Treatment blood pressure targets for hypertension

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Abstract
When treating elevated blood pressure, doctors need to know what blood pressure (BP) target they should try to achieve. The standard of clinical practice for some time has been ≤ 140 ‐ 160/ 90 ‐ 100 mmHg. New guidelines are recommending BP targets lower than this standard. It is not known whether attempting to achieve targets lower than the standard reduces mortality and morbidity. To determine if lower BP targets (≤ 135/85 mmHg) are associated with reduction in mortality and morbidity as compared with standard BP targets (≤ 140‐160/ 90‐100 mmHg). Electronic search of MEDLINE (1966‐2008), EMBASE (1980‐2008), and CENTRAL (up to June 2008); references from review articles, clinical guidelines, and clinical trials. Randomized controlled trials comparing patients randomized to lower or to standard BP targets and providing data on any of the primary outcomes below. Two reviewers (JAA, MIP) independently assessed the included trials and data entry. Primary outcomes were total mortality; total serious adverse events; total cardiovascular events; myocardial infarction, stroke, congestive heart failure and end stage renal disease. Secondary outcomes were achieved mean systolic and diastolic BP and withdrawals due to adverse effects. No trials comparing different systolic BP targets were found. Seven trials (22,089 subjects) comparing different diastolic BP targets were included. Despite a ‐4/‐3 mmHg greater achieved reduction in systolic/diastolic BP, p< 0.001, attempting to achieve "lower targets" instead of "standard targets" did not change total mortality (RR 0.92, 95% CI 0.86‐1.15), myocardial infarction (RR 0.90, 95% CI 0.74‐1.09), stroke (RR 0.99, 95% CI 0.79‐1.25) , congestive heart failure (RR 0.88, 95% CI 0.59‐1.32), major cardiovascular events (RR 0.94, 95% CI 0.83‐1.07), or end‐stage renal disease (RR 1.01, 95% CI 0.81‐1.27). The net health effect of lower targets cannot be fully assessed due to lack of information regarding all total serious adverse events and withdrawals due to adverse effects in 6 of 7 trials. A sensitivity analysis in diabetic patients and in patients with chronic renal disease also did not show a reduction in any of the mortality and morbidity outcomes with lower targets as compared to standard targets. Treating patients to lower than standard BP targets, ≤140‐160/90‐100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients. 高血壓治療之目標 治療高血壓時,醫師應設定目標血壓。臨床上一般以，140  160/90  100 毫米汞柱(mmHg)為目標。目前較新的治療準則則是設定在更低的血壓，然而這是否能進一步降低死亡率及相關併發症則是未知。 探討更嚴格的血壓控制在135/85 毫米汞柱，是否能比傳統的140 – 160/90 – 100 毫米汞柱進一步降低死亡率及相關併發症。 搜尋的資料庫包括MEDLINE (1966 – 2008), EMBASE (1980 – 2008), and CENTRAL (2008/06)裡的review article,臨床治療準則以及臨床試驗。 以隨機對照試驗的方式，比較標準血壓控制，以及血壓控制較低的兩組。 由兩位不同的評論者，獨立評估各個試驗及相關數據。分析目標包括整體死亡率嚴重不良反應整體心血管疾病比例心肌梗塞，中風，心衰竭，及末期腎臟疾病。從屬分析目標包括達成之平均收縮壓及舒張壓，以及因相關不良反應而中輟參與的比例。 ˋ搜尋資料庫並沒有找到針對不同收縮壓目標做探討的研究。另有7個研究，共22,089個受試者，針對不同的舒張壓目標探討。和標準血壓控制目標的組別相比，將血壓控制在較低標準的組別,收縮壓降低至少4毫米汞柱，舒張壓降低至少3毫米汞柱，(p< 0.001)，卻未能改變整體死亡率(RR 0.92, 95% CI 0.86 – 1.15)，心肌梗塞(RR 0.90, 95% CI 0.74 – 1.09)，中風(RR 0.99, 95% CI 0.79 – 1.25)，心衰竭(RR 0.88, 95% CI 0.59 – 1.32)，重大心血管事件(RR 0.94, 95% CI 0.83 – 1.07)，或末期腎臟病(RR 1.01, 95% CI 0.81 – 1.27)的比例。然而在7個研究中，有6個研究缺乏關於整體不良反應及因此中輟參與研究的資訊，因此無法完整評估較低的血壓標準於整體健康之效應。針對糖尿病病人及慢性腎臟病病人之敏感性分析，也表示未能降低死亡率及相關併發症。 將病人的血壓控制在低於標準血壓140 – 160/90100 毫米汞柱，並不能降低死亡率及併發症之比例。此外，由於臨床治療準則建議將糖尿病及慢性腎臟病病人的血壓控制在較低的標準，我們目前正在進行對此一特殊族群之系統性的探討分析。 本摘要由臺北榮民總醫院廖若男翻譯。 此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。 網的高血壓會增加心血管疾病及中風之風險。高血壓的定義是血壓大於140∼160/90∼100毫米汞柱，也因此這被設定為血壓控制的標準。在過去5年，某些特定族群的研究中，觀察到將血壓降低到140/90毫米汞柱以下，可以降低心血管疾病及中風的現象，因此高血壓的專家傾向於將血壓控制在更低的標準，然而這樣的做法尚未廣為接受。這一篇文章即是藉著搜尋所有相關的研究，去探討較低的血壓控制標準是否更好。分析7個研究中，超過22,000個受試者，發現使用更多藥物以達成較低的血壓控制，並不能延長存活率或降低中風、心血管疾病、心臟衰竭、或腎臟衰竭之比例。我們需要更多的研究來針對此一議題做更多的探討，然而到目前為止，並沒有證據支持將血壓控制在比140/90毫米汞柱以下。...