Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data.

Lancet. 2014 Aug 16;384(9943):591-598. doi: 10.1016/S0140-6736(14)61212-5. (Original)
PMID: 25131978

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Disciplines

Family Medicine (FM)/General Practice (GP)

Relevance - 7/7
Newsworthiness - 5/7
General Internal Medicine-Primary Care(US)

Relevance - 7/7
Newsworthiness - 5/7
Cardiology

Relevance - 6/7
Newsworthiness - 5/7
Endocrine

Relevance - 6/7
Newsworthiness - 5/7
Hospital Doctor/Hospitalists

Relevance - 6/7
Newsworthiness - 5/7
Internal Medicine

Relevance - 6/7
Newsworthiness - 5/7
Nephrology

Relevance - 6/7
Newsworthiness - 5/7
Neurology

Relevance - 6/7
Newsworthiness - 5/7

Abstract

BACKGROUND: We aimed to investigate whether the benefits of blood pressure-lowering drugs are proportional to baseline cardiovascular risk, to establish whether absolute risk could be used to inform treatment decisions for blood pressure-lowering therapy, as is recommended for lipid-lowering therapy.

METHODS: This meta-analysis included individual participant data from trials that randomly assigned patients to either blood pressure-lowering drugs or placebo, or to more intensive or less intensive blood pressure-lowering regimens. The primary outcome was total major cardiovascular events, consisting of stroke, heart attack, heart failure, or cardiovascular death. Participants were separated into four categories of baseline 5-year major cardiovascular risk using a risk prediction equation developed from the placebo groups of the included trials (<11%, 11-15%, 15-21%, >21%).

FINDINGS: 11 trials and 26 randomised groups met the inclusion criteria, and included 67,475 individuals, of whom 51,917 had available data for the calculation of the risk equations. 4167 (8%) had a cardiovascular event during a median of 4·0 years (IQR 3·4-4·4) of follow-up. The mean estimated baseline levels of 5-year cardiovascular risk for each of the four risk groups were 6·0% (SD 2·0), 12·1% (1·5), 17·7% (1·7), and 26·8% (5·4). In each consecutive higher risk group, blood pressure-lowering treatment reduced the risk of cardiovascular events relatively by 18% (95% CI 7-27), 15% (4-25), 13% (2-22), and 15% (5-24), respectively (p=0·30 for trend). However, in absolute terms, treating 1000 patients in each group with blood pressure-lowering treatment for 5 years would prevent 14 (95% CI 8-21), 20 (8-31), 24 (8-40), and 38 (16-61) cardiovascular events, respectively (p=0·04 for trend).

INTERPRETATION: Lowering blood pressure provides similar relative protection at all levels of baseline cardiovascular risk, but progressively greater absolute risk reductions as baseline risk increases. These results support the use of predicted baseline cardiovascular disease risk equations to inform blood pressure-lowering treatment decisions.

FUNDING: None.

Clinical Comments

Cardiology

These results support the use of predicted baseline cardiovascular disease risk equations to guide treatment decisions. This is very helpful information for all health care providers who manage HBP treatment.

Endocrine

This CVD risk-based approach to the management of hypertension is already in place in many parts of the UK. This article adds to the evidence behind this approach. The only worry is that statins were not part of the risk equation.

Family Medicine (FM)/General Practice (GP)

The best empirical evidence that we should be using absolute risk charts to determine who should be treated rather than just blood pressure. (There are some guidelines that need to change, too!)

Nephrology

As the accompanying editorial states, the meta-analysis reports the expected, although important, result.

Nephrology

Interesting approach that is consistent with the usual adage that relative risk reduction does not differ substantially amongst sub-groups. Those with higher absolute risk will benefit the most (i.e., as measured by the NNT) from BP-lowering therapy.

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