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More focus needed on prompt treatment to maintain lower BP in high-risk individuals

07 Dec 2018
The impacts of loosened blood pressure guidelines

Less focus must be given on pretreatment blood pressure (BP) levels, which rarely predict future untreated BP levels or rule out capacity to benefit from BP lowering in high cardiovascular risk patients, according to recent study. Focus must be directed instead on prompt, empirical treatment to maintain lower BP for individuals with high BP or high risk.

The investigators searched Medline until February 2018 for randomized trials of BP lowering with over 1,000 patient-years follow-up per group. They estimated baseline mean BP, follow-up mean (usual) BP among patients grouped by 10 mm Hg strata of baseline BP and evaluated the effects of BP lowering on coronary heart disease (CHD) and stroke according to these BP levels.

A total of 86 trials (n=349,488), with mean follow-up of 3.7 years, met the inclusion criteria. Most mean BP change was caused by regression to the mean rather than treatment.

At high baseline BP levels, much of the fall in BP was due to the downwards regression to the mean, even after rigorous hypertension diagnosis. At low baseline BP levels, upwards regression to the mean led to an increase in BP levels even in treatment groups.

In general, a reduction of 6/3 mm Hg in BP lowered CHD by 14 percent (95 percent CI, 11–17 percent) and stroke by 18 percent (15–22 percent). These treatment effects occurred at follow-up BP levels much closer to the mean than baseline BP levels. There was more evidence available in the SBP 130–129 mm Hg range than in any other range.

“Benefits were apparent in numerous high-risk patient groups with baseline mean SBP <140 mm Hg,” the investigators said.

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