Effects of blood pressure lowering according to baseline cardiovascular disease: systematic review and meta-analysis of randomized trials

Abstract

Abstract Background Blood pressure (BP)-lowering is accompanied by reduced cardiovascular (CV) outcomes and death in hypertensive patients. There are no data on the effect of BP lowering in patients with a history of CV disease [i.e., coronary heart disease (CHD), stroke, or heart failure with preserved ejection fraction (HFpEF)]. Purpose To demonstrate the effect of BP-lowering treatment on CV events in patients with different types of baseline CV disease. Methods A systematic review was conducted to identify randomized trials in electronic databases (Pubmed and CENTRAL, search from 1966 to 11/2022) for the effect of BP-lowering treatment against placebo or less aggressive BP reduction on fatal or nonfatal cardiovascular outcomes and all-cause death. Trials or subgroups of trials were identified, including patients with a history of CV disease. We excluded heart failure studies with reduced ejection fraction, acute myocardial infarction, or acute stroke. Risk ratios (RR) were calculated with their 95% confidence interval (CI) under the random-effects model. Results We included 18 BP-lowering treatment trials with 52,359 CHD patients (mean follow-up, 4.2 years; achieved systolic/diastolic BP, 129.2/76.1 mmHg). Despite the fact that mortality outcomes, stroke, and recurrent CHD were not decreased as a result of BP-lowering therapy, the risk of the combined outcome of major CV events (i.e., myocardial infarction, stroke, and heart failure) was reduced by 11% (95% CI, 3-18%) and the risk of recurrent heart failure hospitalization by 28% (95% CI, 18-38%). In addition, we examined 8 trials with 37,866 patients with a history of stroke (mean follow-up, 2.7 years; achieved systolic/diastolic BP, 136.5/79.8 mmHg), in which BP-lowering treatment reduced recurrent stroke by 18% (95% CI, 7-27%) and CV death by 12% (95% CI, 3-21%). Among 5 heart failure trials with 11,597 patients (mean follow-up, 3.4 years; achieved systolic/diastolic BP, 130.8/76.7 mmHg), the combined outcome of major CV events was decreased by 10% (95% CI, 4-16%), and recurrent heart failure hospitalization by 12% (95% CI, 4-19%). Conclusions Maximum CV protection is offered when systolic BP is reduced to levels < 130 mmHg in patients with CHD, to 130-140 mmHg levels in patients with a history of stroke, and to levels of approximately 130 mmHg in patients with heart failure. These findings support the recommendation for more aggressive BP lowering in patients with a history of CHD or optimally treated patients with HFpEF, and for less aggressive BP reduction in post-stroke patients.