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J-Shaped Relationship between Blood Pressure and Mortality in Hypertensive Patients: New Insights from a Meta-Analysis of Individual-Patient Data

Florent Boutitie, MSc; François Gueyffier, MD; Stuart Pocock, PhD; Robert Fagard, MD; Jean Pierre Boissel, MD, INDANA Project Steering Committee
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From Claude Bernard University, Lyon, France; London School of Hygiene and Tropical Medicine, London, United Kingdom; and Leuven University, Leuven, Belgium.


Acknowledgments: The authors thank John Coope, Jeffrey Cuttler, Tord Ekbom, Lawrence Friedman, Mitchell Perry, Ronald Prineas, and Eleanor Schron for contributing data to the INDANA project.

Grant Support: By the European Community as part of the BIOMED 2 program (contract BMH4-CT98-3291).

Requests for Single Reprints: Florent Boutitie, MSc, EA643 Clinical Pharmacology Unit, Faculte RTH Laennec, BP 8071–69376 Lyon Cedex 08, France; e-mail, flb@upcl.univ-lyon1.fr.

Current Author Addresses: Mr. Boutitie and Drs. Gueyffier and Boissel: EA643 Clinical Pharmacology Unit, Faculte RTH Laennec, BP 8071–69376 Lyon Cedex 08, France.

Dr. Pocock: Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom.

Dr. Fagard: Hypertension and Cardiovascular Rehabilitation Unit, University of Leuven, U.Z. Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.

Author Contributions: Conception and design: F. Boutitie, F. Gueyffier, S. Pocock.

Analysis and interpretation of the data: F. Boutitie, F. Gueyffier, S. Pocock, R. Fagard, J.P. Boissel.

Drafting of the article: F. Boutitie, F. Gueyffier, J.P. Boissel.

Critical revision of the article for important intellectual content: F. Boutitie, F. Gueyffier, S. Pocock, R. Fagard.

Final approval of the article: F. Boutitie, F. Gueyffier, S. Pocock, R. Fagard.

Provision of study materials or patients: F. Gueyffier, R. Fagard.

Statistical expertise: F. Boutitie, S. Pocock.

Obtaining of funding: F. Gueyffier, J.P. Boissel.

Administrative, technical, or logistic support: F. Boutitie.

Collection and assembly of data: F. Gueyffier, R. Fagard, J.P. Boissel.


Ann Intern Med. 2002;136(6):438-448. doi:10.7326/0003-4819-136-6-200203190-00007
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Of the 40 777 patients randomly assigned to active treatment or control groups in the seven trials, we analyzed data on the 40 233 total patients alive at 1 year after study entry (Table 1). The mean follow-up was 3.9 years. Among the patients in our analysis, 48.9% (n = 19 692) were men and 27.7% (n = 11 107) were current smokers; 1312 patients (3.3%) had a history of myocardial infarction, 464 (1.1%) had a history of stroke, and 1420 (3.5%) had a history of diabetes mellitus. We could not include data on 31 995 1-year periods of follow-up (18.7%) in assessing a possible relation between fatal events and diastolic blood pressure because of missing blood pressure measurements. Overall, our analysis comprised data on 1655 deaths (56% of which were caused by cardiovascular events) during 126 908 total patient-years of follow-up.

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Figure 1.
Age- and sex-adjusted rates of events in six categories of achieved diastolic blood pressure and predicted continuous relationship in active treatment and control groups.squaresbars

Event rates ( ) and 95% CIs ( ) are shown for the following categories of achieved diastolic blood pressure: ≤ 65, 66–75, 76–85, 86–95, 96–105, and ≥ 106 mm Hg. The number of events is shown below each bar.

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Figure 2.
Age- and sex-adjusted rates of events in eight categories of achieved systolic blood pressure and predicted continuous relationship in active treatment and control groups.squaresbars

Event rates ( ) and 95% CIs ( ) are shown for the following categories of achieved systolic blood pressure: ≤ 120, 121–130, 131–140, 141–150, 151–160, 161–170, 171–180, ≥ 181 mm Hg. The number of events is shown below each bar.

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Summary for Patients

Relationship between Blood Pressure and Death among Treated Hypertensive Patients at the High and Low Ends of Blood Pressure Control

The summary below is from the full report titled “J-Shaped Relationship between Blood Pressure and Mortality in Hypertensive Patients: New Insights from a Meta-Analysis of Individual-Patient Data.” It is in the 19 March 2002 issue of Annals of Internal Medicine (volume 136, pages 438-448). The authors are F Boutitie, F Gueyffier, S Pocock, R Fagard, and JP Boissel. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians–American Society of Internal Medicine.

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