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Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data
Insights
Blood pressure-lowering drugs offer similar relative cardiovascular protection across all risk levels. However, absolute risk reduction increases with higher baseline cardiovascular risk, supporting risk-based treatment decisions.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Trials
Background:
- Investigating the proportionality of blood pressure-lowering drug benefits to baseline cardiovascular risk.
- Assessing the utility of absolute risk in guiding blood pressure-lowering therapy decisions, analogous to lipid-lowering therapy.
Purpose of the Study:
- To determine if blood pressure-lowering drug benefits align with baseline cardiovascular risk levels.
- To evaluate if absolute cardiovascular risk can inform treatment decisions for blood pressure management.
Main Methods:
- Meta-analysis of individual participant data from randomized controlled trials.
- Primary outcome: composite of major cardiovascular events (stroke, heart attack, heart failure, cardiovascular death).
- Participants stratified into four baseline 5-year cardiovascular risk categories (<11%, 11-15%, 15-21%, >21%).
Main Results:
- Analysis included 67,475 individuals from 11 trials.
- Blood pressure-lowering treatment showed similar relative risk reduction across all risk groups (13-18%).
- Absolute risk reduction increased with higher baseline risk, preventing more events in higher-risk individuals (14 to 38 events per 1000 patients over 5 years).
Conclusions:
- Blood pressure lowering provides consistent relative protection irrespective of baseline cardiovascular risk.
- Greater absolute risk reductions are achieved with blood pressure-lowering treatments in individuals with higher baseline cardiovascular risk.
- Utilizing predicted baseline cardiovascular disease risk equations is supported for informing treatment decisions.
Background:
We aimed to investigate whether the benefits of blood pressure-lowering drugs are proportional to baseline cardiovascular risk, to establish whether absolute risk could be used to inform treatment decisions for blood pressure-lowering therapy, as is recommended for lipid-lowering therapy.
Methods:
This meta-analysis included individual participant data from trials that randomly assigned patients to either blood pressure-lowering drugs or placebo, or to more intensive or less intensive blood pressure-lowering regimens. The primary outcome was total major cardiovascular events, consisting of stroke, heart attack, heart failure, or cardiovascular death. Participants were separated into four categories of baseline 5-year major cardiovascular risk using a risk prediction equation developed from the placebo groups of the included trials (<11%, 11-15%, 15-21%, >21%).
Findings:
11 trials and 26 randomised groups met the inclusion criteria, and included 67,475 individuals, of whom 51,917 had available data for the calculation of the risk equations. 4167 (8%) had a cardiovascular event during a median of 4·0 years (IQR 3·4-4·4) of follow-up. The mean estimated baseline levels of 5-year cardiovascular risk for each of the four risk groups were 6·0% (SD 2·0), 12·1% (1·5), 17·7% (1·7), and 26·8% (5·4). In each consecutive higher risk group, blood pressure-lowering treatment reduced the risk of cardiovascular events relatively by 18% (95% CI 7-27), 15% (4-25), 13% (2-22), and 15% (5-24), respectively (p=0·30 for trend). However, in absolute terms, treating 1000 patients in each group with blood pressure-lowering treatment for 5 years would prevent 14 (95% CI 8-21), 20 (8-31), 24 (8-40), and 38 (16-61) cardiovascular events, respectively (p=0·04 for trend).
Interpretation:
Lowering blood pressure provides similar relative protection at all levels of baseline cardiovascular risk, but progressively greater absolute risk reductions as baseline risk increases. These results support the use of predicted baseline cardiovascular disease risk equations to inform blood pressure-lowering treatment decisions.
Funding:
None.
