Intensive blood pressure control to less than 130/80 mmHg may be associated with reduced major adverse cardiovascular events across stages II to IV of cardiovascular-kidney-metabolic syndrome, with no heterogeneity by stage, according to a recent post hoc secondary analysis of a cluster randomized clinical trial.
The primary composite outcome occurred less frequently with intensive therapy. Stroke contributed the largest absolute risk reduction within the composite outcome, and weighted analyses showed a positive net clinical benefit across all stages.
In the cluster randomized clinical trial, researchers enrolled 33,736 participants aged 40 years or older with hypertension from 326 rural villages in China, with a median follow-up of 3.02 years. The villages were randomly assigned to receive either a comprehensive intervention delivered by trained nonphysician community health care practitioners or usual care. The intervention incorporated a protocol-driven, stepped-care antihypertensive algorithm targeting systolic blood pressure (BP) less than 130 mmHg and diastolic BP less than 80 mmHg, in addition to structured lifestyle counseling and facilitated medication access. At 36 months, the intervention group achieved net systolic BP reductions ranging from 21.4 to 26.2 mmHg across syndrome stages.
Cardiovascular-kidney-metabolic syndrome staging was defined according to the 2023 American Heart Association framework. Stage II comprised metabolic risk or moderate- to high-risk chronic kidney disease, stage III included subclinical cardiovascular disease or a predicted 10-year cardiovascular risk of 20% or greater, and stage IV reflected established clinical cardiovascular disease.
The primary end point was a composite of myocardial infarction, stroke, heart failure, or cardiovascular death. All-cause mortality was reduced in stages II and III but not in stage IV. Hypotension occurred more frequently in the intensive treatment group across stages, whereas injurious falls and syncope didn't differ significantly between the groups; kidney adverse events were numerically higher in stage III but weren't statistically significant following correction for multiple comparisons. Absolute risk reductions in major adverse cardiovascular events ranged from 1.85% to 2.92%, whereas absolute risk increases in total adverse events ranged from 0.97% to 1.41%.
The researchers noted that their analysis had several limitations. As a post hoc evaluation of the China Rural Hypertension Control Project, the findings remained susceptible to residual confounding despite statistical adjustment. Cardiovascular-kidney-metabolic syndrome stages were assigned using available clinical measures without confirmation by imaging or biomarker data, which may have influenced classification accuracy, although similar definitions have been used in prior population-based investigations. All of the sites were rural primary care facilities with comparable diagnostic capabilities, reducing the likelihood of systematic staging differences across regions. Because all of the participants had hypertension at baseline, corresponding to at least stage II within the syndrome framework, earlier stages couldn't be assessed. Finally, the trial was conducted in rural, resource-limited settings, and extrapolation to urban or higher-resource health care environments should be undertaken with caution given potential differences in infrastructure and patient populations.
The researchers reported no conflicts of interest.
Source: JAMA Network Open