BP-Lowering Therapy Reports New Benefits in Mild Hypertension

In addition to reducing blood pressure in patients with mild hypertension, blood pressure-lowering therapy may also decrease the likelihood of stroke and death in this patient population, according to new research.

Of the 1 billion people worldwide who have clinically abnormal blood pressure, most have no overt signs of cardiovascular disease and are classified as having grade 1 hypertension—a systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg.

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However, there’s been controversy about the clinical approach to take with this large group of patients because most trials of blood pressure-lowering drugs have enrolled patients with grade 2 or 3 hypertension or focused on high-risk individuals with established cardiovascular disease. 

But this new systematic review may finally provide more definitive answers about how best to manage these patients.

“This systematic review showed that blood pressure-lowering therapy is likely to prevent stroke and mortality in patients with uncomplicated mild hypertension,” says lead study author Johan Sundström, MD, PhD, of Uppsala University in Sweden. “Blood pressure-lowering drug therapy decreased strokes by 28%, cardiovascular deaths by 25%, and total deaths by 22%.” 

The review included 13 randomized controlled trials in more than 15,000 people with blood pressures in the grade 1 hypertension range and without previous known cardiovascular disease.

“A previous meta-analysis was unable to provide firm evidence for a beneficial effect of blood pressure-lowering treatment in uncomplicated mild hypertension, which may have been misinterpreted by some doctors and guideline authors as evidence of a lack of beneficial treatment effect,” Sundström said. “This patient group is large, and a comprehensive summary of the available evidence was badly needed. 

A major advantage of Sundström’s review over the preceding meta-analysis is that it included modern antihypertensive regimens. He also noted that their review nearly doubles the number of patients, quadruples the number of cardiovascular events, and provides data on endpoints not available in the prior meta-analysis.

All of the patients in the 13 trials they analyzed were randomly assigned to receive an antihypertensive drug and a more intense blood pressure-lowering regimen or to a placebo and a less intense blood pressure-lowering regimen.

They saw an average reduction in blood pressure of 3.6 mm Hg systolic and 2.4 mm Hg diastolic in the active groups of the studied. Over the course of 5 years, the active groups also had lower odds for stroke, cardiovascular death, and all-cause death as well as a trend toward lower odds for total cardiovascular events, coronary events, and heart failure, according to the researchers.

They concluded that these findings were consistent with those of large-scale trials of blood pressure reduction in patients with higher blood pressure and/or pre-existing cardiovascular disease.

“Considering the large number of patients with uncomplicated mild hypertension, blood pressure-lowering treatment decisions using an estimate of absolute risk is likely the best approach in these patients,” Sundström said.

He and his team are currently investigating the benefits of such an approach; however, they note that a definitive, adequately powered, large-scale trial in patients with uncomplicated mild hypertension would be an important addition to the evidence base.

“But as such a study is unlikely to ever happen, this review provides the best summary of the available evidence,” Sundström said.

—Colleen Mullarkey

Reference:

Sundström J, Arima H, Jackson R, et al. Effects of blood pressure reduction in mild hypertension: A systematic review and meta-analysis. Ann Intern Med. 2014 Dec 23 [epub ahead of print].