NIHR Signal New evidence for lower blood pressure targets

Published on 4 July 2017

Risk of stroke and heart attack decreases with lower systolic blood pressure such as 120 mmHg and 130 mmHg compared with a higher level of 160 mmHg. Lower target pressures are associated with an increased risk of serious adverse events like fainting. The target with the best balance between efficacy and safety in this research seems to be 130 mmHg.

National guidelines mostly recommend a systolic target of 140 mmHg. Recent trials have assessed the value of a lower 120 mmHg target, with mixed findings. This review aimed to address this uncertainty by pooling 17 trials comparing different blood pressure targets.

The findings from this network meta-analysis cannot be applied to specific population groups, such as those with diabetes. For an individual, the absolute benefits will also depend on the assumed risk before treatment, taking into account all other factors, such as lipid levels, age and smoking.

These results may inform further discussion and NICE guideline updates. The balance of benefits and harms of lower blood pressure targets is likely to be an important determinant.

New evidence for lower blood pressure targets

Why was this study needed?

More than one in four UK adults has high blood pressure (hypertension). Hypertension is estimated to account for 12% of all visits to GPs in England. Associated diseases, like heart disease and stroke, are estimated to cost the NHS over £2 billion every year.

There is uncertainty over the blood pressure target which gives the best balance between benefits and side effects. Most national guidelines recommend an upper (systolic) target of <140mmHg but results from several recent trials have been conflicting. The SPRINT trial found a lower target of 120 mmHg improved overall cardiovascular risk in people without diabetes, while the ACCORD BP trial found this lower target gave little benefit for people with diabetes.

This study aimed to combine the results of trials to shed light on the optimal systolic blood pressure target.

What did this study do?

This systematic review identified 17 randomised controlled trials that compared blood pressure targets in a total 55,163 adult patients.

The authors defined five systolic blood pressure targets, ranging from <120 mmHg to <160 mmHg with three intermediate groups separated by 10 mmHg. The researchers performed network meta-analyses comparing each target with the upper threshold of <160 mmHg within and across trials.

The trials included a heterogeneous population, and it was not possible to take account of level of cardiovascular risk at baseline. The results are therefore not focused on specific groups, such as the elderly or people with diabetes. An additional limitation is that the review only looks at systolic blood pressure alone, not together with diastolic pressure.

What did it find?

  • A target of 120 mmHg reduced the risk of stroke compared with 160 mmHg, but this was on the borderline of statistical significance (rate ratio [RR] 0.54, 95% confidence interval [CI] 0.29 to 1.00). There was no significant difference when comparing the two lowest pressure target groups (120 mmHg vs. 130 mmHg: RR 0.88, 95% CI 0.51 to 1.52).
  • The lower target of 120 mmHg also reduced risk of myocardial infarction, but again this was on the threshold of statistical significance (RR 0.68, 95% CI 0.47 to 1.00). For myocardial infarction , 120 mmHg was ranked as the most likely optimal target, followed by 130 mmHg.
  • Systolic blood pressure target had no effect on outcomes of all-cause death, cardiovascular death and heart failure. The authors state that point estimates of relative risk favoured targets of 120 mmHg and 130 mmHg, but there were no statistically significant findings.
  • Serious adverse effects like low blood pressure, fainting and slow heart rate, were more frequent with the lower target of <120 mmHg compared with higher targets of 140 mmHg (RR 2.12, 95% CI 1.46 to 3.08) and 150 mmHg (RR 1.83, 95% CI 1.05 to 3.20).
  • A systolic blood pressure target of <130 mmHg was assessed to have the best balance of efficacy and safety.

What does current guidance say on this issue?

The NICE guideline on hypertension, updated in 2016, recommends people aged under 80 years aim for a clinic systolic blood pressure below 140 mmHg (140/90 mmHg) and ambulatory or home systolic pressure below 135 mmHg (135/85 mmHg). People aged 80 years and over are recommended to aim for a clinic systolic blood pressure below 150 mmHg (150/90 mmHg) and ambulatory or home systolic pressure below 145 mmHg (145/85 mmHg).

The diabetes guideline recommends people with diabetes maintain blood pressure below 140/80 mmHg or below 130/80 mmHg if there is kidney, eye or stroke damage. The European Guidelines recommend similar targets.

What are the implications?

A lower systolic blood pressure target of 130 mmHg may benefit cardiovascular health.

A survey by NICE in 2015 shows how hypertension is being managed nationally. More than 85% of patients aged 80 years or over with treated hypertension had their previous blood pressure reading at 150/90 mmHg or below. These findings may inform discussion of whether a lower systolic blood pressure target could further reduce cardiovascular events and NHS costs.

However, the balance of benefits against harms of lower blood pressure targets is likely to be an important determinant. This balance should be discussed with patients. Commissioners will also be interested in the health system cost and cost-effectiveness of lowering the targets.

Citation and Funding

Bangalore S, Toklu B, Gianos E, et al. Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials. Am J Med. 2017;130(6):707-19.

No funding information was provided for this study.

Bibliography

Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159-219.

NHS Choices. High blood pressure (hypertension). London: Department of Health; 2016.

NICE. Hypertension in adults: diagnosis and management. CG127. London: National Institute for Health and Clinical Excellence; 2011.

NICE. Hypertension in adults: diagnosis and management – Measuring the use of this guidance. London: National Institute for Health and Clinical Excellence; 2015.

NICE. Type 2 diabetes in adults: management. London: National Institute for Health and Clinical Excellence; 2015.

Public Health England. New figures show high blood pressure costs NHS billions each year. London: The Crown; 2014.

Why was this study needed?

More than one in four UK adults has high blood pressure (hypertension). Hypertension is estimated to account for 12% of all visits to GPs in England. Associated diseases, like heart disease and stroke, are estimated to cost the NHS over £2 billion every year.

There is uncertainty over the blood pressure target which gives the best balance between benefits and side effects. Most national guidelines recommend an upper (systolic) target of <140mmHg but results from several recent trials have been conflicting. The SPRINT trial found a lower target of 120 mmHg improved overall cardiovascular risk in people without diabetes, while the ACCORD BP trial found this lower target gave little benefit for people with diabetes.

This study aimed to combine the results of trials to shed light on the optimal systolic blood pressure target.

What did this study do?

This systematic review identified 17 randomised controlled trials that compared blood pressure targets in a total 55,163 adult patients.

The authors defined five systolic blood pressure targets, ranging from <120 mmHg to <160 mmHg with three intermediate groups separated by 10 mmHg. The researchers performed network meta-analyses comparing each target with the upper threshold of <160 mmHg within and across trials.

The trials included a heterogeneous population, and it was not possible to take account of level of cardiovascular risk at baseline. The results are therefore not focused on specific groups, such as the elderly or people with diabetes. An additional limitation is that the review only looks at systolic blood pressure alone, not together with diastolic pressure.

What did it find?

  • A target of 120 mmHg reduced the risk of stroke compared with 160 mmHg, but this was on the borderline of statistical significance (rate ratio [RR] 0.54, 95% confidence interval [CI] 0.29 to 1.00). There was no significant difference when comparing the two lowest pressure target groups (120 mmHg vs. 130 mmHg: RR 0.88, 95% CI 0.51 to 1.52).
  • The lower target of 120 mmHg also reduced risk of myocardial infarction, but again this was on the threshold of statistical significance (RR 0.68, 95% CI 0.47 to 1.00). For myocardial infarction , 120 mmHg was ranked as the most likely optimal target, followed by 130 mmHg.
  • Systolic blood pressure target had no effect on outcomes of all-cause death, cardiovascular death and heart failure. The authors state that point estimates of relative risk favoured targets of 120 mmHg and 130 mmHg, but there were no statistically significant findings.
  • Serious adverse effects like low blood pressure, fainting and slow heart rate, were more frequent with the lower target of <120 mmHg compared with higher targets of 140 mmHg (RR 2.12, 95% CI 1.46 to 3.08) and 150 mmHg (RR 1.83, 95% CI 1.05 to 3.20).
  • A systolic blood pressure target of <130 mmHg was assessed to have the best balance of efficacy and safety.

What does current guidance say on this issue?

The NICE guideline on hypertension, updated in 2016, recommends people aged under 80 years aim for a clinic systolic blood pressure below 140 mmHg (140/90 mmHg) and ambulatory or home systolic pressure below 135 mmHg (135/85 mmHg). People aged 80 years and over are recommended to aim for a clinic systolic blood pressure below 150 mmHg (150/90 mmHg) and ambulatory or home systolic pressure below 145 mmHg (145/85 mmHg).

The diabetes guideline recommends people with diabetes maintain blood pressure below 140/80 mmHg or below 130/80 mmHg if there is kidney, eye or stroke damage. The European Guidelines recommend similar targets.

What are the implications?

A lower systolic blood pressure target of 130 mmHg may benefit cardiovascular health.

A survey by NICE in 2015 shows how hypertension is being managed nationally. More than 85% of patients aged 80 years or over with treated hypertension had their previous blood pressure reading at 150/90 mmHg or below. These findings may inform discussion of whether a lower systolic blood pressure target could further reduce cardiovascular events and NHS costs.

However, the balance of benefits against harms of lower blood pressure targets is likely to be an important determinant. This balance should be discussed with patients. Commissioners will also be interested in the health system cost and cost-effectiveness of lowering the targets.

Citation and Funding

Bangalore S, Toklu B, Gianos E, et al. Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials. Am J Med. 2017;130(6):707-19.

No funding information was provided for this study.

Bibliography

Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159-219.

NHS Choices. High blood pressure (hypertension). London: Department of Health; 2016.

NICE. Hypertension in adults: diagnosis and management. CG127. London: National Institute for Health and Clinical Excellence; 2011.

NICE. Hypertension in adults: diagnosis and management – Measuring the use of this guidance. London: National Institute for Health and Clinical Excellence; 2015.

NICE. Type 2 diabetes in adults: management. London: National Institute for Health and Clinical Excellence; 2015.

Public Health England. New figures show high blood pressure costs NHS billions each year. London: The Crown; 2014.

Optimal Systolic Blood Pressure Target after SPRINT Insights from a Network Meta-Analysis of Randomized Trials

Published on 23 January 2017

Bangalore, S.,Toklu, B.,Gianos, E.,Schwartzbard, A.,Weintraub, H.,Ogedegbe, G.,Messerli, F. H.

Am J Med , 2017

BACKGROUND: The optimal blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg albeit with an increase in serious adverse effects related to low BP. METHODS: PUBMED, EMBASE, and CENTRAL were searched for randomized trials comparing treating to different BP targets. Trial arms were grouped into five systolic BP target categories: 1) <160 mm Hg; 2) <150 mm Hg; 3) <140 mm Hg; 4) <130 mm Hg and 5) <120 mm Hg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure and safety outcomes of serious adverse effects were evaluated using a network meta-analysis. RESULTS: Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (RR=0.54; 95% CI 0.29-1.00) and myocardial infarction (RR=0.68; 95% CI 0.47-1.00) with systolic BP <120 mm Hg (vs. <160 mm Hg). Sensitivity analysis using achieved systolic BP showed a 72%, 97% and 227% increase in stroke with systolic BP of <140 mm Hg, <150 mm Hg and <160 mm respectively, when compared with systolic BP <120 mm Hg. There was no difference in death, cardiovascular death or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (<120 mm Hg, <130 mm Hg) when compared with higher BP targets (<140 mm Hg or <150 mm Hg). BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2 respectively, as the most efficacious target. There was a significant increase in serious adverse effects with systolic BP <120 mm Hg vs. <150 mm Hg (RR=1.83; 95% CI 1.05-3.20) or vs. <140 mm Hg (RR=2.12; 95% CI 1.46-3.08). BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2 respectively, as the safest target for the outcome of serious adverse effects. Cluster plots for combined efficacy and safety showed that a systolic BP target of <130 mm Hg had optimal balance between efficacy and safety. CONCLUSIONS: In patients with hypertension, a systolic BP target of <130 mm Hg achieved optimal balance between efficacy and safety.

Blood pressure is defined with two numbers. The high number is the systolic blood pressure, which coincides with heart contraction and represents the pressure at which the blood is pumped out of the heart. The low number is the diastolic blood pressure. This is the resting pressure or resistance in the arteries when the heart is filling with blood between beats. Blood pressure is measured in millimetres of mercury (mmHg).

Expert commentary

We haven’t been sure when treating high blood pressure whether lower is better or if there is a J shaped curve. NICE guidelines currently suggest a treatment target of < 140/90 mmHg but this is under review. Two recent large studies (SPRINT and ACCORD) have given conflicting messages adding further uncertainty.

This network meta-analysis of 17 randomised trials shows that the risk of stroke and myocardial infarction is reduced with lower blood pressure targets. The sweet spot for balancing efficacy and side effects seems to be targeting a systolic blood pressure of <130 mmHg.

Dr Angus Nightingale, Consultant Cardiologist, Bristol Heart Institute

Expert commentary

High blood pressure or hypertension affects one in three people in the UK. Hypertension is often called the silent killer disease as it does not produce any symptoms. On the other hand drugs used to treat hypertension may cause side effects and some individuals cannot tolerate them. It is well documented that controlling hypertension significantly prevents heart attacks and strokes. Therefore, finding the perfect balance between maximising benefit of treatment and limiting side effects from drugs is very important. If the results of this study are adopted in the upcoming hypertension guidelines many individuals with hypertension may benefit.

Dr Tarek Francis Antonios, Senior Lecturer & Consultant Physician in Cardiovascular & General Medicine, Lead Clinician of Blood Pressure Unit, St. George's University of London

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  •   Cardiovascular system disorders, Health management, Medicines, Stroke