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What Is the Optimum Target Blood Pressure in Hypertension?

The optimum target blood pressure in patients with hypertension is unknown, and the role of aspirin in such patients is controversial. In the Hypertension Optimal Treatment (HOT) study, 18,790 patients with hypertension from 26 countries were randomly assigned a target diastolic blood pressure of less than or equal to 90 mm Hg, 85 mm Hg, or 80 mm Hg.

Felodipine was given as the initial baseline therapy. Additional therapy included sequential addition of either an angiotensin-converting enzyme (ACE) inhibitor or a beta-blocker; dosage titration of felodipine from 5 to 10 mg/day; doubling the dose of either the ACE inhibitor or beta-blocker; and, as a last step, the addition of a diuretic. Patients in each target group were randomized to receive aspirin (75 mg/day) or placebo. The average follow-up was 3.8 years.

The mean diastolic blood pressures achieved were 85.2 mm Hg, 83.2 mm Hg, and 81.1 mm Hg in the 90-, 85-, and 80-mm Hg target groups, respectively. Compared with the 90-mm Hg group, the 85-mm Hg and 80-mm Hg groups had small reductions in the rate of myocardial infarction (25 percent and 28 percent, respectively), neither of which was significant. However, among 1,501 diabetics, patients in the 80-mm Hg group had half the rate of major cardiovascular events than those in the 90-mm Hg group. Among patients with ischemic heart disease at study entry, patients in the 80-mm Hg group had a 43 percent reduction in stroke, compared with the 90-mm Hg group. For all patients, the lowest risk for cardiovascular events occurred at a diastolic pressure of 82.6 mm Hg and a systolic pressure of 138.5 mm Hg. Aspirin resulted in a 15 percent reduction in major cardiovascular events, including a 36 percent reduction in MI, and had no effect on stroke. Fatal hemorrhage occurred equally in the aspirin and placebo groups, but nonfatal major and minor bleeding were more frequent in patients receiving aspirin.

Comment: This landmark study demonstrates the benefits of lowering diastolic pressure to 85 mm Hg or less. There appears to be no clear benefit from lowering blood pressure substantially below these targets, except for diabetics, whose optimal diastolic pressure was closer to 80 mm Hg. Aspirin had a preventive effect on major cardiovascular events, particularly MI, although it caused a small increase in nonfatal major and minor bleeding.

— KA Eagle

Published in Journal Watch Cardiology July 24, 1998

Citation(s):

Hansson L et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: Principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998 Jun 13 351 1755-1762.

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