Pharmacotherapy for mild hypertension
Initiating drugs for mild hypertension offers minimal overall benefit; possible stroke reduction but more adverse withdrawals. Systematic review and meta-analysis of RCTs; Level 1a (2011 OCEBM).
Background
This 2025 Cochrane update reassessed whether starting antihypertensive pharmacotherapy in untreated mild hypertension without cardiovascular disease improves mortality or major cardiovascular outcomes.
Patients
- Adults with mild hypertension (SBP 140–159 or DBP 90–99 mmHg), no prior cardiovascular disease.
- 5 RCTs; n=9124 (4593 treatment; 4531 control); mean age ~50 years; mixed sex.
- One trial included microalbuminuria; otherwise lower baseline risk.
Intervention
Initiation of monotherapy or step‑up therapy (e.g., thiazides, beta‑blocker, ACE inhibitor).
Control
Placebo or no treatment.
Outcome
- Primary: All-cause mortality; total cardiovascular events.
- Secondary: Stroke; coronary heart disease; withdrawals due to adverse effects (WDAE).
Follow up period
2–5 years (weighted mean 4.4 years).
Results
| Outcome | Effect (RR, 95% CI) | Absolute risks (/1000) | NNT/NNH | Follow-up | Certainty |
|---|---|---|---|---|---|
| All-cause mortality (Primary) | 0.85 (0.64–1.14) | Control 21 → Treat 18 | NNT 333 | 2–5 y | Low |
| Total cardiovascular events (Primary) | 0.93 (0.69–1.24) | Control 25 → Treat 23 | NNT 500 | 2–5 y | Low |
| Stroke (Secondary) | 0.41 (0.20–0.84) | Control 7 → Treat 3 | NNT 250 | 2–5 y | Low |
| Coronary heart disease (Secondary) | 1.12 (0.80–1.57) | Control 18 → Treat 20 | NNH 500 | 2–5 y | Low |
| WDAE (Secondary) | 4.80 (4.14–5.57) | Control 23 → Treat 110 | NNH 12 | Up to 5 y | Low |
Limitations
- Low-certainty evidence: few events, imprecision, some risk of bias.
- Indirectness: stroke driven partly by microalbuminuria trial; WDAE dataset included mixed-risk patients.
- Older drug regimens; limited harms reporting.
- No robust subgroup data (sex, ethnicity, comorbidity).
Funding
Public grants (CIHR, provincial health); low commercial bias risk.
Citation
Wang D, Wright JM, Adams SP, Cundiff DK, Gueyffier F, Grenet G, Ambasta A. Pharmacotherapy for mild hypertension. Cochrane Database of Systematic Reviews. 2025; Issue 9: CD006742. doi:10.1002/14651858.CD006742.pub3.