Optimal systolic blood pressure target for hypertensive patients: a network meta-analysis

Abstract

Background Intensive blood pressure (BP)-lowering to <120 mmHg has recently been shown to reduce mortality and cardiovascular (CV) events in hypertensive patients without diabetes. This challenges existing guidelines. We therefore used network meta-analysis to study the relationship between achieved BP target and outcomes. Methods We searched for randomised controlled trials (RCTs) of different BP targets that reported CV events. The achieved systolic BP (SBP) in different trials was classified into five groups (110-119, 120-129, 130-139, 140-149 and 150-159 mmHg). Frequentist approach and Bayesian framework were used. Results Thirteen RCTs with altogether 48,152 patients were included. All patients were over 50 years old. Stroke and major adverse CV events were reduced when controlling SBP to 120-129 mmHg compared to 130-139 mmHg (OR 0.83, 95% CI 0.69-0.99 and 0.84, 0.73-0.96), 140-149 mmHg (0.70, 0.55-0.90 and 0.75, 0.63-0.90), and 150-159 mmHg (0.39, 0.23-0.67 and 0.42, 0.31-0.58), respectively. More intensive control to <120 mmHg also reduced stroke (0.58, 0.38-0.87, 0.49, 0.31-0.77, and 0.27, 0.14-0.52). In contrast, SBP target of ≥150 mmHg increased myocardial infarction (MI) and CV mortality compared to 120-129 mmHg (1.73, 1.08-2.78 and 2.05, 1.27-3.30) and 130-139 mmHg (1.53, 1.03-2.29 and 1.60, 1.08-2.39). No significant effect of target SBP on all-cause mortality was found. Conclusions Intensive BP-lowering reduces stroke and to a lesser extent, MI. CV mortality is higher if SBP exceeds 150 mmHg. Our network meta-analysis supports a SBP target of 120-130 mmHg for hypertensive patients over 50 years old.