Antihypertensive therapy reduces the risk of cardiovascular events even in patients with no history of heart disease or with normal baseline blood pressure (BP).
This fuels a long-running debate about thresholds for hypertension diagnosis (which may or may not exist). Beyond that, the higher the baseline BP, the better the benefit.
The decision to prescribe antihypertensive medication should not be based simply on a diagnosis of cardiovascular disease or the blood pressure level recorded. Treatment seems to benefit all patients, regardless of those parameters.
According to the main investigator for this study, Dr. Kazem Rahimi, these agents should not be called ‘antihypertensive’ anymore and become ‘risk-modifying’ medications.
As thresholds to consider a patient as hypertensive, European guidelines recommend systolic BPs over 140 mmHg, while US guidelines lower the mark to 130 mmHg.
This work, Blood Pressure Lowering Treatment Trialists Collaboration (BPLTTC), analyzed 348,854 patients from 48 randomized clinical trials. Patients were grouped according to prior diagnosis of cardiovascular disease and then stratified in 7 blood pressure levels (from <120 mmHg up to >170 mmHg).
For every 5-mmHg reduction in blood pressure due to antihypertensive treatment, there was a benefit over 5 years of follow-up. Presence or absence of cardiovascular disease did not modify such benefit in relative terms, and neither did the baseline blood pressure level.
This study shows that the benefit of antihypertensive treatment is proportional to the intensity of systolic blood pressure reduction. The greater the reduction, the greater the benefit.
Each 5-mmHg reduction of systolic blood pressure reduces the risk of major cardiovascular events by 10%, stroke by 13%, heart failure by 14%, ischemic heart disease by 7%, and, finally, cardiovascular death by 5%. This 5-mmHg reduction benefited even patients with <120-mmHg systolic blood pressure at baseline.
There may be some differences depending on the type of antihypertensive drug. Calcium channel blockers may be less effective for the prevention of heart failure but more effective in the reduction of stroke events. The reverse might be true for diuretics.
There is another discussion regarding absolute benefit. If the patient is very young, with no comorbidities or cardiovascular risk factors, the absolute benefit obtained will be very low and will have to be considered against possible drug side effects and costs.
Original Title: Pharmacological blood pressure-lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure.
Reference: Rahimi K. Presentado en forma virtual en el congreso ESC 2020.
We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.