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Meta-Analysis
. 2012;9(8):e1001293.
doi: 10.1371/journal.pmed.1001293. Epub 2012 Aug 21.

Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: a systematic review and meta-analysis

Jicheng Lv  1 , Bruce Neal, Parya Ehteshami, Toshiharu Ninomiya, Mark Woodward, Anthony Rodgers, Haiyan Wang, Stephen MacMahon, Fiona Turnbull, Graham Hillis, John Chalmers, Vlado Perkovic
Affiliations
Meta-Analysis

Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: a systematic review and meta-analysis

Jicheng Lv et al. PLoS Med. 2012.

Abstract

Background: Guidelines recommend intensive blood pressure (BP) lowering in patients at high risk. While placebo-controlled trials have demonstrated 22% reductions in coronary heart disease (CHD) and stroke associated with a 10-mmHg difference in systolic BP, it is unclear if more intensive BP lowering strategies are associated with greater reductions in risk of CHD and stroke. We did a systematic review to assess the effects of intensive BP lowering on vascular, eye, and renal outcomes.

Methods and findings: We systematically searched Medline, Embase, and the Cochrane Library for trials published between 1950 and July 2011. We included trials that randomly assigned individuals to different target BP levels. We identified 15 trials including a total of 37,348 participants. On average there was a 7.5/4.5-mmHg BP difference. Intensive BP lowering achieved relative risk (RR) reductions of 11% for major cardiovascular events (95% CI 1%-21%), 13% for myocardial infarction (0%-25%), 24% for stroke (8%-37%), and 11% for end stage kidney disease (3%-18%). Intensive BP lowering regimens also produced a 10% reduction in the risk of albuminuria (4%-16%), and a trend towards benefit for retinopathy (19%, 0%-34%, p = 0.051) in patients with diabetes. There was no clear effect on cardiovascular or noncardiovascular death. Intensive BP lowering was well tolerated; with serious adverse events uncommon and not significantly increased, except for hypotension (RR 4.16, 95% CI 2.25 to 7.70), which occurred infrequently (0.4% per 100 person-years).

Conclusions: Intensive BP lowering regimens provided greater vascular protection than standard regimens that was proportional to the achieved difference in systolic BP, but did not have any clear impact on the risk of death or serious adverse events. Further trials are required to more clearly define the risks and benefits of BP targets below those currently recommended, given the benefits suggested by the currently available data.

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Conflict of interest statement

JL has received grant support from Pfizer for hypertension research. VP, MW, SM, and JC have received honoraria from Servier for scientific presentations relating to blood pressure. SM and JC were principal investigators on ADVANCE, a blood pressure lowering trial funded by Servier and the Australian National Health and Medical Research Council. BN has received BP-related research support from Servier, and honoraria for scientific presentations related to blood pressure from Novartis, Tanabe, and Servier. AR has received an unrestricted grant from Dr Reddy’s Laboratories for a trial that includes blood pressure-lowering agents. PE, FT, TN, HW, and GH declare they have no competing interests.

Figures

Figure 1
Figure 1. Identification process for eligible studies.
Figure 2
Figure 2. Effect of intensive BP lowering on risk of major cardiovascular events (a), myocardial infarction (b), and stroke (c).
Boxes and horizontal lines represent RR and 95% CI for each trial. Size of boxes is proportional to weight of that trial result. Diamonds represent the 95% CI for pooled estimates of effect and are centered on pooled RR.
Figure 3
Figure 3. Effect of intensive BP lowering on risk of heart failure (a), cardiovascular death (b), and end stage kidney disease (c).
Boxes and horizontal lines represent RR and 95% CI for each trial. Size of boxes is proportional to weight of that trial result. Diamonds represent the 95% CI for pooled estimates of effect and are centered on pooled RR.
Figure 4
Figure 4. Effect of intensive BP lowering on the risk of microvascular outcomes in diabetes.
Figure 5
Figure 5. Effects of intensive BP lowering on the risk of major cardiovascular events in subgroups of trials.
See this image and copyright information in PMC

References

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