Blood pressure-lowering treatment strategies based on cardiovascular risk versus blood pressure: A meta-analysis of individual participant data

• Published in: PLoS medicine 2018-03, Vol.15 (3), p.e1002538-e1002538
• Main Authors: Karmali, Kunal N, Lloyd-Jones, Donald M, van der Leeuw, Joep, Goff, Jr, David C, Yusuf, Salim, Zanchetti, Alberto, Glasziou, Paul, Jackson, Rodney, Woodward, Mark, Rodgers, Anthony, Neal, Bruce C, Berge, Eivind, Teo, Koon, Davis, Barry R, Chalmers, John, Pepine, Carl, Rahimi, Kazem, Sundström, Johan
• Format: Article
• Language: English
• Subjects: Aged; Analysis; Antihypertensive Agents - pharmacology; Atherosclerosis; Biology and Life Sciences; Blood; Blood Pressure; Blood Pressure Determination; Cardiology; Cardiovascular disease; Cardiovascular diseases; Cardiovascular Diseases - drug therapy; Clinical medicine; Clinical trials; Collaboration; Decision making; Diabetes mellitus; Disease prevention; Female; Health risk assessment; Health risks; Heart; Humans; Hypertension; Hypertension - drug therapy; Kaplan-Meier Estimate; Male; Medical research; Medical treatment; Medicine; Medicine and Health Sciences; Meta-analysis; Middle Aged; Practice Guidelines as Topic; Prevention; Primary Prevention; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Statistical analysis; Strategy; Stroke - prevention & control; Thresholds; Treatment Outcome
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1002538

Clinical practice guidelines have traditionally recommended blood pressure treatment based primarily on blood pressure thresholds. In contrast, using predicted cardiovascular risk has been advocated as a more effective strategy to guide treatment decisions for cardiovascular disease (CVD) prevention. We aimed to compare outcomes from a blood pressure-lowering treatment strategy based on predicted cardiovascular risk with one based on systolic blood pressure (SBP) level. We used individual participant data from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) from 1995 to 2013. Trials randomly assigned participants to either blood pressure-lowering drugs versus placebo or more intensive versus less intensive blood pressure-lowering regimens. We estimated 5-y risk of CVD events using a multivariable Weibull model previously developed in this dataset. We compared the two strategies at specific SBP thresholds and across the spectrum of risk and blood pressure levels studied in BPLTTC trials. The primary outcome was number of CVD events avoided per persons treated. We included data from 11 trials (47,872 participants). During a median of 4.0 y of follow-up, 3,566 participants (7.5%) experienced a major cardiovascular event. Areas under the curve comparing the two treatment strategies throughout the range of possible thresholds for CVD risk and SBP demonstrated that, on average, a greater number of CVD events would be avoided for a given number of persons treated with the CVD risk strategy compared with the SBP strategy (area under the curve 0.71 [95% confidence interval (CI) 0.70-0.72] for the CVD risk strategy versus 0.54 [95% CI 0.53-0.55] for the SBP strategy). Compared with treating everyone with SBP ≥ 150 mmHg, a CVD risk strategy would require treatment of 29% (95% CI 26%-31%) fewer persons to prevent the same number of events or would prevent 16% (95% CI 14%-18%) more events for the same number of persons treated. Compared with treating everyone with SBP ≥ 140 mmHg, a CVD risk strategy would require treatment of 3.8% (95% CI 12.5% fewer to 7.2% more) fewer persons to prevent the same number of events or would prevent 3.1% (95% CI 1.5%-5.0%) more events for the same number of persons treated, although the former estimate was not statistically significant. In subgroup analyses, the CVD risk strategy did not appear to be more beneficial than the SBP strategy in patients with diabetes mellitus or established CVD. A blood pressure-lower