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Systolic blood pressure at least 140 mm Hg best place to begin treatment
Clinical Question
At what systolic blood pressure should we begin treatment for the most benefit?
Bottom line
Beginning antihypertensive treatment when the systolic blood pressure (SBP) is greater than 140 mm Hg delays death and prevents major cardiovascular events in some people without pre-existing heart disease; in patients with existing heart disease it prevents further events, but does not extend life. These results may appear to conflict with those from SPRINT trial, which found benefit with lowering SBP to below 120 mm Hg. However, the SPRINT investigators measured blood pressure using automated devices which give readings 10 mm Hg to 20 mm Hg lower than typical office measurements. So, the goal of less than 120 mm Hg in the SPRINT study is likely to be very similar to the goal of less than 140 mm Hg in this study. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Foundation
Setting: Various (meta-analysis)
Synopsis
The authors followed PRISMA guidelines to search 3 databases, including Cochrane CENTRAL, as well as reference lists of identified studies to identify all randomized trials with at least 1000 patient-years of follow-up that compared drug treatment with placebo or compared blood pressure targets against one another. Two researchers independently extracted the data and assessed the quality of the research (more than two-thirds of the studies had a low risk of bias). They identified 74 studies enrolling 306,273 patients (60.1% men, average age 63.6 years). In patients without pre-existing heart disease (ie, primary prevention), lowering SBP that was initially greater than 140 mm Hg decreased the risk of death (relative risk [RR] = .93, 95% CI -.88 to 1.0 if SBP > 160 mm Hg; RR = 0.87, .75 to 1.00 if SBP 140 - 159 mm Hg) and major cardiovascular events (RR = .78, .7 to .87 if > 160 mm Hg; RR = .88, .8 - .96 if 140 - 159 mm Hg). Treating SBP that was initially less than 140 mm Hg did not affect morbidity or mortality. In patients with previous coronary heart disease and a mean SBP of 138 mm Hg, treatment reduced the risk for further major cardiovascular events (RR = .9; .84 to .97), but did not extend life. There was a high degree of heterogeneity among these trial results, reducing our confidence in the results. There was some evidence of publication bias in studies that evaluated the effect on major cardiovascular events, meaning that studies failing to show a difference in outcomes were not published.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Perfect. I am going back to 140 and will get a whole bunch of overly worried patients off of unneccessary drugs because their BP is 125. Mitigating the worry alone will improve their life spans.
This is the same parameter that I have been thought 50 yrs ago in Med school although on untreated elderly with higher systolic pressure one should be carefull and lower systolic slowly according patient tolerance , and be aware that sometimes it is not feasible to achieve ideal ideal lower bp in untreated elderly.
Again, honest disclosure of publication bias by the reviewers is appreciated
Good poem
I think info on ARR is needed. RRR looks good in those with sBP of 140-160, but what is the baseline risk in that cohort? That is relevant to determining if it is worth initiating Rx.