[Skip to Content]
[Skip to Content Landing]
Views 102
Citations 0
Comment & Response
April 2018

Questionable Conclusions Regarding Blood Pressure End Points

Author Affiliations
  • 1The George Institute for Global Health, University of New South Wales Sydney, Newtown, Australia
  • 2The George Institute for Global Health, India, University of New South Wales, Hyderabad, India
JAMA Intern Med. 2018;178(4):575. doi:10.1001/jamainternmed.2018.0340

To the Editor The interpretation by Brunström and Carlberg1 that the reversibility of blood pressure (BP)-related risks (which are continuous from 115/75 mm Hg upwards2) somehow “turns off” at 140/90 mm Hg is incorrect for 2 main reasons. First, it is well-known that for a given intervention, the amount of BP lowering falls with lower baseline BP levels; therefore, lower relative-risk reductions at lower baseline BP levels are fully expected. Second, the results for the subgroup analysis for those with systolic BP less than 140 mm Hg are dominated by large trials of dual renin-angiotensin-aldosterone system antagonism.1 Such trials should not be included in a primary analysis assessing BP lowering because this strategy does not lower BP by any appreciable degree, has neutral or adverse effects on major events in most patient groups, and is generally contraindicated. Why would researchers give large weight to an intervention that would never be used and then infer those conclusions tell us about BP lowering when that intervention does not materially lower BP? Large trials such as ALTITUDE3 included only patients with BP less than 140/90 mm Hg and therefore drag down any overall effects seen in this group. It is surprising this issue was not addressed in a sensitivity analysis or mentioned in the discussion seeing as how the large weight given to these trials, if they are included, is the subject of a separate publication by the authors.4

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×