Cochrane for Clinicians

Putting Evidence into Practice

Blood Pressure Targets for Patients with Hypertension and Cardiovascular Disease

 

Am Fam Physician. 2018 Sep 1;98(5):276-277.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are lower blood pressure (BP) targets for patients with hypertension and a history of cardiovascular disease associated with decreased morbidity and mortality?

Evidence-Based Answer

Achieving a target BP of 135/85 mm Hg or less does not decrease the risk of total cardiovascular events vs. treating to a target of 140 to 160/90 to 100 mm Hg. Further, treating to the lower BP target does not improve total mortality, cardiovascular mortality, or serious adverse effects. More patients discontinue treatment because of adverse effects when treated to the lower BP target.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

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SUMMARY TABLE: STANDARD VS. LOWER BP TARGETS IN PATIENTS WITH HYPERTENSION AND CARDIOVASCULAR DISEASE

Outcomes (average of 4 years)Risk with standard BP target (≤ 140 to 160/90 to 100 mm Hg)Risk with lower BP target (≤ 135/85 mm Hg)NNT or NNH (95% CI)Number of participants (number of studies)Quality of evidence

Total mortality

68 per 1,000

72 per 1,000

NA*

9,484 (6)

Moderate

Serious adverse effects

252 per 1,000

255 per 1,000

NA*

9,484 (6)

Low

Total CV events

127 per 1,000

113 per 1,000

NA*

9,484 (6)

Low

CV mortality

31 per 1,000

32 per 1,000

NA*

9,484 (6)

Moderate

Withdrawals because of adverse effects

7 per 1,000

60 per 1,000

19 (4 to 111)

690 (2)

Very low


BP = blood pressure; CI = confidence interval; CV = cardiovascular; NA = not applicable; NNH = number needed to harm; NNT = number needed to treat.

*—No statistical difference in outcomes.

SUMMARY TABLE: STANDARD VS. LOWER BP TARGETS IN PATIENTS WITH HYPERTENSION AND CARDIOVASCULAR DISEASE

Outcomes (average of 4 years)Risk with standard BP target (≤ 140 to 160/90 to 100 mm Hg)Risk with lower BP target (≤ 135/85 mm Hg)NNT or NNH (95% CI)Number of participants (number of studies)Quality of evidence

Total mortality

68 per 1,000

72 per 1,000

NA*

9,484 (6)

Moderate

Serious adverse effects

252 per 1,000

255 per 1,000

NA*

9,484 (6)

Low

Total CV events

127 per 1,000

113 per 1,000

NA*

9,484 (6)

Low

CV mortality

31 per 1,000

32 per 1,000

NA*

9,484 (6)

Moderate

Withdrawals because of adverse effects

7 per 1,000

60 per 1,000

19 (4 to 111)

690 (2)

Very low


BP = blood pressure; CI = confidence interval; CV = cardiovascular; NA = not applicable; NNH = number needed to harm; NNT = number needed to treat.

*—No statistical difference in outcomes.

Practice Pointers

From 2007 to 2014, the age-adjusted prevalence of hypertension was 29.6% in the United States. Of those patients with hypertension, only 75% were receiving treatment and only 51.8% had their hypertension under control.2 Between 2003 and 2013, the death rate attributable to hypertension increased by 8.2%.3 During this time, the goal of hypertension treatment was a BP of 140/90 mm Hg or less, but this Cochrane review looked at lower BP targets for patients with a history of cardiovascular disease to determine if there is added benefit with more aggressive treatment.1

This Cochrane review included six randomized controlled trials and 9,484 patients. Participants were being treated for hypertension and had a documented cardiovascular history of myocardial infarction, stroke, ischemic heart disease, peripheral vascular disease, or angina. The intervention was a lower BP target (135/85 mm Hg or less) vs. standard BP targets (140 to 160/90 to 100 mm Hg or less). Primary outcomes included total and cardiovascular mortality, serious adverse effects, and total cardiovascular events, defined as the number of parti

Author disclosure: No relevant financial affiliations.


The practice recommendations in this activity are available at http://www.cochrane.org/CD010315.

Editor's Note: The numbers needed to treat/numbers needed to harm reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, the U.S. Army, the U.S. Air Force, or the Uniformed Services University of the Health Sciences.

References

show all references

1. Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev. 2018;(7):CD010315....

2. Hales CM, Carroll MD, Simon PA, Kuo T, Ogden CL. Hypertension prevalence, awareness, treatment, and control among adults aged ≥ 18 years—Los Angeles County, 1999–2006 and 2007–2014. MMWR Morb Mortal Wkly Rep. 2017;66(32):846–849.

3. Mozaffarian D, Benjamin EJ, Go AS, et al.; American Heart Association Statistics Committee; Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics–2016 update: a report from the American Heart Association. Circulation. 2016;133(4):447–454.

4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2018;71(19): 2275–2279]. J Am Coll Cardiol. 2018;71(19):e127–e248.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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