Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy

To investigate the screening performance of measuring blood pressure and other variables in identifying those who will develop, or die from, ischaemic heart disease and stroke. To quantify by how much drugs that lower blood pressure will reduce the risk of ischaemic heart disease and stroke in those designated 'screen positive'.

MEDLINE, Cochrane collaboration and Web of Science databases; Stroke registries; Health Survey for England; Office of National Statistics; BUPA (British United Provident Association) study.

Relevant cohort studies and randomised trials were identified and analysed. Statistical analysis was used to determine drug efficacy and adverse effects.

Lowering blood pressure by 5 mmHg diastolic reduces the risk of stroke by an estimated 34% and ischaemic heart disease by 21% from any pre-treatment level; there is no threshold. These estimates, from cohort studies, have been corroborated by the results of randomised trials in persons with high, average and below average levels of blood pressure. In spite of its importance in causing cardiovascular disease blood pressure is a poor predictor of cardiovascular events. Its poor screening performance is illustrated by the findings that in the largest cohort study, persons in the top 10% of the distribution of systolic blood pressure experienced only 21% of all ischaemic heart disease events and 28% of all strokes at a given age. Combining several reversible risk factors adds little to the screening performance of blood pressure alone; for example the 25% of men aged 5564 at highest computed risk (> or =1%) experience only 46% of all ischaemic heart disease events. The main methods of screening should be to identify all persons with a history of cardiovascular disease events (for example identifying patients at the time of hospital discharge following a first myocardial infarction detects 50% of all heart disease deaths in a population at a false positive rate of 12%), and to use a person's age. Identifying everyone with a history of myocardial infarction or stroke in a population and everyone aged 55 or more would include 98% of all deaths from ischaemic heart disease and stroke. The five main categories of blood pressure lowering drugs, thiazides, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II receptor antagonists and calcium channel blockers, significantly reduce blood pressure from all pre-treatment levels though the extent of the blood pressure reduction increased with pre-treatment blood pressure. The reductions were similar at standard dose for the five categories; average reduction was 9.1 systolic and 5 diastolic. The effect of combinations of two drugs on blood pressure was additive. No effect of age was apparent, given blood pressure. There were no serious metabolic consequences of using these drugs in standard dose.

The evidence presented indicates that three drugs in combination may reduce stroke by about two-thirds and ischaemic heart disease by half. The report suggests that the term hypertension should be avoided because it is not a disease and it implies another category (normotensives) who would not benefit from lowering blood pressure. Blood pressure reduction using combinations of safe, well-established drugs is effective in preventing cardiovascular events. It is therefore suggested that such preventive therapy be considered more widely in people who by virtue of existing disease or simply age are at risk of a heart attack or stroke regardless of initial blood pressure.