Key result
Intensive blood pressure control did not achieve a net clinical benefit compared to standard targets when weighing the benefit of MACE reduction against the risk of serious adverse events.
Why the study?
Does an intensive blood pressure lowering strategy improve net clinical benefit compared to standard blood pressure control?
Meta-Analysis
Does an intensive blood pressure lowering strategy improve net clinical benefit compared to standard blood pressure control?
Intensive blood pressure control does not appear to provide a net clinical benefit over standard control when simultaneously weighing the reduction in cardiovascular events against the increased risk of serious adverse events.
Intensive BP lowering lacks net clinical benefit; challenges guideline emphasis on aggressive targets without SAE balancing.
BACKGROUND: Intensive blood pressure (BP) lowering may offer protective effects against major adverse cardiac event (MACE) but is also associated with a greater risk of a serious adverse event (SAE). The risk-benefit profile of intensive versus standard BP control has not been comprehensively assessed. METHODS: Four studies were identified from a systematic literature search for randomized controlled trials comparing intensive versus standard BP lowering that reported both MACE and SAE endpoints. A previously described statistical approach was applied to characterize the efficacy-safety tradeoff of BP control. The bivariate outcome was computed to quantitatively assess the net clinical benefit (NCB) of intensive BP lowering as compared to standard treatment, with positive values indicating increased risks and negative values indicating decreased risks. RESULTS: Data from the SPRINT trial demonstrated that intensive strategy was superior in MACE but inferior in SAE, thereby eroding the NCB (bivariate outcome: 0.33% [-0.50% to 1.21%]). Intensive strategy from the SPS3 trial fulfilled non-inferiority in both MACE and SAE but did not reach a favorable NCB (-1.31% [-2.25% to 0.01%]). The ACCORD trial suggested that intensive strategy was non-inferior in MACE but inferior in SAE (-0.19% [-0.79% to 1.37%]). Results from the VALISH trial were inconclusive for SAE but suggested non-inferiority in MACE (-1.19% [-3.24% to 0.68%]). CONCLUSIONS: Compared to the standard blood pressure target, pooled data from randomized controlled trials suggest that intensive strategy did not achieve a net clinical benefit when weighing the benefit of MACE reduction against the risk of SAE under the bivariate framework. ABBREVIATIONS: Blood pressure (BP), diastolic blood pressure (DBP), major adverse cardiac event (MACE), net clinical benefit (NCB), serious adverse event (SAE), systolic blood pressure (SBP).
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Chi et al. (2018) conducted a meta-analysis in Hypertension. Intensive blood pressure control vs. Standard blood pressure control was evaluated on Net clinical benefit (bivariate outcome of MACE and SAE). Intensive blood pressure control did not achieve a net clinical benefit compared to standard targets when weighing the benefit of MACE reduction against the risk of serious adverse events.
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