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Researchers call for ‘urgent’ review of BP guidelines

Treatment below current targets significantly reduces the risk of cardiovascular events and death

Mark Gould

Thursday, 24 December 2015

Researchers are calling for an "urgent" revision of both NICE and European Society of Hypertension blood pressure-lowering guidelines. Writing in The Lancet they say that their work reveals that blood pressure-lowering drugs should be offered to all individuals at high risk of having a heart attack or stroke regardless of their blood pressure at the start of treatment.

In the study,* the largest meta-analysis to date involving over 600,000 people, Professor Kazem Rahimi from The George Institute for Global Health at Oxford University and colleagues analysed the findings of 123 large-scale randomised trials comparing different blood pressure targets from January 1966 to July 2015.

They found that treatment with any of the main classes of blood pressure-lowering drugs significantly reduced the risk of major cardiovascular events, stroke, heart failure, and death, proportional to the extent to which blood pressure was lowered. Overall, every 10 mmHg reduction in systolic blood pressure reduced the risks of major cardiovascular disease events and heart disease by about one fifth, and stroke and heart failure by about a quarter, and the risk of death from any cause by 13%.

Importantly, they say these reductions in disease were similar across a wide range of high-risk patients including those with a history of cardiovascular disease, heart failure, diabetes, and kidney disease, irrespective of whether their blood pressure was already low (less than 130 mmHg) to begin with.

The authors call for an urgent revision of current blood pressure-lowering guidelines that have recently relaxed blood pressure targets from 130/85 mmHg to 140/90 mmHg, and for the elderly to even higher targets of 150/90 mmHg. They also recommend a shift from rigid blood pressure targets to individualised risk-based targets, even when blood pressure is below 130 mmHg before treatment.

None of the five major drug classes examined was found to be better than another at protecting against cardiovascular events, with a few exceptions—an extra protective effect of calcium channel blockers in preventing stroke, an extra effect of diuretics in preventing heart failure, and a weaker effect of beta blockers in preventing major cardiovascular outcomes, stroke, and renal failure, and a significantly increased risk of death in some patients, when compared with other drug classes.

“Our findings clearly show that treating blood pressure to a lower level than currently recommended could greatly reduce the incidence of cardiovascular disease and potentially save millions of lives if the treatment was widely implemented. The results provide strong support for reducing systolic blood pressure to less than 130 mmHg, and blood pressure-lowering drugs should be offered to all patients at high risk of having a heart attack or stroke, whatever their reason for being at risk," Prof Rahimi said.

Prof Liam Smeeth, of the London School of Hygiene and Tropical Medicine, told the BBC that he agreed the findings were important for those at highest risk. But he warned: "One important caveat is that not everyone will be able to tolerate having their blood pressure reduced to low levels, and there is a need to balance possible drug side effects and likely benefits."


* Ettehad D, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet, December 2015. DOI: 10.1016/S0140-6736(15)01225-8

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