Overall, the quality of evidence was assessed as low to moderate according to the GRADE assessment.

Authors' conclusions: 

We found no evidence of a difference in total mortality, serious adverse events, or total cardiovascular events between people with hypertension and cardiovascular disease treated to a lower or to a standard blood pressure target. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on adverse events, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (≤ 135/85 mmHg) in people with hypertension and established cardiovascular disease. More trials are needed to examine this topic.

Read the full abstract...
Background: 

This is the first update of the review published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown.

Objectives: 

To determine if 'lower' blood pressure targets (≤ 135/85 mmHg) are associated with reduction in mortality and morbidity as compared with 'standard' blood pressure targets (≤ 140 to 160/90 to 100 mmHg) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease).

Search strategy: 

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to February 2018: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982), along with the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. We applied no language restrictions.

Selection criteria: 

We included randomized controlled trials (RCTs) that included more than 50 participants per group and provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (≤ 135/85 mmHg) compared with standard targets for blood pressure (≤ 140 to 160/90 to 100 mmHg).

Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris.

Data collection and analysis: 

Two review authors independently assessed search results and extracted data using standard methodological procedures expected by Cochrane.

Main results: 

We included six RCTs that involved a total of 9484 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). All RCTs provided individual participant data.

We found no change in total mortality (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.91 to 1.23) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; moderate-quality evidence). Similarly, we found no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; low-quality evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure) (RR 0.89, 95% CI 0.80 to 1.00; low-quality evidence). Studies reported more participant withdrawals due to adverse effects in the lower target arm (RR 8.16, 95% CI 2.06 to 32.28; very low-quality evidence). Blood pressures were lower in the lower target group by 8.9/4.5 mmHg. More drugs were needed in the lower target group, but blood pressure targets were achieved more frequently in the standard target group.

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