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Comment & Response
December 2017

Safety vs Efficacy of Lowering Blood Pressure

Author Affiliations
  • 1Department of Cardiology, Mount Sinai St Luke’s and Mount Sinai West, Mount Sinai Health System, New York, New York
  • 2Department of Cardiology, New York University School of Medicine, New York
  • 3Department of Cardiology, Mount Sinai Medical Center, New York, New York
  • 4Department of Cardiology, University of Bern, Bern, Switzerland
  • 5Department of Cardiology, Jagiellonian University, Krakow, Poland
JAMA Cardiol. 2017;2(12):1398-1399. doi:10.1001/jamacardio.2017.3534

To the Editor We read with interest the thorough network meta-analysis by Bundy et al1 showing that patients with a mean achieved systolic blood pressure (BP) of 120 to 124 mm Hg had significantly lower risk for cardiovascular disease and all-cause mortality compared with other groups. The authors’ conclusion supporting a more intensive BP control is solely based on evaluation of efficacy outcomes, and analysis of safety outcomes is conspicuously missing.1 In our recent network meta-analysis,2 we showed that systolic BP targets of less than 120 mm Hg and less than 130 mm Hg were ranked as the most efficacious targets, but systolic BP targets of less than 140 mm Hg and less than 150 mm Hg were found to be the safest targets. Of note, our network meta-analysis was restricted only to trials with a treat-to-target design and therefore, from a purist perspective, includes trials that were primarily designed to answer the question of target BP. The meta-analysis by Bundy et al1 includes a potpourri of trials with different designs, eg, enrolling patients with or without coronary artery disease and with or without diabetes, and therefore has important limitations. Moreover, the outcome of major cardiovascular disease events is a composite outcome that is not consistently reported in all of the studies. Therefore, it appears that the authors have simply added up the individual components of the end points, thereby double counting some events (and not performed the typical analysis of time to first event).

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