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Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis

Summary Background Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lower... Full description

Journal Title: The Lancet (British edition) 2016, Vol.387 (10017), p.435-443
Main Author: Xie, Xinfang, MD
Other Authors: Atkins, Emily, BHlthSc , Lv, Jicheng, Prof , Bennett, Alexander, BMedSc , Neal, Bruce, Prof , Ninomiya, Toshiharu, Prof , Woodward, Mark, Prof , MacMahon, Stephen, Prof , Turnbull, Fiona, PhD , Hillis, Graham S, Prof , Chalmers, John, Prof , Mant, Jonathan, Prof , Salam, Abdul, MPharm , Rahimi, Kazem, Prof , Perkovic, Vlado, Prof , Rodgers, Anthony, Prof
Format: Electronic Article Electronic Article
Language: English
Subjects:
Quelle: Alma/SFX Local Collection
Publisher: England: Elsevier Ltd
ID: ISSN: 0140-6736
Link: https://www.ncbi.nlm.nih.gov/pubmed/26559744
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title: Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis
format: Article
creator:
  • Xie, Xinfang, MD
  • Atkins, Emily, BHlthSc
  • Lv, Jicheng, Prof
  • Bennett, Alexander, BMedSc
  • Neal, Bruce, Prof
  • Ninomiya, Toshiharu, Prof
  • Woodward, Mark, Prof
  • MacMahon, Stephen, Prof
  • Turnbull, Fiona, PhD
  • Hillis, Graham S, Prof
  • Chalmers, John, Prof
  • Mant, Jonathan, Prof
  • Salam, Abdul, MPharm
  • Rahimi, Kazem, Prof
  • Perkovic, Vlado, Prof
  • Rodgers, Anthony, Prof
subjects:
  • Abridged Index Medicus
  • Albuminuria - complications
  • Albuminuria - physiopathology
  • Analysis
  • Antihypertensive Agents - adverse effects
  • Antihypertensive Agents - therapeutic use
  • Australia
  • Blood pressure
  • Blood Pressure - drug effects
  • Blood Pressure Determination
  • Critical Care - methods
  • Critical Care - standards
  • Humans
  • Hypertension
  • Hypertension - complications
  • Hypertension - drug therapy
  • Hypertensive Retinopathy - etiology
  • Hypertensive Retinopathy - physiopathology
  • Internal Medicine
  • Kidney diseases
  • Kidney Failure, Chronic - complications
  • Kidney Failure, Chronic - physiopathology
  • Myocardial Infarction - complications
  • Myocardial Infarction - physiopathology
  • Practice Guidelines as Topic
  • Randomized Controlled Trials as Topic
  • Stroke - complications
  • Stroke - physiopathology
  • Treatment Outcome
ispartof: The Lancet (British edition), 2016, Vol.387 (10017), p.435-443
description: Summary Background Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies. Methods For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined), and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes. Findings We identified 19 trials including 44 989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3·8 years of follow-up (range 1·0–8·4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4–22]), myocardial infarction (13% [0–24]), stroke (22% [10–32]), albuminuria (10% [3–16]), and retinopathy progression (19% [0–34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI −11 to 34]), cardiovascular death (9% [–11 to 26]), total mortality (9% [–3 to 19]), or end-stage kidney disease (10% [–6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. The absolute ben
language: eng
source: Alma/SFX Local Collection
identifier: ISSN: 0140-6736
fulltext: fulltext
issn:
  • 0140-6736
  • 1474-547X
url: Link


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titleEffects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis
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creatorXie, Xinfang, MD ; Atkins, Emily, BHlthSc ; Lv, Jicheng, Prof ; Bennett, Alexander, BMedSc ; Neal, Bruce, Prof ; Ninomiya, Toshiharu, Prof ; Woodward, Mark, Prof ; MacMahon, Stephen, Prof ; Turnbull, Fiona, PhD ; Hillis, Graham S, Prof ; Chalmers, John, Prof ; Mant, Jonathan, Prof ; Salam, Abdul, MPharm ; Rahimi, Kazem, Prof ; Perkovic, Vlado, Prof ; Rodgers, Anthony, Prof
creatorcontribXie, Xinfang, MD ; Atkins, Emily, BHlthSc ; Lv, Jicheng, Prof ; Bennett, Alexander, BMedSc ; Neal, Bruce, Prof ; Ninomiya, Toshiharu, Prof ; Woodward, Mark, Prof ; MacMahon, Stephen, Prof ; Turnbull, Fiona, PhD ; Hillis, Graham S, Prof ; Chalmers, John, Prof ; Mant, Jonathan, Prof ; Salam, Abdul, MPharm ; Rahimi, Kazem, Prof ; Perkovic, Vlado, Prof ; Rodgers, Anthony, Prof
descriptionSummary Background Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies. Methods For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined), and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes. Findings We identified 19 trials including 44 989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3·8 years of follow-up (range 1·0–8·4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4–22]), myocardial infarction (13% [0–24]), stroke (22% [10–32]), albuminuria (10% [3–16]), and retinopathy progression (19% [0–34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI −11 to 34]), cardiovascular death (9% [–11 to 26]), total mortality (9% [–3 to 19]), or end-stage kidney disease (10% [–6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes. Serious adverse events associated with blood pressure lowering were only reported by six trials and had an event rate of 1·2% per year in intensive blood pressure-lowering group participants, compared with 0·9% in the less intensive treatment group (RR 1·35 [95% CI 0·93–1·97]). Severe hypotension was more frequent in the more intensive treatment regimen (RR 2·68 [1·21–5·89], p=0·015), but the absolute excess was small (0·3% vs 0·1% per person-year for the duration of follow-up). Interpretation Intensive blood pressure lowering provided greater vascular protection than standard regimens. In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg. The net absolute benefits of intensive blood pressure lowering in high-risk individuals are large. Funding National Health and Medical Research Council of Australia.
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languageeng
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subjectAbridged Index Medicus ; Albuminuria - complications ; Albuminuria - physiopathology ; Analysis ; Antihypertensive Agents - adverse effects ; Antihypertensive Agents - therapeutic use ; Australia ; Blood pressure ; Blood Pressure - drug effects ; Blood Pressure Determination ; Critical Care - methods ; Critical Care - standards ; Humans ; Hypertension ; Hypertension - complications ; Hypertension - drug therapy ; Hypertensive Retinopathy - etiology ; Hypertensive Retinopathy - physiopathology ; Internal Medicine ; Kidney diseases ; Kidney Failure, Chronic - complications ; Kidney Failure, Chronic - physiopathology ; Myocardial Infarction - complications ; Myocardial Infarction - physiopathology ; Practice Guidelines as Topic ; Randomized Controlled Trials as Topic ; Stroke - complications ; Stroke - physiopathology ; Treatment Outcome
ispartofThe Lancet (British edition), 2016, Vol.387 (10017), p.435-443
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1Atkins, Emily, BHlthSc
2Lv, Jicheng, Prof
3Bennett, Alexander, BMedSc
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5Ninomiya, Toshiharu, Prof
6Woodward, Mark, Prof
7MacMahon, Stephen, Prof
8Turnbull, Fiona, PhD
9Hillis, Graham S, Prof
10Chalmers, John, Prof
11Mant, Jonathan, Prof
12Salam, Abdul, MPharm
13Rahimi, Kazem, Prof
14Perkovic, Vlado, Prof
15Rodgers, Anthony, Prof
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0Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis
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descriptionSummary Background Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies. Methods For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined), and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes. Findings We identified 19 trials including 44 989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3·8 years of follow-up (range 1·0–8·4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4–22]), myocardial infarction (13% [0–24]), stroke (22% [10–32]), albuminuria (10% [3–16]), and retinopathy progression (19% [0–34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI −11 to 34]), cardiovascular death (9% [–11 to 26]), total mortality (9% [–3 to 19]), or end-stage kidney disease (10% [–6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes. Serious adverse events associated with blood pressure lowering were only reported by six trials and had an event rate of 1·2% per year in intensive blood pressure-lowering group participants, compared with 0·9% in the less intensive treatment group (RR 1·35 [95% CI 0·93–1·97]). Severe hypotension was more frequent in the more intensive treatment regimen (RR 2·68 [1·21–5·89], p=0·015), but the absolute excess was small (0·3% vs 0·1% per person-year for the duration of follow-up). Interpretation Intensive blood pressure lowering provided greater vascular protection than standard regimens. In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg. The net absolute benefits of intensive blood pressure lowering in high-risk individuals are large. Funding National Health and Medical Research Council of Australia.
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0Abridged Index Medicus
1Albuminuria - complications
2Albuminuria - physiopathology
3Analysis
4Antihypertensive Agents - adverse effects
5Antihypertensive Agents - therapeutic use
6Australia
7Blood pressure
8Blood Pressure - drug effects
9Blood Pressure Determination
10Critical Care - methods
11Critical Care - standards
12Humans
13Hypertension
14Hypertension - complications
15Hypertension - drug therapy
16Hypertensive Retinopathy - etiology
17Hypertensive Retinopathy - physiopathology
18Internal Medicine
19Kidney diseases
20Kidney Failure, Chronic - complications
21Kidney Failure, Chronic - physiopathology
22Myocardial Infarction - complications
23Myocardial Infarction - physiopathology
24Practice Guidelines as Topic
25Randomized Controlled Trials as Topic
26Stroke - complications
27Stroke - physiopathology
28Treatment Outcome
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12Salam, Abdul, MPharm
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titleEffects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis
authorXie, Xinfang, MD ; Atkins, Emily, BHlthSc ; Lv, Jicheng, Prof ; Bennett, Alexander, BMedSc ; Neal, Bruce, Prof ; Ninomiya, Toshiharu, Prof ; Woodward, Mark, Prof ; MacMahon, Stephen, Prof ; Turnbull, Fiona, PhD ; Hillis, Graham S, Prof ; Chalmers, John, Prof ; Mant, Jonathan, Prof ; Salam, Abdul, MPharm ; Rahimi, Kazem, Prof ; Perkovic, Vlado, Prof ; Rodgers, Anthony, Prof
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5Antihypertensive Agents - therapeutic use
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7Blood pressure
8Blood Pressure - drug effects
9Blood Pressure Determination
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16Hypertensive Retinopathy - etiology
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18Internal Medicine
19Kidney diseases
20Kidney Failure, Chronic - complications
21Kidney Failure, Chronic - physiopathology
22Myocardial Infarction - complications
23Myocardial Infarction - physiopathology
24Practice Guidelines as Topic
25Randomized Controlled Trials as Topic
26Stroke - complications
27Stroke - physiopathology
28Treatment Outcome
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abstractSummary Background Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies. Methods For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined), and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes. Findings We identified 19 trials including 44 989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3·8 years of follow-up (range 1·0–8·4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4–22]), myocardial infarction (13% [0–24]), stroke (22% [10–32]), albuminuria (10% [3–16]), and retinopathy progression (19% [0–34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI −11 to 34]), cardiovascular death (9% [–11 to 26]), total mortality (9% [–3 to 19]), or end-stage kidney disease (10% [–6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes. Serious adverse events associated with blood pressure lowering were only reported by six trials and had an event rate of 1·2% per year in intensive blood pressure-lowering group participants, compared with 0·9% in the less intensive treatment group (RR 1·35 [95% CI 0·93–1·97]). Severe hypotension was more frequent in the more intensive treatment regimen (RR 2·68 [1·21–5·89], p=0·015), but the absolute excess was small (0·3% vs 0·1% per person-year for the duration of follow-up). Interpretation Intensive blood pressure lowering provided greater vascular protection than standard regimens. In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg. The net absolute benefits of intensive blood pressure lowering in high-risk individuals are large. Funding National Health and Medical Research Council of Australia.
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