How Should We Select Patients for Blood Pressure–Lowering Treatment? NEJM article

This is very interesting, as I developed unexplained high blood pressure years ago (when I had ME) and the first treatment - an ACE inhibitor - made me so ill I ended up in hospital with severe hyponatraemia (low blood sodium). It was almost low enough to kill me.

Maybe I don't need to take blood pressure lowering drugs at all! (I haven't had any heart problems as far as I know)

https://www.jwatch.org/na49648/2019...ients-blood-pressure-lowering?ijkey=EagjvFHes

How Should We Select Patients for Blood Pressure–Lowering Treatment?

Bruce Soloway, MD reviewing Herrett E et al. Lancet 2019 Aug 24 Kahan T. Lancet 2019 Aug 24

A retrospective study suggests that we should look at overall cardiovascular risk, regardless of baseline BP.

Should treatment to lower blood pressure (BP) be initiated based on baseline BP, overall cardiovascular (CV) risk, or a combination of the two? In a retrospective study, researchers analyzed CV outcomes in a British cohort of 1.2 million primary care patients (age range, 30–79) without baseline CV disease. They calculated how CV outcomes would have changed with one of four selection strategies for BP-lowering treatment:

• BP >140/90 mm Hg alone
  
• BP >140/90 mm Hg plus either CV risk score >20% (on QRISK2) or known diabetes or renal disease; or BP >160/90 mm Hg alone
  
• BP >140/90 mm Hg plus CV risk score >10%
  
• CV risk score >10% alone
  

More patients were eligible for treatment based on high BP alone than with any of the other strategies (39% vs. 22%, 27%, and 29%). During average follow-up of 4.3 years, the CV risk–only strategy identified a larger proportion of patients who developed CV disease than did any of the other strategies (68% vs. 63%, 47%, and 56%). Assuming that BP-lowering treatment would lower CV risk by 20%, the number needed to treat to prevent 1 adverse CV outcome during 10 years would be slightly lower with the CV risk–only strategy than with the other strategies (27 vs. 38, 28, and 29).

Comment

These data suggest that treatment to lower BP is most efficient when it is targeted to patients with elevated CV risk, regardless of baseline BP. One caveat is that the study cohort included few patients with systolic BP <120 mm Hg; thus, the analysis does not address patients with high CV risk but low baseline BP (e.g., a 65-year-old male smoker with hyperlipidemia and BP of 110/60 mm Hg). Current guidelines that recommend using both BP and CV-risk criteria might merit re-evaluation.

 

Here's the second review article on the issue:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31665-4/fulltext

and here is the first one referred to:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31359-5/fulltext