title: Cardiovascular outcomes at different on-treatment blood pressures in the hypertensive patients of the VALUE trial.
abstract: OBJECTIVE
  Recent hypertension guidelines recommend that also in high cardiovascular (CV) risk, hypertensive patients blood pressure (BP) is lowered to <140/90 mmHg as no evidence is available supporting the lower target of <130/80 mmHg recommended in previous guidelines. Whether this represents the optimal treatment strategy is debated, however.
  
  
  RESULTS
  The high CV risk hypertensive patients of the Valsartan Antihypertensive Long-term use Evaluation (VALUE) trial were divided into subgroups according to (i) the percentage of on-treatment visits in which BP was reduced to <140/90 or <130/80 mmHg or (ii) the mean systolic or diastolic BP (SBP/DBP) values achieved during the entire treatment period or up to the occurrence of an event. A progressive increase from <25 to ≥75% of the visits in which BP was <140/90 mmHg was accompanied by a significant, progressive marked decrease in the covariate adjusted risk of CV morbidity and mortality, cause specific CV events (myocardial infarction, heart failure, and stroke), and all-cause mortality. Except for a persistent progressive decrease in stroke, no significant trend to a risk decrease occurred for a similar progressive increment of the proportion of visits with BP <130/80 mmHg. Increasing the proportion of visits with a BP <140/90 mmHg (but not <130/80 mmHg) was accompanied by a decreased risk of events also when differences in baseline risk were adjusted using a propensity score. Finally, compared with patients remaining at a mean on-treatment SBP ≥140 or DBP ≥90 mmHg, the risk of all events was markedly reduced when on-treatment mean SBP was lowered to a mean SBP of 130-139 mmHg or a mean DBP of 80-89 mmHg, whereas at on-treatment mean SBP <130 mmHg or DBP <80 mmHg, an additional risk reduction was found for stroke but for any other type of event, the risk of which remained similar or only slightly greater than that seen at the higher BP target.
  
  
  CONCLUSIONS
  In the high CV risk, hypertensives of the VALUE trial reducing BP consistently to <140/90 mmHg had marked beneficial effects both when data were calculated as proportion of visits at BP target or as on-treatment mean BP. Reducing BP to <130/80 mmHg led only to some possible further benefit on stroke, whereas the risk of other outcomes remained substantially similar to or slightly greater than that seen at the higher target. Thus, aggressive BP reductions when CV risk is high may not offer substantial advantages, except perhaps in patients or conditions in which stroke risk is particularly common.
authors.affiliation: IRCCS Istituto Auxologico Italiano, University of Milano-Bicocca, Via Ariosto, 13, 20146 Milan, Italy giuseppe.mancia@unimib.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Mancia
authors.affiliation: Faculty of Medicine, Department of Cardiology, University of Oslo, Ullevaal Hospital, Oslo, Norway Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
authors.forename: Sverre E
authors.initials: SE
authors.lastname: Kjeldsen
authors.affiliation: Novartis Pharma, East Hanover, NJ, USA.
authors.forename: Dion H
authors.initials: DH
authors.lastname: Zappe
authors.affiliation: Novartis Pharma AG, Basel, Switzerland.
authors.forename: Björn
authors.initials: B
authors.lastname: Holzhauer
authors.affiliation: Novartis Pharma, East Hanover, NJ, USA.
authors.forename: Tsushung A
authors.initials: TA
authors.lastname: Hua
authors.affiliation: IRCCS Istituto Auxologico Italiano, University of Milan, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Zanchetti
authors.affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Stevo
authors.initials: S
authors.lastname: Julius
authors.affiliation: Cardiovascular Division, State University of New York, Downstate College of Medicine, New York, NY, USA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Weber
mesh_terms: D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control; D012307:Risk Factors; D020521:Stroke / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control; D016896:Treatment Outcome; D000068756:Valsartan / Q000627:therapeutic use*
chemical_list: D000959:Antihypertensive Agents; D000068756:Valsartan
keywords: Antihypertensive treatment; Blood pressure; Cardiovascular risk; Coronary disease; Heart failure; Stroke