Effects of Intensive Blood Pressure Lowering on Cardiovascular and Renal Outcomes

A Systematic Review and Meta-Analysis

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

Research output: Contribution to journalArticle

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. Please see later in the article for the Editors' Summary.

Original languageEnglish (US)
Article numbere1001293
JournalPLoS Medicine
Volume9
Issue number8
DOIs
StatePublished - Aug 2012

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Meta-Analysis
Blood Pressure
Kidney
Risk Reduction Behavior
Stroke
Coronary Disease
Blood Vessels
Albuminuria
Hypotension
Libraries
Chronic Kidney Failure
Myocardial Infarction
Placebos
Guidelines

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Lv, J., Neal, B., Ehteshami, P., Ninomiya, T., Woodward, M., Rodgers, A., ... Perkovic, V. (2012). Effects of Intensive Blood Pressure Lowering on Cardiovascular and Renal Outcomes: A Systematic Review and Meta-Analysis. PLoS Medicine, 9(8), [e1001293]. https://doi.org/10.1371/journal.pmed.1001293

Effects of Intensive Blood Pressure Lowering on Cardiovascular and Renal Outcomes : A Systematic Review and Meta-Analysis. / Lv, Jicheng; Neal, Bruce; Ehteshami, Parya; Ninomiya, Toshiharu; Woodward, Mark; Rodgers, Anthony; Wang, Haiyan; MacMahon, Stephen; Turnbull, Fiona; Hillis, Graham; Chalmers, John; Perkovic, Vlado.

In: PLoS Medicine, Vol. 9, No. 8, e1001293, 08.2012.

Research output: Contribution to journalArticle

Lv, J, Neal, B, Ehteshami, P, Ninomiya, T, Woodward, M, Rodgers, A, Wang, H, MacMahon, S, Turnbull, F, Hillis, G, Chalmers, J & Perkovic, V 2012, 'Effects of Intensive Blood Pressure Lowering on Cardiovascular and Renal Outcomes: A Systematic Review and Meta-Analysis', PLoS Medicine, vol. 9, no. 8, e1001293. https://doi.org/10.1371/journal.pmed.1001293
Lv, Jicheng ; Neal, Bruce ; Ehteshami, Parya ; Ninomiya, Toshiharu ; Woodward, Mark ; Rodgers, Anthony ; Wang, Haiyan ; MacMahon, Stephen ; Turnbull, Fiona ; Hillis, Graham ; Chalmers, John ; Perkovic, Vlado. / Effects of Intensive Blood Pressure Lowering on Cardiovascular and Renal Outcomes : A Systematic Review and Meta-Analysis. In: PLoS Medicine. 2012 ; Vol. 9, No. 8.
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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. Please see later in the article for the Editors' Summary.",
author = "Jicheng Lv and Bruce Neal and Parya Ehteshami and Toshiharu Ninomiya and Mark Woodward and Anthony Rodgers and Haiyan Wang and Stephen MacMahon and Fiona Turnbull and Graham Hillis and John Chalmers and Vlado Perkovic",
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AU - Ninomiya, Toshiharu

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AU - Rodgers, Anthony

AU - Wang, Haiyan

AU - MacMahon, Stephen

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AB - 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. Please see later in the article for the Editors' Summary.

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