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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
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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:
  • Albuminuria - complications
  • Albuminuria - physiopathology
  • Analysis
  • Antihypertensive Agents - adverse effects
  • Antihypertensive Agents - therapeutic use
  • Australia
  • Blood pressure
  • Blood Pressure - drug effects
  • Blood Pressure Determination
  • Cardiovascular disease
  • Critical Care - methods
  • Critical Care - standards
  • Diabetes
  • 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
  • Medical research
  • Medical treatment
  • Mortality
  • Myocardial Infarction - complications
  • Myocardial Infarction - physiopathology
  • Practice Guidelines as Topic
  • Randomized Controlled Trials as Topic
  • Stroke - complications
  • Stroke - physiopathology
  • Studies
  • Systematic review
  • 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
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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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subjectAlbuminuria - complications ; Albuminuria - physiopathology ; Analysis ; Antihypertensive Agents - adverse effects ; Antihypertensive Agents - therapeutic use ; Australia ; Blood pressure ; Blood Pressure - drug effects ; Blood Pressure Determination ; Cardiovascular disease ; Critical Care - methods ; Critical Care - standards ; Diabetes ; 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 ; Medical research ; Medical treatment ; Mortality ; Myocardial Infarction - complications ; Myocardial Infarction - physiopathology ; Practice Guidelines as Topic ; Randomized Controlled Trials as Topic ; Stroke - complications ; Stroke - physiopathology ; Studies ; Systematic review ; Treatment Outcome
ispartofThe Lancet (British edition), 2016, Vol.387 (10017), p.435-443
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1Atkins, Emily, BHlthSc
2Lv, Jicheng, Prof
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4Neal, Bruce, Prof
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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0Albuminuria - complications
1Albuminuria - physiopathology
2Analysis
3Antihypertensive Agents - adverse effects
4Antihypertensive Agents - therapeutic use
5Australia
6Blood pressure
7Blood Pressure - drug effects
8Blood Pressure Determination
9Cardiovascular disease
10Critical Care - methods
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12Diabetes
13Humans
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15Hypertension - complications
16Hypertension - drug therapy
17Hypertensive Retinopathy - etiology
18Hypertensive Retinopathy - physiopathology
19Internal Medicine
20Kidney diseases
21Kidney Failure, Chronic - complications
22Kidney Failure, Chronic - physiopathology
23Medical research
24Medical treatment
25Mortality
26Myocardial Infarction - complications
27Myocardial Infarction - physiopathology
28Practice Guidelines as Topic
29Randomized Controlled Trials as Topic
30Stroke - complications
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32Studies
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34Treatment Outcome
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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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21Kidney Failure, Chronic - complications
22Kidney Failure, Chronic - physiopathology
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24Medical treatment
25Mortality
26Myocardial Infarction - complications
27Myocardial Infarction - physiopathology
28Practice Guidelines as Topic
29Randomized Controlled Trials as Topic
30Stroke - complications
31Stroke - physiopathology
32Studies
33Systematic review
34Treatment Outcome
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eissn1474-547X
codenLANCAO
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.
copEngland
pubElsevier Ltd
pmid26559744
doi10.1016/S0140-6736(15)00805-3
oafree_for_read