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Published on: May 17, 2024
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Pharmacotherapy for mild hypertension.
Dominic Wang1, James M Wright2, Stephen P Adams2
1Department of Medicine, University of British Columbia, Vancouver, Canada.
The Cochrane Database of Systematic Reviews
|April 2, 2026
Summary
Initiating antihypertensive therapy for mild hypertension may not lower mortality or cardiovascular events but could reduce stroke risk. However, it may increase withdrawal due to adverse effects (WDAEs).
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Mild hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) without cardiovascular disease lacks definitive treatment guidelines.
- Previous reviews showed no benefit of initiating antihypertensive therapy on mortality or cardiovascular events.
- Conflicting evidence necessitates an updated assessment of pharmacotherapy's efficacy and risks.
Purpose of the Study:
- To reassess the efficacy and risks of initiating antihypertensive pharmacotherapy in adults with untreated mild hypertension and no pre-existing cardiovascular disease.
- Primary objective: evaluate impact on all-cause mortality and total cardiovascular events (stroke, myocardial infarction, heart failure).
- Secondary objectives: evaluate impact on stroke, coronary heart disease, and withdrawal due to adverse effects (WDAEs).
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs) with at least one-year duration.
- Searched multiple databases including Cochrane Hypertension, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP up to June 2024.
- Individual patient data from five trials (9124 participants) were analyzed using fixed-effect models; risk of bias assessed with Cochrane's RoB 1 tool.
Main Results:
- Antihypertensive initiation showed low-certainty evidence for little to no reduction in all-cause mortality (RR 0.85), total cardiovascular events (RR 0.93), and coronary heart disease (RR 1.12).
- A potential reduction in stroke risk was observed (RR 0.41), but with low-certainty evidence.
- A significant increase in withdrawal due to adverse effects (WDAEs) was noted (RR 4.80), with low-certainty evidence.
Conclusions:
- Initiating antihypertensive therapy in mild, untreated hypertension without cardiovascular disease may not reduce mortality, total cardiovascular events, or coronary heart disease.
- A possible reduction in stroke risk exists, but this is offset by a potential increase in WDAEs.
- The certainty of evidence for all outcomes was downgraded due to imprecision, indirectness, and risk of bias.
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