Department of Medicine, Penn State University Heart and Vascular Institute, Hershey, Pennsylvania.
Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center and College of Medicine, Hershey, Pennsylvania.
JAMA Netw Open. 2021 Oct 1;4(10):e2128980. doi: 10.1001/jamanetworkopen.2021.28980.
Low diastolic blood pressure (DBP) has been found to be associated with increased adverse cardiovascular events; however, it is unknown whether intensifying blood pressure therapy in patients with an already low DBP to achieve a lower systolic blood pressure (SBP) target is safe or effective.
To evaluate whether there is an association of baseline DBP and intensification of blood pressure-lowering therapy with the outcomes of all-cause death and cardiovascular events.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed patients who were randomized to intensive or standard BP control in the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial and Systolic Blood Pressure Intervention Trial (SPRINT). Data were collected from September 1999 to June 2009 (ACCORD-BP) and from October 2010 to August 2015 (SPRINT). Data were analyzed from December 2020 to June 2021.
Baseline DBP as a continuous variable.
All-cause death and a composite cardiovascular end point (CVE) that included cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.
A total of 14 094 patients (mean [SD] age, 66.2 [8.9] years; 8504 [60.4%] men) were included in this analysis. There were significant nonlinear associations between baseline DBP and all-cause death (eg, baseline DBP 50 vs 80 mm Hg: hazard ratio [HR], 1.48; 95% CI, 1.06-2.08; P = .02) and the composite CVE (eg, baseline DBP 50 vs 80 mm Hg: HR, 1.45; 95% CI, 1.27-3.04; P = .003) observed among all participants. Findings for the interaction between baseline DBP and treatment group assignment for all cause death did not reach statistical significance. For intensive vs standard therapy, the HR of death for a baseline DBP of 50 mm Hg was 1.80 (95% CI, 0.95-3.39; P = .07) and that for a baseline DBP of 80 mm Hg was 0.77 (95% CI, 0.59-1.01; P = .05). Overall, there was no interaction found between baseline DBP and treatment group assignment for the composite CVE. Over the range of baseline DBP values, significant reductions in the composite CVE for patients assigned to intensive vs standard therapy were found for baseline DBP values of 80 mm Hg (HR, 0.78; 95% CI, 0.62-0.98; P = .03) and 90 mm Hg (HR, 0.74; 95% CI, 0.55-0.98; P = .04).
This pooled cohort study found no evidence of a significant interaction between baseline DBP and treatment intensity for all-cause death or for a composite CVE. These results are hypothesis generating and merit further study.
已发现较低的舒张压（DBP）与心血管不良事件增加相关；然而，尚不清楚在已经低 DBP 的患者中强化降压治疗以实现更低的收缩压（SBP）目标是否安全或有效。
评估基线 DBP 与降压治疗强化之间与全因死亡和心血管事件结局的关联。
设计、设置和参与者：这项队列研究分析了在行动控制心血管风险中的糖尿病-血压（ACCORD-BP）试验和收缩压干预试验（SPRINT）中随机分配至强化或标准血压控制的患者。数据于 1999 年 9 月至 2009 年 6 月（ACCORD-BP）和 2010 年 10 月至 2015 年 8 月（SPRINT）期间收集。数据于 2020 年 12 月至 2021 年 6 月进行分析。
基线 DBP 作为连续变量。
全因死亡和复合心血管终点（CVE），包括心血管死亡、非致死性心肌梗死和非致死性卒中。
共有 14094 名患者（平均[SD]年龄，66.2[8.9]岁；8504[60.4%]为男性）纳入本分析。基线 DBP 与全因死亡（例如，基线 DBP 50 与 80mmHg：风险比[HR]，1.48；95%CI，1.06-2.08；P=0.02）和复合 CVE（例如，基线 DBP 50 与 80mmHg：HR，1.45；95%CI，1.27-3.04；P=0.003）之间存在显著的非线性关联。全因死亡的基线 DBP 与治疗组分配之间的交互作用的发现没有达到统计学意义。对于强化治疗与标准治疗，基线 DBP 为 50mmHg 时的死亡 HR 为 1.80（95%CI，0.95-3.39；P=0.07），而基线 DBP 为 80mmHg 时的 HR 为 0.77（95%CI，0.59-1.01；P=0.05）。总体而言，在复合 CVE 方面，基线 DBP 与治疗组分配之间没有发现交互作用。在基线 DBP 值范围内，与标准治疗相比，强化治疗的复合 CVE 在基线 DBP 值为 80mmHg（HR，0.78；95%CI，0.62-0.98；P=0.03）和 90mmHg（HR，0.74；95%CI，0.55-0.98；P=0.04）时显著降低。
这项汇总队列研究未发现全因死亡或复合 CVE 结局的基线 DBP 和治疗强度之间存在显著的交互作用。这些结果是产生假说的，值得进一步研究。
