Clinical Question

Does intensive lowering of blood pressure (BP) improve the lives of patients with hypertension?

Bottom Line

Patients with hypertension who are treated intensively are less likely to have major cardiovascular (CV) events, stroke, or progression of albuminuria or retinopathy than those treated less intensively, but intensive lowering had no meaningful effect on myocardial infarctions (MIs), heart failure, or mortality. (Level of Evidence = 1a)

Synopsis

This team of researchers reviewed several databases and registries to identify randomized trials that lasted at least six months and that compared more intensive vs. less intensive BP lowering in patients with hypertension. Two authors independently determined which studies to include and assessed the included studies' methodologic quality. They were interested in a range of clinically meaningful outcomes (e.g., mortality) as well as irrelevant outcomes (e.g., progression of albuminuria), singly or as a composite. Ultimately, they included 21 reports from 19 trials with nearly 45,000 patients followed for an average of four years. Approximately one-half of the studies were of modest to poor quality.

The intensive treatment group had mean BP levels of 133/76 mm Hg compared with 140/81 mm Hg in the less-intensive group. The data show small reductions in the rate of major CV events (5.7% vs. 5.8%; number needed to treat [NNT] = 838) and stroke (2.4% vs. 2.6%; NNT = 406), but no significant reduction in the rate of MIs (2%). Although there were decreases in the rates of albuminuria progression and retinopathy progression, there were no significant decreases in the rates of heart failure, end-stage kidney disease, overall mortality, or CV mortality. Most studies failed to report on the harms of intensive BP lowering. In the six studies that did, serious harms occurred in 1.2% per year in the intensive group vs. 0.9% per year in the nonintensive group, with severe hypotension occurring in 0.3% per year vs. 0.1%. Finally, patients with preexisting diabetes mellitus, renal disease, or vascular disease treated more intensively generally had better outcomes than those treated less intensively.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Outpatient (any)

Reference: XieXAtkinsELvJet alEffects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet2016;387(10017):435–443.