Blood pressure targets in patients with coronary artery disease: observations from traditional and Bayesian random effects meta-analysis of randomised trials

Context

Most guidelines for treatment of hypertension including the Joint National Committee-7 recommend a blood pressure (BP) goal of <140/90 mm Hg for hypertensive patients and a more aggressive goal of <130/80 mm Hg for patients with coronary artery disease (CAD), based largely on expert consensus.

Objective

To evaluate the BP targets in patients with CAD

Data Sources

PUBMED, EMBASE and CENTRAL Study Selection: Randomised clinical trials (RCTs) of antihypertensive therapy in patients with CAD, enrolling at least 100 patients, with achieved systolic pressure of <=135 mm Hg in the ‘intensive BP’ group and <=140 mm Hg in the ‘standard BP’ group with follow-up for at least 1 year and evaluating cardiovascular outcomes.

Data Extraction

The following efficacy outcomes were extracted- all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, angina pectoris, heart failure and revascularisation.

Results

We identified 15 RCTs enrolling 66 504 participants with 276 328 patient-years of follow-up. Intensive BP group (≤135 mm Hg) was associated with a 15% decrease in heart failure rate and 10% decrease in stroke rate, driven largely by trials with a more intensive BP group (≤130 mm Hg), with similar outcomes for death and cardiovascular death and was associated with a 105% increase in the risk of hypotension. More intensive BP group (≤130 mm Hg) was also associated with a reduction in myocardial infarction and angina pectoris. The results were similar in a Bayesian random effects model. In addition, lower seemed to be better (based on regression analysis) for the outcomes of myocardial infarction, stroke, heart failure and perhaps angina.

Conclusions

The present body of evidence suggests that in patients with CAD, intensive systolic BP control to ≤135 mm Hg and possibly to ≤130 mm Hg is associated with a modest reduction in stroke and heart failure but at the expense of hypotension. Lower was better, although not consistently so for myocardial infarction, stroke, heart failure and perhaps angina. Further trials are needed to prove these findings.