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Risk–benefit profile of intensive blood pressure treatment

2018; Elsevier BV; Volume: 6; Issue: 8 Linguagem: Inglês

10.1016/s2213-8587(18)30175-x

2213-8595

João Sérgio Neves, Lia Leitão, Rita Magriço, Catarina Viegas Dias, Miguel Bigotte Vieira,

Sodium Intake and Health

We read with interest the article by Srinivasan Beddhu and colleagues1Beddhu S Greene T Boucher R et al.Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trials.Lancet Diabetes Endocrinol. 2018; 6: 555-563Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar that reported the effect of intensive blood pressure treatment on the incidence of chronic kidney disease. The authors did a combined secondary analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial2The SPRINT Research GroupA randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373: 2103-2116Crossref PubMed Scopus (3210) Google Scholar and the Systolic Blood Pressure Intervention Trial (SPRINT).3Margolis KL O'Connor PJ Morgan TM et al.Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial.Diabetes Care. 2014; 37: 1721-1728Crossref PubMed Scopus (165) Google Scholar They concluded that intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in patients both with and without type 2 diabetes. Although we agree that these results are important for helping physicians to manage patients with hypertension, considering the potential cardiovascular benefits of intensive treatment is also essential. SPRINT showed a decrease in major cardiovascular events or death with intensive blood pressure treatment in patients without diabetes.2The SPRINT Research GroupA randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373: 2103-2116Crossref PubMed Scopus (3210) Google Scholar A post-hoc analysis of SPRINT-eligible participants of the ACCORD trial (patients with type 2 diabetes and additional cardiovascular risk factors) also showed that intensive blood pressure treatment was associated with a reduced risk of cardiovascular events.4Buckley LF Dixon DL Wohlford 4th, GF Wijesinghe DS Baker WL Van Tassell BW Intensive versus standard blood pressure control in SPRINT-eligible participants of ACCORD-BP.Diabetes Care. 2017; 40: 1733-1738Crossref PubMed Scopus (44) Google Scholar Thus, the evaluation of the risk–benefit association of intensive treatment and the identification of predictors of the risk–benefit association are of major relevance in patients both with and without diabetes. We used the SPRINT Data Analysis Challenge dataset to evaluate the risk–benefit profile of intensive blood pressure treatment focusing on the balance between cardiovascular events or death and incident chronic kidney disease.5Magriço R Bigotte Vieira M Viegas Dias C Leitão L Neves JS BP reduction, kidney function decline, and cardiovascular events in patients without CKD.Clin J Am Soc Nephrol. 2018; 13: 73-80Crossref PubMed Scopus (13) Google Scholar Large reductions in mean arterial pressure were associated with increased incident chronic kidney disease. In a propensity score analysis, a reduction in mean arterial pressure of less than 20 mm Hg was associated with a number needed to treat (NNT; cardiovascular events or death) of 44 and a number needed to harm (NNH; kidney function decline) of 65, a reduction of between 20 mm Hg and less than 40 mm Hg was associated with an NNT of 42 and an NNH of 35, and a reduction of more than 40 mm Hg was associated with an NNT of 95 and an NNH of 16. Thus, intensive treatment seems to be less favourable when a larger reduction in mean arterial pressure is needed to achieve the blood pressure target than a smaller reduction in mean arterial pressure. Our results highlight the importance of considering the risk–benefit profile of intensive blood pressure treatment in patients without diabetes. In patients with diabetes, assessing the risk–benefit profile of intensive treatment according to the magnitude of blood pressure reduction would also have been interesting. Future research should also focus on the evaluation of personalised targets for blood pressure treatment according to the balance between the risk of incident chronic kidney disease and the potential cardiovascular benefit. We declare no competing interests. Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trialsIntensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Full-Text PDF Risk–benefit profile of intensive blood pressure treatment – Authors' replyWe thank João Sérgio Neves and colleagues for their letter on our paper on incident chronic kidney disease in the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial.1 We agree that a concurrent assessment of the presumed benefits and adverse effects of treatment is desirable. However, on-treatment observational analyses provide limited capacity to assess benefits and risks of treatment. Their paper2 on achieved mean arterial pressure and the risk of incident chronic kidney disease in SPRINT highlights the perils of drawing causal inferences on modification of the effects of the intervention on outcomes by use of a post-randomisation exposure variable (achieved mean arterial pressure in this instance). Full-Text PDF