AVERAGE ACHIEVED BP <130/80 MMHG IN HIGH-RISK MIDDLE-AGED AND OLDER HYPERTENSIVE PATIENTS PROVIDES STRONG CARDIOVASCULAR PROTECTION EXCEPT IN LEFT VENTRICULAR HYPERTROPHY

Objective: Evidence that reducing blood pressure (BP) to <130/80 mmHg rather than to <140/90 mmHg by antihypertensive treatment in hypertensive patients is conflicting. Left ventricular hypertrophy (LVH) is common in hypertension, and low perfusion pressure may result in ischemia in patients with LVH. We investigated whether average achieved BP <130/80 mmHg implied cardiovascular benefits in high-risk middle-aged and older hypertensive patients who participated in the VALUE Trial. Considering a previous report of excess mortality in LVH patients with in-treatment systolic BP (SBP) <130 mmHg, we paid special attention to whether the average achieved SBP <130 mmHg may cause harm in similar patients with LVH. Design and method: Of the 15,245 participants, we identified 13,803 patients without cardiovascular events during the first six months after randomization during which previous medications were discontinued and study drugs up-titrated. Of these, 2,458 patients had LVH on an electrocardiogram (ECG). Cox analyses adjusted for age, gender, and baseline variables compared cardiac and all-cause mortality and other pre-specified endpoints for patients who achieved average SBP 130 - 139 mmHg (No LVH group n = 4,863, ECG LVH group n = 929) and <130 mmHg (No LVH group n = 2,107, ECG LVH group n = 305). Reference groups were patients who achieved an average SBP > = 140 mmHg following the first excluded six months (No LVH group n = 4,375, ECG LVH group n = 1,224). Results: The No LVH group with average achieved BP <130/80 mmHg had a significantly lower incidence of all endpoints except for myocardial infarction. The ECG LVH group with average achieved SBP <130 mmHg had increased cardiac mortality (HR = 1.98, p = 0.032) and all-cause mortality (HR = 1.74, p = 0.007), and SBP <130 mmHg was not associated with a reduction in any endpoint. However, as in those without LVH, the ECG-LVH group had fewer strokes and heart failure with an average achieved diastolic BP <80 mmHg. Conclusions: Our data suggest that target SBP <130 mmHg may cause harm and needs further investigation in middle-aged and older patients with LVH detected by ECG. Otherwise, the average achieved BP <130/80 mmHg prevents most cardiovascular endpoints in middle-aged and older hypertensive patients with high cardiovascular risk but without LVH.