Lancet Sprints To The Front With A Blood Pressure Meta-Analysis

A new meta-analysis published in the Lancet on Friday lends fresh support to calls for more intensive blood pressure treatments. The publication comes only days before the highly anticipated presentation of the NIH’s SPRINT trial at the American Heart Association, which is also expected to offer support for stricter blood pressure control.

Blood pressure goals were relaxed after the ACCORD trial failed to convincingly show an advantage for intensive blood pressure control in a patient population of hypertensives who also had diabetes. Now the new meta-analysis and, apparently, the SPRINT trial, appear to mark the moment when the pendulum has started to move back towards intensive control.

The Lancet authors analyzed data from 19 trials involving nearly 45,000 patients. On average, blood pressure in the intensive treatment groups was 133/76 mm Hg compared with 140/81 mm Hg in the control groups.

The authors reported significant reductions in the primary endpoint and other individual endpoints of interest:

• 14% reduction in major cardiovascular events (95% confidence interval 4%-22%)
• 13% reduction in MI (0%-24%)
• 22% reduction in stroke (10%-32%)
• 10% reduction in albuminuria (3%-16%)
• 19% reduction in retinopathy progression (0%-34%)

There were no significant differences in heart failure, cardiovascular death, total mortality, or end-stage kidney disease.

Serious adverse events linked to antihypertensive treatment were recorded in only six of the trials and occurred at an event rate of 1.2% per year in the intensive treatment group versus 0.9% in controls. This difference did not reach statistical significance (RR 1·35, CI 0.93–1.97]). There was a small but significant increase in severe hypotension in the intensive treatment group, with an event rate of 0.3% per year versus 0.1% (p=0.015).

“A key finding was the consistency of findings across major patient groups—those with cardiovascular disease, diabetes, renal disease and also those with just hypertension,” said co-author Professor Jicheng Lv (Peking University First Hospital, Beijing, China), in a Lancet press release.

“Several major clinical guidelines on managing high blood pressure, including those of NICE and the European Society of Hypertension, have recently raised blood pressure targets from 130/85 mmHg to 140/90 mmHg for high-risk patients. But our robust evidence clearly shows that treating blood pressure to a lower level than currently recommended targets results in better health outcomes for patients,” said the lead author of the paper, Anthony Rodgers (The George Institute of Global Health, Sydney, Australia) in the press release.

In an accompanying comment,  Mattias Brunström and Bo Carlberg (Umeå University, Umeå, Sweden) write that the paper “provides strong evidence that intensive blood pressure reduction is more beneficial than less intensive blood pressure reduction.” They note that the findings “will probably be supported further by forthcoming results” from SPRINT. But, they caution, despite “convincing” findings, the overall results should not be applied to all populations studied in the trials included in the meta-analysis. “In particular, it is not yet obvious that patients with diabetes mellitus, or very elderly patients, will benefit from lower treatment targets than the recommended goal of lower than 140/90 mm Hg.”