CARDIOVASCULAR OUTCOMES AT DIFFERENT

ON-TREATMENT BLOOD PRESSURES IN THE

HYPERTENSIVE PATIENTS OF THE VALUE TRIAL
Giuseppe Mancia1*, Sverre E. Kjeldsen2*3, Dion H. Zappe4, Bjorn Holzhauer5,
Tsushung A. Hua4, Alberto Zanchetti6, Stevo Julius7, and Michael A. Weber

Dewi Resnawita
Abdul Hakim Alkatiri
INTRODUCTION
Recent review emphasized that little evidence supports blood
pressure (BP) in individuals at high cardiovascular (CV) risk should
be reduced to <130/80 mmHg rather than to < 140/90 mmHg

Post hoc analysis : lower BP target might lead to an attenuation or

even a disappearance of the protective effect of antihypertensive
treatment

In the present study we adressied above issue by analysing VALUE

trial database
METHODS

Design & Patient in VALUE trial

patients Qualifying risk factor

BP 2 arms : valsartan (start 80mg) & Amlodipine (start 5 mg)

Followed up to 4-6 years (every month for 6 mo. & every
measurement 6 mo. thereafter).
& follow up Measured with mercury sphygmomanometer after patient
sitting for 5 min,
METHODS
Primary endpoint : first cardiac event
Clinical Secondary endpoint : all major CV event, fatal and
outcomes nonfatal stroke, myocardial infarction, hospitalized
heart failure, and CV or all-cause mortality

Relative risk of each endpoint was quantified for each

Data subgroup, using an
proportional hazards model
exponential time-to-event

analysis Cox regression model was stratified according to the

deciles of a propensity score.
Data analysis
BP <140/90
SBP and
dan
DBP
<130/80
< 25 % (mmHg) >140, 130-139, <130
mmHg

25-49 % >90, 80-89, <80

50-74 %

>75 %
RESULTS
Event incidence and risk according to percentage of visits with blood
pressure <140/90 mmHg

Both for the primary and for all secondary endpoints,

the event incidence decreased progressively as the
percentage of visits with BP < 140/90 mmHg increased

The greatest reduction in risk almost always occurred when

BP control (< 140/90 mmHg) progressed from <25 to 25-49%
of the visits, with a further more modest or no decrease when
the rate of BP control increased to 50-74 and >75% of the
visits
Figure 2 Figure 3
Event incidence and risk according to percentage
of visits with blood pressure <130/80 mmHg
Progressive increase in the percentage of visits with BP < 130/80
mmHg was not accompanied by a progressive reduction of the
incidence of outcome, except stroke
Risk of all types of outcomes were significantly reduced when per cent
BP control < 130/80 mmHg increased from <25 to 25-49% but relative
risk increased and often lost significance when per cent control rose to
>50%.
Event risk according to achieved mean systolic
blood pressure or diastolic blood pressure values
Compared with patients in whom mean on-treatment SBP remained
>140mmHg, the adjusted risk of all events decreased significantly and
markedly in the group in which mean SBP was reduced to between
130 and 139 mmHg nd was not further reduced in the group with SBP
< 130 mmHg
DISCUSSION
Two distinct types of analysis point to the same
conclusion that targeting SBP/DBP to values < 140/90
mmHg, and achieving target with consistency, is
accompanied by a marked reduction in all types of
hypertension-associated outcomes.

Meta-analysis : Significant reduction of all outcomes when

SBP was reduced by active treatment within the range of
130-139 mmHg
 Our findings support the recommendation of the recent
European and American guidelines to adopt a BP of <
140/90 mmHg as the target to reach with treatment,
independently of the level of CV risk.

According to the present data, this strategy would not

substantially interfere with the protective effect that
accompanies the SBP reduction.
 Intense BP reduction could represent a treatment strategy
to be recommended in populations in which stroke
accounts for the largest fraction of morbid or fatal CV
events.

it further suggests that lack of BP control over a large

number of visits may contribute to the persistently high
level of organ damage
 CONCLUSION
in high-risk hypertensives, aggressive BP
reductions may enhance cerebrovascular pro-
tection, with no reversal, or only a partial
attenuation, of the overall CV benefit achieved by
the less aggressive BP target recommended by
guidelines.
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