Does all-cause mortality increase with lower Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP) values achieved through pharmacological treatment?

From the Guidelines

Lowering blood pressure too much through pharmacological means can indeed increase all-cause mortality, particularly in elderly patients and those with coronary artery disease, creating a J-curve relationship. While treating hypertension generally reduces cardiovascular risk, pushing systolic blood pressure (SBP) below approximately 120 mmHg or diastolic blood pressure (DBP) below 70 mmHg may increase mortality risk. This phenomenon appears most pronounced in patients with existing cardiovascular disease, where overly aggressive BP lowering can compromise coronary perfusion. Common medications associated with this risk include ACE inhibitors (like lisinopril), ARBs (such as losartan), calcium channel blockers (amlodipine), and diuretics (hydrochlorothiazide) 1. For most adults with hypertension, targeting SBP between 120-140 mmHg and DBP between 70-90 mmHg provides optimal benefit while minimizing risk, as shown in the SPRINT trial 1. The physiological explanation involves reduced coronary perfusion pressure during diastole, which can lead to myocardial ischemia, particularly in patients with arterial stiffness or coronary disease. Some key points to consider include:

• The SPRINT trial demonstrated a significantly lower risk of CVD events and all-cause mortality with intensive SBP lowering to <120 mmHg 1.
• The 2017 ACC/AHA hypertension guideline recommends a BP target of less than 130/80 mm Hg for adults with hypertension 1.
• However, individualizing blood pressure targets based on patient age, comorbidities, and overall cardiovascular risk profile is crucial to minimize risk and maximize benefit 1. Clinicians should therefore individualize blood pressure targets and carefully monitor patients to avoid overly aggressive BP lowering.

From the Research

All-Cause Mortality and Blood Pressure Targets

• The relationship between all-cause mortality and lower blood pressure targets achieved via pharmacology is complex and has been investigated in several studies 2, 3, 4, 5.
• A systematic review and meta-analysis found that intensive blood pressure-lowering treatment reduces the risk of cardiovascular events, but there was no significant reduction in all-cause death 4.
• Another study found that lower blood pressure targets do not reduce total mortality and may even increase the risk of adverse events 3, 5.
• The optimal blood pressure target for patients with hypertension remains unclear, and individualized treatment approaches are recommended 2, 5.

Blood Pressure Targets and Cardiovascular Outcomes

• Lower blood pressure targets may reduce the risk of myocardial infarction and congestive heart failure, but this reduction is not reflected in total serious adverse events 5.
• The benefits of lower blood pressure targets do not outweigh the harms for the general population of patients with elevated blood pressure 5.
• Combination therapy with multiple antihypertensive agents may be necessary to achieve adequate blood pressure control, especially in patients with chronic kidney disease or proteinuria 6.

Individualized Treatment Approaches

• Patients with different comorbidities, such as heart failure or diabetes, may require specialized treatment approaches 6.
• The selection of antihypertensive medications should be based on individual patient characteristics, including cardiovascular condition and potential contraindications 2, 6.
• Further research is needed to determine the optimal blood pressure targets for specific patient populations and to identify potential harms associated with lower blood pressure targets 3, 5.