James Brophy, MD, FRCP, PhD
Do antihypertensive drugs reduce mortality and morbidity in adults with mild hypertension and no cardiovascular (CV) disease?
Included studies had duration ≥ 1 year and compared antihypertensive drug therapy, as monotherapy or as part of a stepped-care approach, with placebo or no antihypertensive treatment in men and nonpregnant women > 18 years of age who had mild hypertension (systolic blood pressure [BP] 140 to 159 mm Hg or diastolic BP 90 to 99 mm Hg) and did not have CV disease. Trials were included if > 80% of patients had mild hypertension or individual patient data for the subgroup of patients with mild hypertension were available. Primary outcomes were mortality and total CV events (stroke, myocardial infarction [MI], and congestive heart failure). Other outcomes were stroke, coronary heart disease (MI or sudden death), and treatment withdrawal because of adverse drug effects.
MEDLINE and EMBASE/Excerpta Medica to May 2011; CENTRAL (Cochrane Library 2011, Issue 1); reviews and meta-analyses identified in the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness; and reference lists were searched for randomized controlled trials (RCTs). Investigators were contacted. 4 RCTs (n = 8912, mean age range 38 to 72 y, 43% to 100% men, follow-up range 2 to 5 y) met inclusion criteria. Individual patient data for subgroups of patients with mild hypertension were obtained from 3 RCTs (n = 7 to 6061 per trial), and all data from the other RCT were included because > 80% of patients had mild hypertension (n = 1012). All trials compared antihypertensive treatment (chlorothiazide, methyldopa, propranolol, pindolol, hydralazine, clonidine, bendrofluazide, atenolol, or reserpine) with placebo.
The trials in this review were judged to have a moderate to high risk for bias. Meta-analysis in patients with mild hypertension showed that antihypertensive drug therapy did not reduce mortality, stroke, coronary heart disease, or total CV events more than placebo (Table). 1 RCT in patients with any hypertension found that antihypertensive drug therapy increased withdrawals due to adverse drug effects more than placebo (n = 17 354, 11% vs 2.3%, P < 0.001).
Low-quality evidence suggests that antihypertensive drug therapy does not reduce mortality or cardiovascular events after up to 5 years of follow-up in adults with mild hypertension in the setting of primary prevention.
Antihypertensive drug therapy vs placebo in patients with mild hypertension*
*CHD = coronary heart disease; CV = cardiovascular; other abbreviations defined in Glossary. Weighted event rates, RRR, RRI, and CI calculated from risk ratios and control event rates in article using a fixed-effect model.
†Quality of evidence was very low (mortality and total CV events) or not reported (stroke and CHD) based on Grading of Recommendations Assessment, Development, and Evaluation criteria (4 grades: very low, low, moderate, and high quality).
Brophy J. Review: Low-quality evidence fails to show that antihypertensive drugs affect outcomes in mild hypertension. Ann Intern Med. ;157:JC6–6. doi: 10.7326/0003-4819-157-12-201212180-02006
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Published: Ann Intern Med. 2012;157(12):JC6-6.
Cardiology, Coronary Risk Factors, Hypertension, Nephrology.
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