4, 5However, a lower than anticipated event rate and shorter follow-up left the trial underpowered and there was no statistically significant difference between arms in event rates (HR 0.88, 95% CI 0.73–1.06).
In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial all 10,251 participants were randomised to more or less intensive control of blood glucose and then 4733 participants went into the blood pressure trial (blood pressure targets <120 mmHg vs <140 mmHg). Previous trials had suggested similar effects but may have been underpowered. 3 The trial was stopped early (mean follow-up 3.3 years) due to a clear reduction of cardiovascular events in the intensive treatment arm (hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.64–0.89) as well as reduced all-cause mortality (HR 0.73, 95% CI 0.60–0.90). The most recent is the Systolic Blood Pressure Intervention Trial (SPRINT), where 9361 people at high cardiovascular risk, but without diabetes, were randomised to systolic targets of <120 mmHg (intensive treatment) or <140 mmHg (standard treatment). Several large trials have randomised participants to different targets for systolic blood pressure. This is when cardiovascular disease causes both lower blood pressure and a high risk of cardiovascular events and death, but the blood pressure level itself is not necessarily responsible for the higher risk of death. The challenge in interpreting these data is that they are likely to be confounded by reverse causality. These studies found that the lowest risk was at about 130–140 mmHg systolic, but suggested that blood pressure below this range was associated with a higher cardiovascular risk. 1 Meanwhile other studies included people at a higher risk of cardiovascular events, where many or even all had existing cardiovascular disease. Studies of low-risk individuals reported log-linear relationships between systolic blood pressure and cardiovascular events down to the lowest levels for which adequate data were available (about 115 mmHg). There has been much debate about the interpretation of observational data describing the relationship between blood pressure and cardiovascular outcomes.
However many people will require antihypertensive drugs to reduce their blood pressure. Lifestyle changes including a healthy diet, quitting smoking, and increasing exercise are effective at reducing blood pressure. High blood pressure is one of the key modifiable risk factors for adverse cardiovascular outcomes such as heart attack and stroke.
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