Reduction of diastolic blood pressure: Should hypertension guidelines include a lower threshold target?

Table 1 Summary of studies evaluating blood pressure thresholds

Study	Type	n	Age1	CAD2	DM2	CKD2	CVA2	Baseline DBP3	DBP J-curve by outcome	DBP J-curve Nadir3
Studies to target DBP
1967 JAMA	RCT	143	51	22	6			121	CV events and all-cause mortality	Not observed at 92
1970 JAMA	RCT	380	51					104	CV events and all-cause mortality	Not observed at 86
1979 Lancet	Case-Control	169	51					124	MI	90
1998 Lancet (HOT)	RCT	18790	62	6	8		1	105	CV events; CV and all-cause mortality	82-86
Studies in the elderly
1991 JAMA (SHEP)	RCT	4736	72	5	10		1	77	CVA and other CV events; CV mortality	Not observed at 70
1997 Lancet (Syst- Eur)	RCT	4695	70	30			4	86	CVA and other CV events; all-cause and CV mortality	Not observed at 81
2008 N Engl J Med (HYVET)	RCT	3845	84	12	6.8		7	90	CVA; all-cause mortality; CV mortality; CVA mortality	Not observed at 84
2016 JAMA (SPRINT)	RCT	2636	80	25	0	44	0	71	All CV events; CV mortality; all-cause mortality	Not observed at 65
Studies in CAD
2005 J Hypertens (ACTION)	Post-Hoc	7661	64	100	15			80	CV mortality; event or procedure; all-cause mortality; CVA	73
2006 Ann Intern Med (INVEST)	Post-Hoc	22576	66	100	29	2	5	87	All-cause mortality; non-fatal MI or CVA	84
2009 J Hypertension (ONTARGET)	Post-Hoc	25588	66	75	37		21	82	CV mortality and all CV events	75-79
2010 Am J Med (INVEST)	Post-Hoc	22576	66	100	29	2	5	87	All-cause mortality; non-fatal MI or CVA	70-75
2010 Eur Heart J (TNT)	Post-Hoc	10001	60	100	15		5	79	All CV events; CV and all-cause mortality	81
2010 Circulation (PROVE IT-TIMI)	Post-Hoc	4162	58	100	18	11	6	75	All-cause mortality and all CV events	84-85
2011 Circulation (ONTARGET)	Post-Hoc	12554	66	75	37		21	82	CV mortality and all CV events	80
2012 Hypertension (SMART)	Post-Hoc	5788	57 vs 65	60	17		28	82	CV events and all-cause morality	82
2016 Eur Rev MedPharmacol Sci	RCT	369	67	100	7			105	All CV events	75-80
2016 Eur Heart J (VALUE)	Post-Hoc	15244	67	46	32		20	87	All CV events; all-cause mortality	80
Studies in DM
1998 BMJ (UKPDS)	RCT	1148	56		100			94	All cause mortality	Not observed at 83
2002 Kidney Int (ABCD)	RCT	480	59		100			84	GFR changes; CV event; retinopathy; neuropathy	Not observed at 75
2005 J Am SocNephrol (IDNT)	RCT	1715	59	29	100	100		87	CV events and mortality	85
2010 JAMA (INVEST)	Post-Hoc	6400	66	100	100	4	9	85	All-cause mortality; non-fatal MI or CVA	SBP nadir 115, but no corresponding DBP nadir reported
2010 N Engl J Med (ACCORD)	RCT	4733	62	34	100			76	Non-fatal MI or CVA; CV mortality	Not observed at 68
2012 BMJ	Cohort	126092	67	10	100			83	All-cause mortality	75
Epidemiology studies
1991 BMJ (Framingham)	Cohort	5209	30-62						CV mortality; non-CV mortality	75-79
2003 Ann Intern Med (NHANES II)	Cohort	7830	54		5			82	All-cause mortality; CV mortality	79
2011 J Gen InternMed (NHANES I)	Cohort	13792	25-75						All-cause mortality	70-79
2014 J Am CollCardiol	Cohort	398419	64	19	30	24	8	73	All-cause mortality; ESRD	60-79

¹Mean and

²Units are %;

³Units are mmHg. ABCD: Appropriate Blood Pressure Control in Diabetes; ACCORD: Action to Control Cardiovascular Risk in Diabetes; CV: Cardiovascular; HOT: Hypertension Optimal Treatment; HYVET: Hypertension in the Very Elderly Trial; IDNT: Irbesartan Diabetic Nephropathy Trial; INVEST: International Verapamil SR Trandolapril Study; MI: Myocardial Infarction; NHANES: National Health and Nutrition Examination Survey; ONTARGET: Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial; PROVE IT-TIMI: Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction; RCT: Randomized Controlled Trial; SHEP: Systolic Hypertension in the Elderly Program; SMART: Secondary Manifestations of Arterial Disease; SPRINT: Systolic Blood Pressure Intervention Trial; Syst-Eur: Systolic Hypertension in Europe; TNT: Treating to New Targets; UKPDS: United Kingdom Prospective Diabetes Study; VALUE: Valsartan Antihypertensive Long-term use Evaluation.