Elsevier

The Lancet

Volume 335, Issue 8693, 7 April 1990, Pages 827-838
The Lancet

EPIDEMIOLOGY
Blood pressure, stroke, and coronary heart disease: Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context

https://doi.org/10.1016/0140-6736(90)90944-ZGet rights and content

Abstract

There are 14 unconfounded randomised trials of antihypertensive drugs (chiefly diuretics or beta-blockers): total 37 000 individuals, mean treatment duration 5 years, mean diastolic blood pressure (DBP) difference 5-6 mm Hg. In prospective observational studies, a long-term difference of 5-6 mm Hg in usual DBP is associated with about 35-40% less stroke and 20-25% less coronary heart disease (CHD). For those dying in the trials, the DBP difference had persisted only 2-3 years, yet an overview showed that vascular mortality was significantly reduced (2p<0·0002); non-vascular mortality appeared unchanged. Stroke was reduced by 42% SD 6 (95% confidence interval 33-50%; 289 vs 484 events, 2p<0·0001), suggesting that virtually all the epidemiologically expected stroke reduction appears rapidly. CHD was reduced by 14% SD 5 (95% CI 4-22%; 671 vs 771 events, 2p<0·01), suggesting that just over half the epidemiologically expected CHD reduction appears rapidly. Although this significant CHD reduction could well be worthwhile, its size remains indefinite for most circumstances (though beta-blockers after myocardial infarction are of substantial benefit). At present, therefore, a sufficiently high risk of stroke (perhaps because of age, blood pressure, or, in particular, history of cerebrovascular disease) may be the clearest indication for antihypertensive treatment.

References (85)

  • Ab Carter

    Hypotensive therapy in stroke survivors

    Lancet

    (1970)
  • I. Hjermann et al.

    Effects of diet and smoking intervention on the incidence of coronary heart disease

    Lancet

    (1981)
  • Ob Holland et al.

    Diuretic-induced ventricular ectopic activity

    Am J Med

    (1981)
  • V. Papademetriou et al.

    Diuretic-induced hypokalemia in uncomplicated systemic hypertension: Effect of plasma potassium correction on cardiac arrhythmias

    Am J Cardiol

    (1983)
  • Rp Ames et al.

    Elevation of serum lipid levels during diuretic therapy of hypertension

    Am J Med

    (1976)
  • Jm Cruickshank et al.

    Benefits and potential harm of lowering high blood pressure

    Lancet

    (1987)
  • G. Berglund et al.

    Beta-blockers or diuretics in hypertension? A six-year follow-up of blood pressure and metabolic side effects

    Lancet

    (1981)
  • J. Berkson

    Are there two regressions?

    J Am Stat Assoc

    (1950)
  • C. Fletcher et al.

    The natural history of chronic bronchitis and emphysema.

    An eight-year study of early chronic obstructive lung disease in working men in London.

    (1976)
  • M. Harrington et al.

    Results of treatment of malignant hypertension

    Br Med J

    (1959)
  • S. Bjork et al.

    The effect of active drug treatment in severe antihypertensive disease

    Acta Med Scand

    (1961)
  • Jv Hodge et al.

    Results of hypotensive therapy in arterial hypertension: based on experience with 497 patients treated and 156 controls, observed for periods of one to eight years

    Br Med J

    (1961)
  • Ga Perera

    Antihypertensive drug versus symptomatic treatment in primary hypertension

    JAMA

    (1960)
  • Veterans Administration Cooperative Study Group on Antihypertensive Agents

    Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressure averaging 115 through 129 mm Hg

    JAMA

    (1967)
  • Report of the British Hypertension Society working party

    Treating mild hypertension. Agreement from the large trials

    Br Med J

    (1989)
  • World Health Organisation/International Society of Hypertension, Mild Hypertension Liaison Committee

    Trials of the treatment of mild hypertension: an interim analysis

    Lancet

    (1982)
  • Dg Beevers et al.

    The treatment of mild hypertension: a review

    Eur Heart J

    (1981)
  • Rg Wilcox et al.

    Treatment of high blood pressure: should clinical practice be based on results of clinical trials?

    Br Med J

    (1986)
  • Secondary prevention of vascular disease by prolonged antiplatelet treatment

    Br Med J

    (1988)
  • First report of the Early Breast Cancer Trialists Collaborative Group. Adjuvant endocrine and cytotoxic therapy in...
  • Hs Sacks et al.

    Should mild hypertension be treated? An attempted meta-analysis of the clinical trials

    Mount Sinai J Med

    (1985)
  • Pr Hebert et al.

    The community-based randomized trials of pharmacologic treatment of mild-to-moderate hypertension

    Am J Epidemiol

    (1988)
  • US Public Health Service Hospitals Cooperative Study Group (Smith WM)

    Treatment of mild hypertension: results of a ten-year intervention trial

    Circ Res

    (1977)
  • Veterans Administration/National Heart, Lung and Blood Institute Study Group for Cooperative Studies on Anttihypertensive Therapy: Mild Hypertension (Perry HM)

    Treatment of mild hypertension: preliminary results of a two-year feasibility trial

    Circ Res

    (1977)
  • Veterans Administration/National Heart, Lung, and Blood Institute Study Group for Evaluating Treatment in Mild Hypertension

    Evaluation of drug treatment in mild hypertension: VA-NHLBI feasibility trial

    Ann NY Acad Sci

    (1978)
  • Hypertension Detection and Follow-up Proggram Cooperative Group

    Five-year findings of the Hypertension Detection and Follow-up Program. I. Reduction in mortality in persons with high blood pressure, including mild hypertension

    JAMA

    (1979)
  • Hypertension Detection and Follow-up Program Cooperative Group

    Five-year findings of the Hypertension Detection and Follow-up Program. II. Mortality by race-sex and age

    JAMA

    (1979)
  • Hypertension Detection and Follow-up Program Cooperative Group

    Five-year findings of the Hypertension Detection and Follow-up Program. III. Reduction in stroke incidence among persons with high blood pressure

    JAMA

    (1982)
  • Hypertension Detection and Follow-up Program Cooperative Group

    The effect of treatment on mortality in "mild" hypertension

    N Engl J Med

    (1982)
  • Hypertension Detection and Follow-up Program Cooperative Group

    Effect of stepped care on the incidence of myocardial infarction and angina pectoris

    Hypertension

    (1984)
  • P. Leren et al.

    Oslo hypertension study

    Drugs

    (1986)
  • Australian National Blood Pressure Management Committee

    The Australian therapeutic trial in mild hypertension

    Lancet

    (1980)
  • Cited by (3552)

    • The Natural History of Untreated Hypertension

      2023, Hypertension: A Companion to Braunwald's Heart Disease
    View all citing articles on Scopus

    Correspondence to Clinical Trial Service Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK.

    View full text