Elevated systolic blood pressure and risk of cardiovascular and renal disease: Overview of evidence from observational epidemiologic studies and randomized controlled trials☆,☆☆,★
Section snippets
Observational studies
Results from several prospective studies indicate that the association between systolic blood pressure and risk of CHD, stroke, and ESRD is continuous, graded and independent. Furthermore, they suggest that the association of systolic blood pressure with these outcomes is stronger than that of diastolic blood pressure. This evidence is summarized in the next three sections.
Randomized controlled trials
Over the past several decades, many antihypertensive drug treatment trials have been conducted to determine whether blood pressure reduction decreases the risk of cardiovascular disease.26 Results from these trials have been pooled in several meta-analyses to obtain a more precise and accurate estimate of the effect of antihypertensive treatment on clinical outcomes.3, 4, 26, 27 However, all of these meta-analyses have emphasized the effect of diastolic blood pressure reduction on the risk of
Characteristics of participants in 10 systolic blood pressure reduction trials
Characteristics of the 18,542 participants who were enrolled in these trials as well as important elements of the study design used in each trial are summarized in Table I.
Trial, year, and reference Sample size Entry SBP (mm Hg) Entry DBP (mm Hg) Mean age (years) Men (%) Mean follow-up (years) Blinding Main drug type(s)* Mean SBP reduction (mm Hg)† Mean DBP reduction (mm Hg)† Veterans Administration,
Effects of systolic blood pressure reduction on CHD and stroke
Overall, 412 CHD events occurred in the participants who were assigned to active treatment and 520 in those who were allocated to control (Table II). When the results from the 10 trials were pooled, a highly significant reduction in the odds of total and fatal CHD (both P < .001) was observed among the participants allocated to active treatment. The reduction in total CHD was 21% (95% confidence intervals [CI] 10% to 31%) and the reduction in fatal CHD was 27% (95% CI 13% to 38%). As shown in
Effects of systolic blood pressure reduction on death from cardiovascular disease and from all causes
Overall, 467 deaths from cardiovascular disease occurred in the participants who were allocated to active treatment and in 617 of their counterparts who were allocated to control (Table II). The overall reduction in cardiovascular disease mortality rates for active treatment compared with control was 25% (95% CI 15% to 34%; P < .001). In 5 of the 10 trials, the reduction in cardiovascular disease mortality rates was statistically significant (Figure 9).
Subgroup analysis
Reduction in CHD and stroke risk by hypertension status is presented in Table III.
Hypertension status and trial number Active treatment Control treatment % Risk reduction (95% CI) P value Fatal events Total events No. of participants Fatal events Total events No. of participants Fatal Total Fatal Total Coronary heart disease SDH (n = 8) 159 275 4515 225 333 4596 28 (12-42) 17 (2-29) .001 .03 ISH (n = 2) 91 137 4763 116 187 4668 23 (–1-42) 28 (10-43) .06
Conclusion
In conclusion, prospective observational studies have repeatedly demonstrated that systolic blood pressure is an independent and strong predictor of risk of CHD, stroke, and ESRD. Pooling of the data available from randomized controlled clinical trials indicates that an average reduction of 12 to 13 mm Hg in systolic pressure over 4 years of follow-up is associated with a 21% reduction in CHD, 37% reduction in stroke, 25% reduction in total cardiovascular mortality rate, and 13% reduction in
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From the Department of Biostatistics and Epidemiology, Tulane University School of Public Health and Tropical Medicine.
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Reprint requests: Jiang He, MD, PhD, Department of Biostatistics and Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1430 Tulane Ave, SL 18, New Orleans, LA 70112-2699. E-mail: [email protected]
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