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
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Rodgers A, Atkins E, Salam A. Questionable Conclusions Regarding Blood Pressure End Points. JAMA Intern Med. 2018;178(4):575. doi:10.1001/jamainternmed.2018.0340
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