Optimal Targets in Treatment of Hypertension
Optimal Targets in Treatment of Hypertension
Objectives To investigate the optimal systolic blood pressure goal above which new antihypertensive medications should be added or doses of existing medications increased (“systolic intensification threshold”) and to determine the relation between delays in medication intensification and follow-up and the risk of cardiovascular events or death.
Design Retrospective cohort study.
Setting Primary care practices in the United Kingdom, 1986-2010.
Participants 88 756 adults with hypertension from The Health Improvement Network nationwide primary care research database.
Main outcome measures Rates of acute cardiovascular events or death from any cause for patients with different hypertension treatment strategies (defined by systolic intensification threshold, time to intensification, and time to follow-up over the course of a 10 year treatment strategy assessment period) after adjustment for age, sex, smoking status, socioeconomic deprivation, history of diabetes, cardiovascular disease or chronic kidney disease, Charlson comorbidity index, body mass index, medication possession ratio, and baseline blood pressure.
Results During a median follow-up of 37.4 months after the treatment strategy assessment period, 9985 (11.3%) participants had an acute cardiovascular event or died. No difference in risk of the outcome was seen between systolic intensification thresholds of 130-150 mm Hg, whereas systolic intensification thresholds greater than 150 mm Hg were associated with progressively greater risk (hazard ratio 1.21, 95% confidence interval 1.13 to 1.30; P<0.001 for intensification threshold of 160 mm Hg). Outcome risk increased progressively from the lowest (0-1.4 months) to the highest fifth of time to medication intensification (hazard ratio 1.12, 1.05 to 1.20; P=0.009 for intensification between 1.4 and 4.7 months after detection of elevated blood pressure). The highest fifth of time to follow-up (>2.7 months) was also associated with increased outcome risk (hazard ratio 1.18, 1.11 to 1.25; P<0.001).
Conclusions Systolic intensification thresholds higher than 150 mm Hg, delays of greater than 1.4 months before medication intensification after systolic blood pressure elevation, and delays of greater than 2.7 months before blood pressure follow-up after antihypertensive medication intensification were associated with increased risk of an acute cardiovascular event or death. These findings support the importance of timely medical management and follow-up in the treatment of patients with hypertension.
Hypertension is the single most common risk factor for both cardiovascular and overall disease burden and mortality worldwide, and the medical treatment of hypertension mitigates this risk. Management of hypertension is also among the most common reasons for ambulatory visits to physicians’ clinics among non-pregnant adults worldwide. However, many key aspects of optimal medical management for hypertension remain unclear.
The evidence that medically treating patients with stage 1 (140-159 mm Hg) systolic hypertension improves outcomes is limited, and current guidelines differ substantially in their recommendations for management. In addition, for all patients little evidence is available to guide the optimal time interval between measurement of elevated blood pressure and addition or dose escalation of antihypertensive medications (“medication intensification”) or between medication intensification and follow-up measurement of blood pressure. Routine clinical practice differs from clinical trials in that substantial delays may exist between the observation of an elevated blood pressure and medication intensification, or between medication intensification and follow-up measurement of blood pressure, but the effect of such delays on patients’ outcomes is not understood.
We therefore did a retrospective cohort study to investigate the systolic intensification threshold, time to intensification, and time to follow-up that are associated with the lowest risk of cardiovascular events or death.
Abstract and Introduction
Abstract
Objectives To investigate the optimal systolic blood pressure goal above which new antihypertensive medications should be added or doses of existing medications increased (“systolic intensification threshold”) and to determine the relation between delays in medication intensification and follow-up and the risk of cardiovascular events or death.
Design Retrospective cohort study.
Setting Primary care practices in the United Kingdom, 1986-2010.
Participants 88 756 adults with hypertension from The Health Improvement Network nationwide primary care research database.
Main outcome measures Rates of acute cardiovascular events or death from any cause for patients with different hypertension treatment strategies (defined by systolic intensification threshold, time to intensification, and time to follow-up over the course of a 10 year treatment strategy assessment period) after adjustment for age, sex, smoking status, socioeconomic deprivation, history of diabetes, cardiovascular disease or chronic kidney disease, Charlson comorbidity index, body mass index, medication possession ratio, and baseline blood pressure.
Results During a median follow-up of 37.4 months after the treatment strategy assessment period, 9985 (11.3%) participants had an acute cardiovascular event or died. No difference in risk of the outcome was seen between systolic intensification thresholds of 130-150 mm Hg, whereas systolic intensification thresholds greater than 150 mm Hg were associated with progressively greater risk (hazard ratio 1.21, 95% confidence interval 1.13 to 1.30; P<0.001 for intensification threshold of 160 mm Hg). Outcome risk increased progressively from the lowest (0-1.4 months) to the highest fifth of time to medication intensification (hazard ratio 1.12, 1.05 to 1.20; P=0.009 for intensification between 1.4 and 4.7 months after detection of elevated blood pressure). The highest fifth of time to follow-up (>2.7 months) was also associated with increased outcome risk (hazard ratio 1.18, 1.11 to 1.25; P<0.001).
Conclusions Systolic intensification thresholds higher than 150 mm Hg, delays of greater than 1.4 months before medication intensification after systolic blood pressure elevation, and delays of greater than 2.7 months before blood pressure follow-up after antihypertensive medication intensification were associated with increased risk of an acute cardiovascular event or death. These findings support the importance of timely medical management and follow-up in the treatment of patients with hypertension.
Introduction
Hypertension is the single most common risk factor for both cardiovascular and overall disease burden and mortality worldwide, and the medical treatment of hypertension mitigates this risk. Management of hypertension is also among the most common reasons for ambulatory visits to physicians’ clinics among non-pregnant adults worldwide. However, many key aspects of optimal medical management for hypertension remain unclear.
The evidence that medically treating patients with stage 1 (140-159 mm Hg) systolic hypertension improves outcomes is limited, and current guidelines differ substantially in their recommendations for management. In addition, for all patients little evidence is available to guide the optimal time interval between measurement of elevated blood pressure and addition or dose escalation of antihypertensive medications (“medication intensification”) or between medication intensification and follow-up measurement of blood pressure. Routine clinical practice differs from clinical trials in that substantial delays may exist between the observation of an elevated blood pressure and medication intensification, or between medication intensification and follow-up measurement of blood pressure, but the effect of such delays on patients’ outcomes is not understood.
We therefore did a retrospective cohort study to investigate the systolic intensification threshold, time to intensification, and time to follow-up that are associated with the lowest risk of cardiovascular events or death.
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