Matthew Nudy, MD: Balancing the Benefits and Risk of Intensive Blood Pressure Control

New data from a trio of studies presented at the American College of Cardiology 2024 (ACC.24) Annual Scientific Session are offering insight into the benefits and risks of intensive blood pressure targeting based on systematic reviews and meta-analyses of randomized controlled trial data.

“There's really a lot of a lot of variability among these different studies. But like I said, when we excluded some of the trials, there was a statistically significant reduction in all-cause mortality and there was reduction in non-fatal stroke that we found as well. So, I think that there isn't a one size fits all approach for every single patient as far as intensive versus standard blood pressure control,” explained study investigator Matthew Nudy, MD, assistant professor of Medicine and Public Health Sciences at Penn State College of Medicine. “I think there are a lot of factors that need to be taken into account, like age of the patient, how frail is the patient? Is the patient experiencing polypharmacy? And are there any adherence issues to medications? So, I think there really needs to be like an individualized approach to intensive blood pressure control for patients.”

Intensive Blood Pressure Control and Nonfatal Myocardial Infarction

A systematic review and meta-analysis of 9 randomized controlled trials, the investigators’ study into the effects of intensive blood pressure control on nonfatal myocardial infarction included data from 25,524 participants. These individuals had a mean age of 66.9 (Standard Deviation [SD], 7.0) years, 43.9% were female, and the mean follow-up time was 3.8 years.

The primary outcome of interest of the study was the risk ratio (RR) for non-fatal myocardial infarction associated with intensive blood pressure control relative to standard blood pressure control.

Upon analysis, results indicated use of intensive blood pressure control did not significantly reduce the risk of non-fatal myocardial infarction among participants (7.5 vs 8.4 events per 1000 patient-years; RR 0.89; 95% CI 0.76 to 1.03; I2 = 0.00), with this effect not sensitive to the exclusion of any individual trial and not in correlation with any of the regressor variables tested by investigators.

Intensive Blood Pressure Control and Nonfatal Stroke

The systematic review and meta-analysis examining the effect of intensive blood pressure control on nonfatal stroke also featured 9 randomized controlled trials. These studies provided investigators with a cohort of 32,924 for inclusion. These individuals had a mean age of 66.7 (SD, 7.0) years, 43.3% were female, and the mean follow-up time was 4.0 years.

Upon analysis, results indicated intensive blood pressure control was associated with significant reduction in nonfatal relative to standard control, with this treatment effect not sensitive to the exclusion of any individual trial. Investigators found exclusi0on of the JATOS trial reduced heterogeneity the most (I2 = 12.7), while meta-regression revealed a significant correlation favoring intensive blood pressure control as follow-up time increased (R2 = 1.00; regression coefficient -0.11; P = .03).

Intensive Blood Pressure Control and All-Cause Mortality

The largest of the 3 systematic reviews and meta-analyses presented by Nudy and colleagues at ACC.24 contained 19 randomized control trials evaluating the effects of intensive and standard blood pressure control on all-cause mortality. From these 19 trials, investigators obtained information related to 55,821 participants for inclusion in their analysis.

Upon analysis, results indicated intensive blood pressure control did not result in a significant reduction in all-cause mortality (9.5 vs 10.0 events per 1000 patient-years; RR, 0.90; 95% Confidence Interval [CI] CI 0.80-1.02; I2 = 32.6). Investigators pointed out this effect became statistically significant with the individual exclusion of the HOT and JATOS trials. In meta regression analyses, results suggested a significant correlation favoring intensive control as the baseline risk of all-cause mortality in the control group increased (R2 = 1.00; coefficient -0.01; P = .001).

For more on these studies, check out our interview with Nudy from the conference floor at ACC.24.

References:

1. Bussa R, Nudy M, Ahmed M, et al. A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFECT OF INTENSIVE BLOOD PRESSURE CONTROL ON NONFATAL MYOCARDIAL INFARCTION. Presented at: American College of Cardiology (ACC.24) Annual Scientific Session. April 6 – 8, 2024. Atlanta, GA.
2. Bussa R, Nudy M, Ahmed M, et al. A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFECT OF INTENSIVE BLOOD PRESSURE CONTROL ON NONFATAL STROKE. Presented at: American College of Cardiology (ACC.24) Annual Scientific Session. April 6 – 8, 2024. Atlanta, GA.
3. Bussa R, Nudy M, Ahmed M, et al. A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFECT OF INTENSIVE BLOOD PRESSURE CONTROL ON ALL-CAUSE MORTALITY. Presented at: American College of Cardiology (ACC.24) Annual Scientific Session. April 6 – 8, 2024. Atlanta, GA.