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Blood pressure–lowering drugs reduce cardiovascular events most in people with the highest initial risk

Sundstrom J, Arima H, Woodward M, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384:591-8.

Review question

Do drugs that are used to treat high blood pressure reduce major cardiovascular events (e.g., stroke, heart attack, coronary heart disease) more in people who initially have a higher vs lower risk of those events?


High blood pressure is usually defined as having a systolic blood pressure of 140 mm Hg or more or a diastolic blood pressure of 90 mm Hg or more. High blood pressure doesn’t always cause symptoms but can, over time, weaken or narrow blood vessels and cause strokes, heart attacks, or other heart problems.

Drugs that lower blood pressure can also reduce risk of cardiovascular events. They may work better in people who are initially at higher risk of cardiovascular events (e.g., older people, smokers, people with a family history of high blood pressure).

How the review was done

The researchers included data from 11 randomized controlled trials involving 51,917 people (average age 65 years, 45% women) in their analysis.

The key features of the trials were:

  • drugs were given to lower blood pressure and included angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace®], perindopril [Aceon®], trandolapril [Mavik®]), calcium channel blockers (e.g., amlodipine [Norvasc®, Amvaz®], felodipine [Plendil®]), and diuretics (e.g., indapamide [Lozol®]);
  • most drugs were compared with placebo, although some trials compared higher-dose with lower-dose drugs; and
  • outcome was major cardiovascular events (any of stroke, coronary heart disease [heart attack], heart failure [problems with the heart’s ability to pump blood], or other cardiovascular events).

What the researchers found

Compared with control (placebo or lower-dose drugs), blood pressure–lowering drugs:

  • reduced major cardiovascular events regardless of initial risk level; and
  • had a greater effect in people with the highest initial risk.


Blood pressure–lowering drugs reduce major cardiovascular events in people with different initial levels of risk. They provide the most benefit in people with the highest initial risk.

Blood pressure (BP)–lowering drugs vs control* in people with different levels of initial risk for major cardiovascular (CV) events†

Initial risk for CV event over 5 years

Number of people in risk group

Rate of events with BP-lowering drugs

Rate of events with control

Absolute effect of BP-lowering drugs over 5 years‡

< 11%




About 14 fewer people out of 1000 had a major CV event

11% to 15%




About 20 fewer people out of 1000 had a major CV event

15% to 21%




About 24 fewer people out of 1000 had a major CV event

> 21%




About 38 fewer people out of 1000 had a major CV event

*Most trials compared BP–lowering drugs with placebo; some compared higher-dose with lower-dose BP-lowering drugs.

†Major CV events include stroke, coronary heart disease (heart attack), heart failure (problems with the heart’s ability to pump blood), or other CV events.

‡The tendency for absolute benefit to increase along with initial risk was statistically significant.

Related Topics


Angiotensin-converting enzyme inhibitors
A group of medications that control the hormone system that regulates blood pressure and water balance in the body.
Calcium channel blockers
A group of medications that reduce the stiffness of large blood vessels and therefore lower (systolic) blood pressure.
Coronary heart disease
Also known as coronary artery disease (CAD), is a narrowing of the blood vessels (coronary arteries) that supply oxygen and blood to the heart.
The lower number in a blood pressure reading. It is the pressure when the heart rests between beats.
Medications that increase the elimination of water from the body. Used to treat heart failure, high blood pressure, and some kidney diseases.
A harmless, inactive, and simulated treatment.
Randomized controlled trials
Studies where people are assigned to one of the treatments purely by chance.
The higher number in a blood pressure reading. It is the pressure in the arteries when the heart beats.
The body's network of blood vessels. It includes the arteries, veins, and capillaries that carry blood to and from the heart.

Related Web Resources

  • Coronary artery disease risk screening

    Health Link B.C.
    Men over 40 and women past menopause or over 50 should get screened for coronary artery disease (CAD) every 1 to 3 years. Your risk is higher if you have diabetes, high blood pressure, abdominal obesity, kidney disease, family history of CAD or if you smoke.
  • High cholesterol: Does reducing the amount of fat in your diet help?

    Informed Health Online
    Eat less saturated fats in your diet to help prevent heart disease. Eat less meat, butter, cheese and cream to improve your health long-term.
  • Statins: Should I Take Them to Prevent a Heart Attack or Stroke?

    This patient decision aid helps people considering taking medicines called statins to lower their risk of heart attack and stroke by comparing the benefits, risks, and side effects of both options. It also includes alternative treatment options to taking statins such as trying to lower risk with lifestyle changes.
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