Achieved diastolic blood pressure and pulse pressure at target systolic blood pressure (120-140 mmHg) and cardiovascular outcomes in high-risk patients: Results from ONTARGET and TRANSCEND trials

Aims: Current guidelines of hypertensive management recommend upper limits for systolic (SBP) and diastolic blood pressure (DBP). J-curve associations of BP with risk exist for some outcomes suggesting that lower limits of DBP goals may also apply. We examined the association between mean attained DBP and cardiovascular (CV) outcomes in patients who achieved an on-treatment SBP in the range of 120 to < 140 mmHg in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomized AssessmeNt Study in ACE iNtolerant participants with cardiovascular Disease (TRANSCEND) trials on patients with high CV risk. This SBP range was associated with the lowest CV risk. Methods: We analysed the outcome data from patients age 55 years or older with CV disease from the ONTARGET and TRANSCEND trials that randomized high-risk patients to ramipril, telmisartan, and the combination. In patients with controlled SBP (on-treatment 120 to < 140 mmHg), the composite outcome of CV death, myocardial infarction, stroke and hospital admission for heart failure, the components thereof, and all-cause mortality were analysed according to mean on-treatment DBP as categorical ( < 70, 70 to < 80, 80 to < 90, and ≥90 mmHg) and continuous variable as well as the change of DBP according to baseline DBP. Pulse pressure (PP) was related to outcomes as a continuous variable. Results: In 16 099 of 31 546 patients, mean achieved SBP was 120 to < 140 mmHg. The nominally lowest risk for all outcomes was observed at an achieved DBP of 70 to < 80 mmHg. A higher achieved DBP was associated with a higher risk for the outcomes of stroke and of hospitalization for heart failure (≥80 mmHg) and myocardial infarction (≥90 mmHg). A lower achieved DBP ( < 70 mmHg) was associated with a higher risk for the primary outcome [hazard ratio (HR) 1.29, 95% confidence interval (95% CI) 1.15–1.45; P  <  0.0001], myocardial infarction HR 1.54 (95% CI 1.26–1.88, P  <  0.0001) and hospitalization for heart failure HR 1.81 (95% CI 1.47–2.24, P  <  0.0001) and all-cause death (HR 1.19, 95% CI 1.04–1.35; P  <  0.0001) while there was no signal for stroke and CV death compared to DBP 70 to < 80 mmHg. A decrease of DBP was associated with lower risk when baseline DBP was > 80 mmHg. The associations to outcomes were similar when patients were divided to SBP 120 to < 130 mmHg or 130 to < 140 mmHg for DBP or PP. Conclusion: Compared to a DBP of 70 to < 80 mmHg, lower and higher DBP was associated with a higher risk in patients achieving a SBP of 120 to < 140 mmHg. Associations of DBP and PP to risk were similar notably at controlled SBP. These data suggest at optimal achieved SBP, risk is still defined by low or high DBP. These findings support guidelines which take DBP at optimal SBP control into consideration.