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Blood pressure lowering in isolated diastolic hypertension and cardiovascular risk: an individual patient data
Zeinab Bidel1, Milad Nazarzadeh1, Dexter Canoy2
1Deep Medicine, Nuffield Department of Women's & Reproductive Health, Medical Sciences Division, University of Oxford, Second Floor, Osney One Building, Osney Mead, Oxford, OX2 0EW, UK.
Insights
Treating isolated diastolic hypertension (IDH) with blood pressure-lowering medication is as effective as in patients without IDH. These benefits persist even with lower diastolic blood pressure levels.
Area of Science:
- Cardiology
- Hypertension Research
- Clinical Trials
Background:
- Blood pressure lowering significantly reduces cardiovascular disease (CVD) risk.
- The efficacy of treating normal systolic blood pressure with elevated diastolic blood pressure, known as isolated diastolic hypertension (IDH), remains unclear.
Purpose of the Study:
- To investigate the effectiveness of blood pressure-lowering treatments in individuals with and without isolated diastolic hypertension (IDH).
- To analyze treatment effects across various baseline diastolic blood pressure levels in individuals with normal systolic blood pressure.
Main Methods:
- A meta-analysis of individual participant data from 51 randomized controlled trials.
- Included 358,325 participants, with 15,845 identified as having IDH (systolic BP < 130 mmHg and diastolic BP ≥ 80 mmHg).
- Used Cox proportional hazard models to analyze BP-lowering effects, stratified by trial and baseline diastolic BP categories.
Main Results:
- A 5 mmHg systolic blood pressure reduction similarly lowered major cardiovascular event risk in individuals with IDH (HR 0.91) and without IDH (HR 0.90).
- No significant heterogeneity in treatment effects was observed across different baseline diastolic blood pressure levels (down to <60 mmHg) among individuals with systolic BP < 130 mmHg.
- Treatment effects were consistent regardless of CVD history, age, prior medication use, or BP measurement methods.
Conclusions:
- Pharmacological blood pressure-lowering therapy demonstrates comparable effectiveness in individuals with and without isolated diastolic hypertension (IDH).
- The relative risk reductions for cardiovascular events do not diminish with lower baseline diastolic blood pressure levels.
- No significant differences in treatment effectiveness were detected across various clinical phenotypes.
Background And Aims:
Blood pressure (BP) lowering reduces cardiovascular disease (CVD) risk; however, the benefits of treating patients with normal systolic BP but elevated diastolic BP remain uncertain.
Methods:
Data from 51 randomized controlled trials were pooled to compare BP-lowering effects in participants with and without isolated diastolic hypertension (IDH), defined as systolic BP < 130 mmHg and diastolic BP ≥ 80 mmHg. Treatment effects were stratified across baseline diastolic BP categories (range < 60 to ≥90 mmHg) among individuals with baseline systolic BP < 130 mmHg. Fixed-effect one-stage individual participant data meta-analyses were used, and Cox proportional hazard models, stratified by trial, were applied to analyse the data.
Results:
Among 358 325 participants, 15 845 (4.4%) had IDH. At a median follow-up of 4.2 years, a 5 mmHg reduction in systolic BP reduced the risk of major cardiovascular events similarly in individuals with IDH [hazard ratio 0.91; 95% confidence interval (CI) 0.82-1.01] and those without IDH (hazard ratio 0.90; 95% CI 0.89-0.92; P for interaction = 1.00). Analyses by baseline diastolic BP showed no evidence of heterogeneity in treatment effects among individuals with baseline systolic BP < 130 mmHg (P for interaction = .26). Relative treatment effects were not statistically different by CVD history, age, prior medication use, and BP measurement methods.
Conclusions:
The study found no evidence to suggest that pharmacological BP-lowering therapy in individuals with IDH is less or more effective than in those without IDH. Relative risk reductions also did not diminish in those with lower diastolic BP, down to <60 mmHg at baseline. No meaningful differences across various clinical phenotypes were detected.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.