Managing Blood Pressure in Adults Systematic Evidence Review From the Blood Pressure Expert Panel, 2013 Contents Foreword ............................................................................................................................................ vi Blood Pressure Expert Panel ..............................................................................................................vii Section 1: Background and Description of the NHLBI Cardiovascular Risk Reduction Project ............ 1 A. Background .............................................................................................................................. 1 Section 2: Process and Methods Overview ......................................................................................... 3 A. Evidence-Based Approach ....................................................................................................... 3 i. Overview of the Evidence-Based Methodology ................................................................. 3 ii. System for Grading the Body of Evidence ......................................................................... 4 iii. Peer-Review Process ....................................................................................................... 5 B. Critical Question–Based Approach ........................................................................................... 5 i. How the Questions Were Selected ................................................................................... 5 ii. Rationale for the Questions Selected ................................................................................ 5 Section 3: Inclusion/Exclusion Criteria for the Evidence Review ......................................................... 7 A. Literature Search Yield ............................................................................................................. 8 B. Populations Addressed in This Report ..................................................................................... 8 C. Definition of High Blood Pressure or Hypertension ................................................................... 8 D. Limitations ................................................................................................................................ 9 Section 4: Evidence Statements for Critical Question 1 (Pharmacotherapy and BP Thresholds) .................................................................................................................................. 11 Section 5: Evidence Statements for Critical Question 2 (Pharmacotherapy Treatment and BP Goals) .................................................................................................................................... 19 A. Statements for the General Population................................................................................... 19 B. Statements for the Population With Chronic Kidney Disease ................................................. 25 C. Statements for the Population With Diabetes ......................................................................... 28 Section 6: Evidence Statements for Critical Question 3 (Antihypertensive Agents) ........................... 33 A. Statements for the General Population................................................................................... 33 i. Summary of Evidence Statements for the General Population ........................................ 33 B. Other Drug Classes ................................................................................................................ 37 i. ACEIs Versus Other Drugs ............................................................................................. 38 ii. ARBs Versus Other Drugs .............................................................................................. 39 iii. Thiazide and Thiazide-Type Diuretics Versus Other Drugs ............................................. 40 iv. Beta Blockers Versus Other Drugs ................................................................................. 48 v. Calcium Channel Blockers Versus Other Drugs .............................................................. 50 vi. Combination Therapy ...................................................................................................... 52 vii. Other Drug Classes ........................................................................................................ 53 C. Statements for the Population With Chronic Kidney Disease ................................................. 54 i. Comments on Other Studies That Met the Eligibility Criteria But Were Not Addressed in the Above Evidence Statements ................................................................ 56 D. Statements for the Adult Population With Diabetes ................................................................ 57 i. Diuretic Evidence Statements in Diabetes ...................................................................... 57 ii. Beta Blocker Evidence Statements in Diabetes .............................................................. 59 iii. Angiotensin-Converting Enzyme Inhibitors Evidence Statements in Diabetes ................. 60 iv. Calcium Channel Blockers Evidence Statements in Diabetes ......................................... 61 MANAGING BLOOD PRESSURE IN ADULTS: SYSTEMATIC EVIDENCE REVIEW FROM THE BLOOD PRESSURE EXPERT PANEL, 2013 iii v. Combination Therapy in Diabetes ................................................................................... 62 vi. Evidence Statements for Blacks With Diabetes ............................................................... 63 Appendix A: Methods ................................................................................................................ A–1 Appendix B: Development of Evidence Tables and Summary Tables ....................................... B–1 Appendix C: Search Strategy Overview and Syntax of Queries .................................................C–1 Appendix D: Summary Tables ..................................................................................................D–1 Appendix E: Abbreviations and Acronyms ................................................................................ E–1 Appendix F: Names of Studies .................................................................................................. F–1 References ................................................................................................................................R–1 List of Tables Table 1. Evidence Quality Grading System ......................................................................................... 4 Table 2. Angiotensin-Converting Enzyme Inhibitors (ACEIs) Versus Calcium Channel Blockers (CCBs) ......................................................................................................................................... 33 Table 3. ACEIs Versus Angiotensin II Receptor Blockers (ARBs) ..................................................... 33 Table 4. Beta Blockers Versus ACEIs ............................................................................................... 34 Table 5. Beta Blockers Versus CCBs ............................................................................................... 34 Table 6. Beta Blockers Versus ARBs ................................................................................................ 34 Table 7. CCBs versus ARBs ............................................................................................................. 35 Table 8. Thiazide and Thiazide-Type Diuretics Versus Beta Blockers .............................................. 35 Table 9. Thiazide and Thiazide-Type Diuretics Versus ACEIs .......................................................... 35 Table 10. Thiazide and Thiazide-Type Diuretics Versus CCBs ......................................................... 36 Table 11. Thiazide and Thiazide-Type Diuretics Versus ARBs ......................................................... 36 Table 12. Thiazide and Thiazide-Type Diuretics Versus Alpha Blockers ........................................... 36 Table 13. Combination Therapy: ACEI/CCB Versus ACEI/Diuretic ................................................... 37 Table A–1. Quality Assessment Tool for Controlled Intervention Studies ........................................ A–7 Table B–1. Evidence Quality Grading System ................................................................................ B–3 Table C–1. Examples of Simple Queries ........................................................................................C –1 Table C–2. Attributes, Their Values, and Explanation .....................................................................C –2 Table C–3. Common Macro Queries Used in Search Strategies .................................................... C–2 Table D–1a. Evidence From Randomized Controlled Trials on Initiating Antihypertensive Pharmacological Therapy at SBP Thresholds <140 mmHg ........................................................ D–1 Table D–1b. Evidence From Randomized Controlled Trials on Initiating Antihypertensive Pharmacological Therapy at SBP Thresholds >140 mmHg ........................................................ D–2 Table D–1c. Evidence From Randomized Controlled Trials on Initiating Antihypertensive Pharmacological Therapy at SBP Thresholds ≥160 mmHg ........................................................ D–3 Table D–1d. Evidence From Randomized Controlled Trials on