Re-Thinking Blood Pressure Lowering

Study Questions:

Do benefits of blood pressure lowering differ by baseline blood pressure, presence of comorbidities, or drug class?


This was a systematic review and meta-analysis. All randomized controlled trials of blood pressure lowering treatment published between 1966 and 2015 were eligible for inclusion. Data were extracted for major cardiovascular disease events, coronary heart disease, stroke, heart failure, renal failure, and all-cause mortality. Analyses were intended to establish the effect of a 10 mm Hg blood pressure reduction on adverse outcomes, the effect of a 10 mm Hg blood pressure reduction at different baseline blood pressure levels, the effects of a 10 mm Hg blood pressure reduction on adverse outcomes in the presence of comorbidities, and the effects of different classes of blood pressure lowering drugs.


A total of 123 studies with 613,815 participants met criteria for the meta-analysis. Every 10 mm Hg reduction in systolic blood pressure significantly reduced the risk of major cardiovascular events (relative risk [RR], 0.80; 95% confidence interval [CI], 0.77-0.83), coronary heart disease (RR, 0.83; 95% CI, 0.78-0.88), stroke (RR, 0.73; 95% CI, 0.68-0.78), and heart failure (RR, 0.72; 95% CI, 0.67-0.78). Similar proportional risk reductions (per 10 mm Hg lower systolic blood pressure) were observed in trials with higher mean baseline systolic blood pressure and trials with lower mean baseline systolic blood pressure. Different drug classes were of largely similar effectiveness, except beta-blockers were less efficacious than other medications for the prevention of major cardiovascular disease events, stroke, and heart failure. Save diabetes and chronic kidney disease, other comorbidities did not exert a proportional risk reduction in major cardiovascular disease events.


Every 10 mm Hg reduction in systolic blood pressure reduced the risk of major cardiovascular disease events by 20%, coronary heart disease by 17%, stroke by 27%, heart failure by 28%, and all-cause mortality by 13%.


This is a large and well-conducted meta-analysis that corroborates findings from such data as the SPRINT trial (The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015;373;2103-16), challenging guidelines that have relaxed blood pressure lowering thresholds. The authors reinforce data from SPRINT by demonstrating better outcomes associated with systolic blood pressures <130 mm Hg.

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