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Maybe a 5 mm HG Reduction in Systolic BP is enough?


Lancet. 2021 May 1;397(10285):1625-1636. doi: 10.1016/S0140-6736(21)00590-0

Study Summary

This is a meta-analysis of 340,000+ individuals using participant-level data from 48 randomized trials of blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens. Patients with heart failure or recent acute myocardial infarction were excluded. Primary outcome was a major cardiovascular event (fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischemic heart disease, or heart failure causing death or requiring admission to hospital). 


After a median 4·15 years' follow-up 12·3% had at least one major cardiovascular event. In those without previous CV disease, the incidence for developing a major cardiovascular event was 31·9 (95% CI 31·3-32·5) per 1000 person-years in the comparator group and 25·9 (25·4-26·4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39·7 (95% CI 39·0-40·5) and 36·0 (95% CI 35·3-36·7).
Hazard ratios (HR) associated with a reduction of systolic blood pressure by 5 mm Hg for a major cardiovascular event were 0·91, 95% CI 0·89-0·94 for participants without previous cardiovascular disease and 0·89, 0·86-0·92, for those with previous cardiovascular disease. 


A 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, in both those with and without cardiovascular disease. The Treatment goal of 5 mm HG reduction of blood pressure is effective for primary and secondary prevention of major cardiovascular disease.


This paper raises many questions about how we define hypertension and continues the debate about what should be our treatment goals. Lowering CV events were the outcomes used, but ESRD was not discussed. When you add in the potential harms of aggressive BP lower (falls/orthostatic hypotension, drug side effects, etc.), maybe a 5 mm HG is enough. But, don't hold your breath waiting for the American College of Cardiology to make this recommendation.

More from 5MC

Acute Coronary Syndrome: Myocardial Infarction, Emergency Medicine; Hypotension, Orthostatic; Side Effects From Medicines; Stroke, Acute.

Contributed by Frank J. Domino, MD, May 12, 2021