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

PLoS Med. 2012;9(8):e1001293. doi: 10.1371/journal.pmed.1001293. Epub 2012 Aug 21.

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.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Antihypertensive Agents / adverse effects
  • Antihypertensive Agents / pharmacology*
  • Antihypertensive Agents / therapeutic use
  • Blood Pressure / drug effects*
  • Cardiovascular Diseases / drug therapy
  • Cardiovascular Diseases / pathology
  • Cardiovascular Diseases / physiopathology
  • Cardiovascular System / drug effects*
  • Cardiovascular System / pathology
  • Cardiovascular System / physiopathology*
  • Clinical Trials as Topic
  • Humans
  • Kidney / drug effects*
  • Kidney / physiopathology*
  • Kidney Diseases / drug therapy
  • Kidney Diseases / pathology
  • Kidney Diseases / physiopathology
  • Regression Analysis
  • Risk Factors
  • Treatment Outcome

Substances

  • Antihypertensive Agents

Grant support

JL was supported by an Amgen Renal Research Fellowship. VP was supported by an Australian Heart Foundation Career Development Award. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.