Top POEMs of 2015: Cardiovascular Disease

Top 20 POEMs of 2015

Some Benefit to Treating Mild Hypertension to Prevent Stroke, CV Deaths, and Overall Mortality

Clinical question
What are the benefits of treating mild hypertension?

Bottom line
Treating mild hypertension over 5 years decreases the risk of stroke, cardiovascular death, and overall mortality in a small proportion of patients. The numbers needed to treat (NNT) — the numbers of patients who need to be treated to prevent one additional outcome from occurring — are below. Pay attention to the confidence intervals (CIs), which tell us the best case/worst case possibilities. Also note that some of these intervals are very large, meaning that we can't place much confidence in the reported NNT. (LOE = 1a)(

Sundstrom J, Arima H, Jackson R, et al, for the Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of blood pressure reduction in mild hypertension: A systematic review and meta-analysis. Ann Intern Med 2015;162(3):184-191.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

The authors used the literature search results of a previous Cochrane meta-analysis and updated it by searching several databases. They included studies that lasted at least 1 year and evaluated treatment of grade 1 hypertension (range = 140/90 mmHg to 159/99 mmHg) in patients with no previous cardiac disease. They were able to use individual patient data (instead of comparing only the results across studies) for a total of 15,266 patients. The risk of bias in the studies was low. The research included single drug treatment and stepped-care approaches. Over an average 5 years of treatment there was no significant decrease in overall cardiovascular events, coronary events, or, predictably, heart failure. The likelihood of a stroke, death due to a cardiovascular event, or all-cause mortality was lower with treatment (see below). Overall, 5.6% of patients withdrew from treatment because of adverse effects (number needed to treat to harm = 36, 95% CI 23-75). NNT for 5 years (95% CI): Stroke: 173 (108-810) Cardiovascular death: 95 (55-1188) Overall mortality: 99 (66-273) Heart failure: not significant Coronary events: not significant

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Low-Dose Aspirin Not Effective for Primary Prevention of CV Events (Again) and Increases Risk of Serious Bleeding

Clinical question
Is low-dose aspirin beneficial for the primary prevention of cardiovascular disease in high-risk older adults with atherosclerotic risk factors?

Bottom line
A systematic review/meta-analysis published in 2011 (Am Heart J 2011;162(1):115-124.e2) based on 9 studies of more than 100,000 patients found no overall benefit to aspirin for the primary prevention of cardiovascular events in patients without clinical cardiovascular disease (CVD). This recent study of high-risk older adults in Japan similarly found no benefit to low-dose aspirin, including in the subgroups of hypertension, hyperlipidemia, diabetes, obesity, male gender, smoking, and family history of CVD. The risks of major gastrointestinal bleeding and brain hemorrhage were significantly increased. It's time to let this one go. (LOE = 1b-)(

Ikeda Y, Shimada K, Teramoto T, et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors. A randomized clinical trial. JAMA 2014;312(23):2510-2520.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

These investigators identified consecutive adults, aged 60 to 85 years, presenting to their local health clinic in Japan with a history of hypertension, dyslipidemia, or diabetes, but with no history of atherosclerotic disease, including coronary artery disease, cerebrovascular disease (including transient ischemic attack), vascular disease requiring surgery or intervention, or atrial fibrillation. Patients with a history of gastrointestinal bleeding or bleeding diathesis were excluded. Eligible patients (N = 14,658) received standard treatment for cardiac risk factors and randomly received (concealed allocation assignment) 100 mg enteric-coated aspirin daily or no aspirin in an open-label fashion. Individuals who assessed outcomes remained masked to treatment group assignment. Complete follow-up occurred for nearly 90% of patients at 5 years. Using intention-to-treat analysis, no significant differences occurred between the 2 groups in the primary end point of the composite of death from cardiovascular causes, nonfatal stroke, and nonfatal myocardial infarction. The individual outcomes of nonfatal myocardial infarction and transient ischemic attack were significantly lower in the aspirin group, but gastrointestinal bleeding events and serious extracranial hemorrhage requiring hospitalization were also significantly increased with daily aspirin use. No overall significant differences occurred for all-cause mortality between groups. Finally, no differences were detected between the 2 groups when doing subgroup analyses for specific risk factors, including hypertension, dyslipidemia, diabetes, male sex, aged at least 70 years, body mass index, smoking, or family history of CVD.

David Slawson, MD
Director of Information Sciences
University of Virginia Health System
Charlottesville, VA

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