Hypertension Treatment Strategy Based on Clinical Trials Liu Lisheng,Is antihypertensive treatment beneficial? Trials of active treatment vs. placebo (or more vs. less) When should drug treatment start?(BP level? Mild hypertension? Risk stratifications?) Whom should be treated? (Severe, mild, ISH) To what extent? Is BP lowering by different antihypertensive agents equally beneficial? Necessity of Conducting Large-scale Clinical Studies using Asian Subjects,Is antihypertensive treatment beneficial? Trials of active treatment vs. placebo (or more vs. less) When should drug treatment start?(BP level? Mild hypertension? Risk stratifications?) Whom should be treated? (Severe, mild, ISH) To what extent? Is BP lowering by different antihypertensive agents equally beneficial? Necessity of Conducting Large-scale Clinical Studies using Asian Subjects,Isolated systolic hypertension,(%),(%),Stroke,CHD,All cause,CV,Non CV,Fatal and non-fatal events,Mortality,Systolic-diastolic hypertension,Stroke,CHD,All cause,CV,Non CV,Fatal and non-fatal events,Mortality,Event Reduction in Patients on Active Antihypertensive Treatment versus Placebo or No Treatment,ESH-ESC Hypertension Guidelines. J Hypertens. 2003.,0.01,0.01,0.001,NS,0.001,0.001,0.02,0.01,NS,0.001,Blood Pressure Lowering Treatment Trialists Collaboration Effects of Different Blood-Pressure-Lowering Regimens on Major Cardiovascular Events:,BPLT Trialists Collaboration. Lancet. 2003;362:152735.,Results of ProspectivelyDesigned Overviews of Randomized Trial,Meta-Analysis of Antihypertensive Treatment Trials: Effects on Major Cardiovascular Events,BPLT Trialists Collaboration. Lancet. 2003;362:152735.,Placebo-controlled studiesACEI vs placeboCA vs placeboMore vs lessActive vs active regimen studiesACEI vs D/BBCA vs D/BBACEI vs CA,Trials5 3 46 9 5,Relative risk0.78 (0.730.83) 0.82 (0.710.95) 0.85 (0.760.95)1.02 (0.981.07) 1.04 (1.001.09) 0.97 (0.921.03),0.5,1.0,2.0,Favours 2nd listed,Favours 1st listed,Relative risk,BP difference5 / 2 8 / 4 4 / 3+2 / 0 +1 / 0 +1 /+1,Meta-Analysis of Antihypertensive Treatment Trials: Effects on Stroke,BPLT Trialists Collaboration. Lancet. 2003;362:152735.,Placebo-controlled studiesACEI vs placeboCA vs placeboMore vs lessActive vs active regimen studiesACEI vs D/BBCA vs D/BBACEI vs CA,Trials5 4 45 9 5,BP difference5 / 2 8 / 4 4 / 3+2 / 0 +1 / 0 +1 /+1,Relative risk0.72 (0.640.81) 0.62 (0.470.82) 0.77 (0.630.95)1.09 (1.001.18) 0.93 (0.861.00) 1.12 (1.011.25),0.5,1.0,2.0,Favours 2nd listed,Favours 1st listed,Relative risk,Meta-Analysis of Antihypertensive Treatment Trials: Effects on CHD Events,BPLT Trialists Collaboration. Lancet. 2003;362:152735.,Placebo-controlled studiesACEI vs placeboCA vs placeboMore vs lessActive vs active regimen studiesACEI vs D/BBCA vs D/BBACEI vs CA,Trials5 4 45 9 5,Relative risk0.80 (0.730.88) 0.78 (0.620.99) 0.95 (0.811.11)0.98 (0.911.05) 1.01 (0.941.08) 0.96 (0.881.04),0.5,1.0,2.0,Favours 2nd listed,Favours 1st listed,Relative risk,BP difference5 / 2 8 / 4 4 / 3+2 / 0 +1 / 0 +1 /+1,Meta-Analysis of Antihypertensive Treatment Trials: Effects on Heart Failure,BPLT Trialists Collaboration. Lancet. 2003;362:152735.,Placebo-controlled studiesACEI vs placeboCA vs placeboMore vs lessActive vs active regimen studiesACEI vs D/BBCA vs D/BBACEI vs CA,Trials5 3 43 7 4,Relative risk0.82 (0.690.98) 1.21 (0.931.58) 0.84 (0.591.18)1.07 (0.961.19) 1.33 (1.211.47) 0.82 (0.730.92),0.5,1.0,2.0,Favours 2nd listed,Favours 1st listed,Relative risk,BP difference5 / 2 8 / 4 4 / 3+2 / 0 +1 / 0 +1 /+1,Comparisons of ARB-Based Regimens With Control Regimens,BPLT Trialists Collaboration. Lancet. 2003;362:152735.,0.5,1.0,2.0,Favours Control,Favours ARB,Relative risk,StrokeCHDHeart failureMajor CV eventsCV deathTotal mortality,Trials443444,Relative risk (95% CI)0.79 (0.690.90)0.96 (0.851.09)0.84 (0.720.97)0.90 (0.830.96)0.96 (0.851.08)0.94 (0.861.02),396/8412435/8412302/59351135/8412491/8412887/8412,500/8379450/8379359/59191268/8379511/8379943/8379,Diff. in BP (mean, mmHg)2 / 12 / 12 / 12 / 12 / 12 / 1,P0.460.430.260.780.340.59,Events / Participants,Trials Comparing Different Antihypertensive Regimens: New Onset Diabetes,Zanchetti, Ruilope. J Hypertens. 2002;20:2099110.,TrialSHEP HOPE NORDIL STOP-2 INSIGHT NICS-EH CAPPP STOP-2 STOP-2 LIFE SCOPE ALLHAT ALLHAT INVEST,ComparisonD vs P ACE vs P CA vs D/B CA vs D/B CA vs D CA vs D ACEI vs D/B ACEI vs D/B ACEI vs CA AIIA vs B AIIA vs usual D vs CA D vs ACEI CA vs B,Years34.54.5 53.5 56.1 5 54.83.7 4 42.7,18.63.6 - -4.3 0 - - - 64.3 11.6 11.66.9,PNS 0.001 NS NS 0.05 NS0.039 NS NS 0.0010.090.04 0.001,Treatment,27.5 5.4 - - 5.6 1.9 - - - 8 5.3 9.8 9.1 7.9,- - 9.4 9.9 - - - 9.6 9.6 13.0,2- - 10.8 10.0 - - - 10.09.9 17.4,RR (95% CI)- 0.66 (0.510.85) 0.87 (0.731.04) 0.97 (0.731.29) - - 0.86 (0.740.99) 0.96 (0.721.27) 0.98 (0.741.31) 0.75 (0.630.88) - - - 0.87 (0.780.97),