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Cochrane Database of Systematic Reviews

Objetivos de presión arterial para el tratamiento de los pacientes con hipertensión y enfermedad cardiovascular

Esta versión no es la más reciente

Información

DOI:
https://doi.org/10.1002/14651858.CD010315.pub3Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 20 julio 2018see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Hipertensión

Copyright:
  1. Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Luis Carlos Saiz

    Correspondencia a: Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain

    [email protected]

  • Javier Gorricho

    Planning, Evaluation and Management Service, General Directorate of Health, Government of Navarre, Pamplona, Spain

  • Javier Garjón

    Drug Prescribing Service, Navarre Health Service, Pamplona, Spain

  • Mª Concepción Celaya

    Drug Prescribing Service, Navarre Health Service, Pamplona, Spain

  • Juan Erviti

    Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain

  • Leire Leache

    Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain

Contributions of authors

LC Saiz is the lead author. He coordinated the review, entered the text of the review into RevMan, conducted external correspondence, appraised inclusion criteria and quality, and extracted and analyzed study data.

J Gorricho led the protocol, appraised inclusion criteria and quality of studies, extracted study data, and drafted the final review.

J Garjón appraised inclusion criteria and quality of studies, extracted study data, and drafted the final review.

MC Celaya appraised inclusion criteria and quality of studies and drafted the final review.

J Erviti appraised inclusion criteria and quality of studies and drafted the final review.

L Leache appraised inclusion criteria and quality of studies, extracted study data, and drafted the final review.

All review authors participated in writing of the Discussion and Conclusions.

Sources of support

Internal sources

  • Navarre Health Service and Health Department of the Government of Navarre, Spain.

    Working time of authors (employees of the Government of Navarre).

    Facilities.

External sources

  • European Social Fund Operational Programme 2007‐2013, Other.

    50% of the full research project, as salary from September 2012 to December 2015 for the Pharmacotherapy Research Coordinator in the Navarre Health Service (LCS).

  • University of British Columbia, Vancouver, Canada.

    Bibliographic searches. Methodological support.

Declarations of interest

LC Saiz: none known.

J Gorricho: none known.

J Garjón: none known.

MC Celaya: none known.

J Erviti: none known.

L Leache: none known.

Acknowledgements

We are grateful to:

  • James M Wright and the Cochrane Hypertension Group, for their encouragement, support, and assistance;

  • Lourdes Muruzábal, María del Mar Malón, Rodolfo Montoya, and Antonio López, for their relevant contributions as authors to a previous version of this systematic review;

  • the Biomedical Information Center of Navarre, which provided most of the published documents reviewed in this report (Stephen Adams, Vancouver, Canada, provided assistance with some references that were especially difficult to find);

  • Miguel Ángel Imízcoz, cardiologist, who provided specific advice related to ascertainment of cardiovascular events from individual patient data;

  • Agustín Ciapponi and Demian Glujovsky, of the Institute of Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina, who provided access to Early Review Organizing Software;

  • Annalisa Perna, Giuseppe Remuzzi, and Piero Ruggenenti, of Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy, who provided individual patient data for REIN‐2 2005;

  • Kate Fletcher, of the University of Birmingham, Birmingham, UK, and Jonathan Mant, of the University of Cambridge, Cambridge, UK, who provided individual patient data for Past BP 2016; and

  • Larrye Loss and Julie Ye, from AstraZeneca, Wilmington (DE), USA, who provided access to protocol, forms, Clinical Study Report, and individual patient data for the HOT 1998 study. This manuscript was not prepared in collaboration with AstraZeneca staff and does not necessarily reflect the opinions or views of the company. According to the Data Transfer Agreement, AstraZeneca was entitled to make comments to the final report but approval was given with no remarks;

Data from SPS3 2013 were supplied by the National Institute of Neurological Disorders and Stroke (NINDS). This manuscript does not necessarily reflect the opinions or views of the SPS3 study, the NINDS Central Repositories, or the NINDS.

AASK 2002 and MDRD 1994 were conducted by the AASK/MDRD Investigators and supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Data from the AASK 2002 and MDRD 1994 studies reported here were supplied by the NIDDK Central Repositories. This manuscript was not prepared in collaboration with investigators in the AASK 2002 and MDRD 1994 studies and does not necessarily reflect the opinions or views of the AASK/MDRD studies, the NIDDK Central Repositories, or the NIDDK.

This manuscript was prepared with ACCORD and SPRINT_POP Research Materials obtained from the NHLBI Biologic Specimen and Data Repository Information Coordination Center and does not necessarily reflect the opinions or views of ACCORD, SPRINT_POP, or the National Heart, Lung and Blood Institute (NHLBI).

Version history

Published

Title

Stage

Authors

Version

2022 Nov 18

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

Review

Luis Carlos Saiz, Javier Gorricho, Javier Garjón, Mª Concepción Celaya, Juan Erviti, Leire Leache

https://doi.org/10.1002/14651858.CD010315.pub5

2020 Sep 09

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

Review

Luis Carlos Saiz, Javier Gorricho, Javier Garjón, Mª Concepción Celaya, Juan Erviti, Leire Leache

https://doi.org/10.1002/14651858.CD010315.pub4

2018 Jul 20

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

Review

Luis Carlos Saiz, Javier Gorricho, Javier Garjón, Mª Concepción Celaya, Juan Erviti, Leire Leache

https://doi.org/10.1002/14651858.CD010315.pub3

2017 Oct 11

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

Review

Luis Carlos Saiz, Javier Gorricho, Javier Garjón, Mª Concepción Celaya, Lourdes Muruzábal, Mª del Mar Malón, Rodolfo Montoya, Antonio López

https://doi.org/10.1002/14651858.CD010315.pub2

2013 Jan 31

Blood pressure targets for the treatment of patients with hypertension and cardiovascular disease

Protocol

Javier Gorricho, Javier Garjón, Mª Concepción Celaya, Lourdes Muruzábal, Rodolfo Montoya, Antonio López Andrés, Mª del Mar Malón, Luis Carlos Saiz

https://doi.org/10.1002/14651858.CD010315

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Results of the search.
Figuras y tablas -
Figure 1

Results of the search.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Lower versus standard, outcome: 1.1 Total mortality.
Figuras y tablas -
Figure 3

Forest plot of comparison: 1 Lower versus standard, outcome: 1.1 Total mortality.

Forest plot of comparison: 1 Lower versus standard, outcome: 1.2 Serious adverse events.
Figuras y tablas -
Figure 4

Forest plot of comparison: 1 Lower versus standard, outcome: 1.2 Serious adverse events.

Forest plot of comparison: 1 Lower versus standard, outcome: 1.3 Cardiovascular events.
Figuras y tablas -
Figure 5

Forest plot of comparison: 1 Lower versus standard, outcome: 1.3 Cardiovascular events.

Forest plot of comparison: 1 Lower versus standard, outcome: 1.4 Cardiovascular mortality.
Figuras y tablas -
Figure 6

Forest plot of comparison: 1 Lower versus standard, outcome: 1.4 Cardiovascular mortality.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 1 Total mortality.
Figuras y tablas -
Analysis 1.1

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 1 Total mortality.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 2 Serious adverse events.
Figuras y tablas -
Analysis 1.2

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 2 Serious adverse events.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 3 Cardiovascular events.
Figuras y tablas -
Analysis 1.3

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 3 Cardiovascular events.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 4 Cardiovascular mortality.
Figuras y tablas -
Analysis 1.4

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 4 Cardiovascular mortality.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 5 Withdrawals due to adverse effects.
Figuras y tablas -
Analysis 1.5

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 5 Withdrawals due to adverse effects.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 6 Blood pressure target achieved at 1 year.
Figuras y tablas -
Analysis 1.6

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 6 Blood pressure target achieved at 1 year.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 7 Systolic blood pressure change from baseline at end of 1 year.
Figuras y tablas -
Analysis 1.7

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 7 Systolic blood pressure change from baseline at end of 1 year.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 8 Diastolic blood pressure change from baseline at end of 1 year.
Figuras y tablas -
Analysis 1.8

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 8 Diastolic blood pressure change from baseline at end of 1 year.

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 9 Number of antihypertensive drugs needed at the end of study.
Figuras y tablas -
Analysis 1.9

Comparison 1 Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease, Outcome 9 Number of antihypertensive drugs needed at the end of study.

Summary of findings for the main comparison. Lower blood pressure targets compared with standard blood pressure targets for mortality and morbidity

Lower blood pressure targets compared with standard blood pressure targets for mortality and morbidity

Patient or population: cardiovascular disease with high blood pressure
Setting: outpatients (average duration of trials 4 years)
Intervention: lower blood pressure targets (≤ 135/85 mmHg)
Comparison: standard blood pressure targets (≤ 140 to 160/90 to 100 mmHg)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with standard blood pressure target

Risk with lower blood pressure target

Total mortality

Study population

RR 1.06
(0.91 to 1.23)

9484
(6 RCTs)

⊕⊕⊕⊝
MODERATEa

68 per 1000

72 per 1000
(62 to 84)

Serious adverse events

Study population

RR 1.01
(0.94 to 1.08)

9484
(6 RCTs)

⊕⊕⊝⊝
LOWa,b

252 per 1000

255 per 1000
(237 to 272)

Total cardiovascular events

Study population

RR 0.89
(0.80 to 1.00)

9484
(6 RCTs)

⊕⊕⊝⊝
LOWa,c

127 per 1000

113 per 1000
(102 to 127)

Cardiovascular mortality

Study population

RR 1.03

(0.82 to 1.29)

9484

(6 RCTs)

⊕⊕⊕⊝
MODERATEa

31 per 1000

32 per 1000

(25 to 40)

Withdrawals due to

adverse effects

Study population

RR 8.16
(2.06 to 32.28)

690
(2 RCT)

⊕⊝⊝⊝
VERY LOWa,d

7 per 1000

60 per 1000
(15 to 239)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio.

GRADE Working Group grades of evidence.
High quality: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

aDowngraded one level owing to serious imprecision (95% CI is wider than the minimal important difference).

bDowngraded one level owing to incomplete available data.

cDowngraded one level owing to high risk of bias.

dDowngraded two levels because only two of the smaller studies reported this outcome.

Figuras y tablas -
Summary of findings for the main comparison. Lower blood pressure targets compared with standard blood pressure targets for mortality and morbidity
Table 1. Baseline characteristics of included study participants

Mean (SD) unless otherwise stated

AASK 2002

ACCORD BP 2010

HOT 1998

Past BP 2016

SPRINT 2015

SPS3 2013

Number of participants

155

1531

3232

295

1562

2709

Sex (% male)

68%

63%

53%

64%

76%

62%

Age in years

57 (9)

62 (8)

62 (‐)

71 (9)

70 (9)

63 (11)

Ethnic group (% Caucasian)

0%

62%

92%

98%

71%

53%

Diabetes

0%

100%

12%

10%

0%

36%

Current smoker

31%

13%

16%

13%

14%

20%

Systolic blood pressure

149 (28)

138 (16)

174 (15)

143 (14)

138 (16)

146 (18)

Diastolic blood pressure

93 (16)

74 (11)

106 (3)

80 (10)

74 (12)

79 (11)

Ischemic heart disease (IHD)

25%

86%

95%

22%

‐‐‐

11%

Stroke

69%

20%

7%

85%

0%

99%

Peripheral vascular disease

23%

‐‐‐

‐‐‐

7%

‐‐‐

‐‐‐

Thiazides

‐‐‐

51%

‐‐‐

35%

‐‐‐

35%

ACEI/ARB

‐‐‐

84%

‐‐‐

65%

‐‐‐

71%

Calcium channel blocker

‐‐‐

26%

‐‐‐

43%

‐‐‐

28%

Beta blocker

‐‐‐

57%

‐‐‐

20%

‐‐‐

27%

Other antihypertensive drugs

‐‐‐

28%

‐‐‐

11%

‐‐‐

8%

Number of antihypertensive drugs

‐‐‐

3.0 (1.4)

1.0 (‐‐)

1.1 (0.8)

2.1 (1.0)

1.7 (1.1)

(‐‐) no information is available. Ischemic heart disease, stroke, and peripheral vascular disease percentages are totally independent of each other because participants can have more than one cardiovascular event at the same time. A similar explanation can be offered with respect to percentages in the different classes of antihypertensive drugs.

Abbreviations: ACEI: angiotensin‐converting enzyme inhibitor; ARB: angiotensin receptor blocker; IHD: ischemic heart disease; SD: standard deviation.

Figuras y tablas -
Table 1. Baseline characteristics of included study participants
Table 2. Lower versus standard blood pressure target; people with diabetes, difference in targets ≥ 10 mmHg

Outcome

Studies

Participants

Statistical Method

Effect Estimate

Total mortality

ACCORD BP 2010, HOT 1998, SPS3 2013

2773

Risk Ratio (M‐H, Fixed, 95% CI)

1.15 [0.91,1.45]

Cardiovascular mortality

ACCORD BP 2010, HOT 1998, SPS3 2013

2773

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.69,1.39]

Cardiovascular events

ACCORD BP 2010, HOT 1998, SPS3 2013

2773

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.74,1.03]

Serious adverse events

ACCORD BP 2010, HOT 1998, SPS3 2013

2773

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.88,1.15]

Figuras y tablas -
Table 2. Lower versus standard blood pressure target; people with diabetes, difference in targets ≥ 10 mmHg
Comparison 1. Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total mortality Show forest plot

6

9484

Risk Ratio (M‐H, Fixed, 95% CI)

1.06 [0.91, 1.23]

2 Serious adverse events Show forest plot

6

9484

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.94, 1.08]

2.1 Total serious adverse events

1

1562

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.91, 1.09]

2.2 Subset of total serious adverse events

5

7922

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.92, 1.11]

3 Cardiovascular events Show forest plot

6

9484

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.80, 1.00]

4 Cardiovascular mortality Show forest plot

6

9484

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.82, 1.29]

5 Withdrawals due to adverse effects Show forest plot

2

690

Risk Ratio (M‐H, Fixed, 95% CI)

8.16 [2.06, 32.28]

6 Blood pressure target achieved at 1 year Show forest plot

6

8588

Risk Ratio (M‐H, Fixed, 95% CI)

1.21 [1.17, 1.24]

7 Systolic blood pressure change from baseline at end of 1 year Show forest plot

6

8546

Mean Difference (IV, Random, 95% CI)

‐8.90 [‐13.24, ‐4.56]

8 Diastolic blood pressure change from baseline at end of 1 year Show forest plot

6

8546

Mean Difference (IV, Random, 95% CI)

‐4.50 [‐6.35, ‐2.65]

9 Number of antihypertensive drugs needed at the end of study Show forest plot

5

7910

Mean Difference (IV, Random, 95% CI)

0.56 [0.16, 0.96]

Figuras y tablas -
Comparison 1. Lower versus standard blood pressure targets for people with hypertension and history of cardiovascular disease