Acupuncture for hypertension: Cochrane systematic review

Abstract

Background

Elevated blood pressure (hypertension) affects about one billion people worldwide. It is important as it is a major risk factor for stroke and myocardial infarction. However, it remains a challenge for the medical profession as many people with hypertension have blood pressure (BP) that is not well controlled. According to Traditional Chinese Medicine theory, acupuncture has the potential to lower BP.

Objectives

To assess the effectiveness and safety of acupuncture for lowering blood pressure in adults with primary hypertension.

Search methods

We searched the Hypertension Group Specialised Register (February 2017); the Cochrane Central Register of Controlled Trials (CENTRAL) 2017, Issue 2; MEDLINE (February 2017); Embase (February 2017), China National Knowledge Infrastructure (CNKI) (January 2015), VIP Database (January 2015), the World Health Organisation Clinical Trials Registry Platform (February 2017)
and ClinicalTrials.gov (February 2017). There were no language restrictions.

Selection criteria

We included all randomized controlled trials (RCTs) that compared the clinical effects of an acupuncture intervention (acupuncture used alone or add-on) with no treatment, a sham acupuncture or an antihypertensive drug in adults with primary hypertension.

Data collection and analysis

Two review authors independently selected studies according to inclusion and exclusion criteria. They extracted data and assessed the risk of bias of each trial, and telephoned or emailed the authors of the studies to ask for missing information. A third review author resolved disagreements. Outcomes included change in systolic blood pressure (SBP), change in diastolic blood pressure (DBP), withdrawal due to adverse effects, and any adverse events. We calculated pooled mean differences (MD) with 95% confidence intervals (CI) for continuous outcomes using a fixed-effect or random-effects model where appropriate.

Main results

Twenty-two RCTs (1744 people) met our inclusion criteria. The RCTs were of variable methodological quality (most at high risk of bias because of lack of blinding). There was no evidence for a sustained BP lowering effect of acupuncture; only one trial investigated a sustained effect and found no BP lowering effect at three and six months after acupuncture. Four sham acupuncture controlled trials provided very low quality evidence that acupuncture had a short-term (one to 24 hours) effect on SBP (change) -3.4 mmHg (-6.0 to -0.9) and DBP -1.9 mmHg (95% CI -3.6 to -0.3). Pooled analysis of eight trials comparing acupuncture with angiotensin-converting enzyme inhibitors and seven trials comparing acupuncture to calcium antagonists suggested that acupuncture lowered short-term BP better than the antihypertensive drugs. However, because of the very high risk of bias in these trials, we think that this is most likely a reflection of bias and not a true effect. As a result, we did not report these results in the 'Summary of findings' table. Safety of acupuncture could not be assessed as only eight trials reported adverse events.

Authors' conclusions

At present, there is no evidence for the sustained BP lowering effect of acupuncture that is required for the management of chronically elevated BP. The short-term effects of acupuncture are uncertain due to the very low quality of evidence. The larger effect shown in non-sham acupuncture controlled trials most likely reflects bias and is not a true effect. Future RCTs must use sham acupuncture controls and assess whether there is a BP lowering effect of acupuncture that lasts at least seven days.

Author(s)

Yang Jie, Chen Jiao, Yang Mingxiao, Yu Siyi, Ying Li, Liu Guan J, Ren Yu-lan, Wright James M, Liang Fan-rong

Summary

Acupuncture for primary hypertension in adults

Background

Hypertension (high blood pressure) affects about one billion people worldwide. Moreover, hypertension increases the risk of stroke and heart attack. Acupuncture is an important part of Traditional Chinese Medicine, in which thin needles are inserted into the skin at defined points. Acupuncture has been used to lower blood pressure and relieve symptoms of hypertension.

Study characteristics

We performed a systematic review of medical databases to find clinical trials that compared the effects of acupuncture to controls (sham (pretend) acupuncture, no treatment, or medicines) on blood pressure and safety in adults with hypertension. The results are current to February 2017.

Key results and certainty of the evidence

We found 22 trials including 1744 people. The trials did not look at death and general health. Four trials compared acupuncture with sham acupuncture and suggested a small short-lasting (one to 24 hours) reduction in blood pressure. The other trials were of very poor quality. There was no evidence for a long-lasting lowering of blood pressure by acupuncture that would be useful in the treatment of hypertension. We could not assess the safety of acupuncture as few trials reported this. At present, there is no evidence that acupuncture is useful in the management of long-lasting hypertension. Future trials must be designed to measure a sustained blood pressure lowering effect of acupuncture.

Reviewer's Conclusions

Implications for practice

At present, there is no evidence for the sustained blood pressure lowering effect of acupuncture that is required for the management of hypertension. Acupuncture may be associated with a short-term (one to 24 hour) reduction in blood pressure; however, in sham acupuncture trials, the effect at best is small (reduction in systolic/diastolic blood pressure of 3/2 mmHg) and likely clinically irrelevant. The larger effect shown in non-sham acupuncture controlled trials most likely reflects bias and not a true effect.

Implications for research

As hypertension is a chronic condition, it is essential that for acupuncture to be useful it must cause a sustained blood pressure lowering effect. Future randomized controlled trials (RCTs) are needed to determine whether acupuncture lowers blood pressure for at least seven days and preferably longer. The control group in these RCTs must be sham acupuncture. RCTs with improper controls and measuring short term effects on blood pressure are not needed.

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