ArticlesBlood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data
Introduction
The merits of using an individual's predicted absolute risk of cardiovascular disease to inform treatment decisions for the prevention of cardiovascular disease, rather than using only the level of one cardiovascular disease risk factor, have been recognised for decades.1, 2, 3 Most countries and cardiovascular societies now regard this evidence as sufficient to recommend that lipid-lowering treatment should be based on patients' predicted cardiovascular disease risk rather than LDL cholesterol concentrations.3, 4, 5, 6 Blood pressure-lowering treatment recommendations, however, are still based mainly on blood pressure levels.7, 8, 9 The American Heart Association and the American College of Cardiology are the most recent organisations to switch to cardiovascular disease risk-based cholesterol treatment guidelines, and a Cholesterol Treatment Trialists' (CTT) Collaboration meta-analysis using individual participant data from statin trials 10 was influential in their decision to move away from treatment thresholds based mainly on LDL cholesterol concentrations. That meta-analysis involved retrospectively calculating a baseline 5-year vascular risk for all participants, which enabled the investigators to estimate the relative and absolute benefits of lipid lowering in different baseline risk categories. The findings clearly show that baseline vascular risk is a major determinant of the absolute benefits of statin treatment (figure 1 ).
The Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) has investigated the effects of blood pressure lowering on cardiovascular events in major patient subgroups, defined using individual patient data. The available data now provide a unique opportunity to compare the effects of blood pressure-lowering drugs in subgroups of patients at different levels of baseline absolute risk of cardiovascular events, in much the same way as has been done for lipid-lowering therapy in the CTT meta-analysis. 10
We postulated that the relative cardiovascular disease risk reductions achieved with blood pressure-lowering therapy would be similar across population groups with different levels of baseline cardiovascular disease risk, and therefore that the absolute risk reductions would be greater for subgroups with higher levels of baseline cardiovascular disease risk. We aimed to test this hypothesis by doing a meta-analysis of individual patient data.
Section snippets
Study eligibility
The methods used have been reported previously, 11 and only the main components are summarised here. In brief, trials were eligible if they met the original inclusion criteria specified in the protocol, 11 and were part of the subset of studies that randomly allocated patients to either a blood pressure-lowering drug or placebo, or to a more intensive or less intensive blood pressure regimen. Trials had to have a minimum of 1000 patient-years of planned follow-up in each randomised group, and
Results
11 trials and 26 randomised groups met the inclusion criteria (some trials were factorial or included more than two groups), and included 67 475 individuals (appendix).16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 Data for the calculation of the risk equations were available for 51 917 patients. The mean estimated baseline absolute 5-year risk of cardiovascular disease events in this sample was 11·7% (7·5), with the four risk groups defined as having estimated 5-year cardiovascular
Discussion
In this meta-analysis of more than 50 000 patients, pharmacological blood pressure lowering produced relative reductions in cardiovascular risk that were similar across patient groups with markedly varying levels of baseline estimated cardiovascular risk, while delivering progressively greater absolute risk reductions at higher levels of baseline risk. This same pattern was apparent in a range of subsidiary analyses done on the primary composite cardiovascular outcome after adjusting for
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