Risk-based treatment approach should be considered for patients with hypertension

Aug 28 2014

By Nikki Withers, medwireNews Reporter

Blood pressure (BP)-lowering treatment should target patients at greatest cardiovascular risk and not just those with the highest baseline levels, suggest findings of a meta-analysis.

The analysis of over 50,000 patients found that BP-lowering drugs provide a similar relative benefit across different levels of predicted cardiovascular risk, but progressively greater absolute risk reductions as baseline risk increases.

“A risk-based treatment approach is likely to be more cost effective than a blood pressure-based approach, and could simultaneously reduce the numbers of patients needing treatment, and control drug costs, while increasing the numbers of averted strokes and heart attacks”, write the authors in The Lancet.

The researchers explain that most countries currently recommend that lipid-lowering treatment should be based on patients’ predicted cardiovascular disease risk rather than low-density lipoprotein cholesterol concentrations. However, BP-lowering treatment recommendations are still based mainly on BP levels.

The team used data from 11 trials and 26 randomised groups where participants were assigned to receive either a BP-lowering drug or placebo, or to receive a more intensive or less intensive BP regimen. In all, 51,917 individuals had data available for the calculation of the risk equations. They were separated into four categories of baseline 5-year cardiovascular risk (<11%, 11–15%, 15–21%, >21%).

During a median follow-up period of 4 years, 4167 (8%) participants had a major cardiovascular event, defined as stroke, myocardial infarction, heart failure or cardiovascular death.

Johan Sundström (Uppsala University, Sweden) and co-authors report that BP-lowering treatment reduced the relative risk of cardiovascular events in patients in the four groups of increasing estimated baseline cardiovascular risk by 18%, 15%, 13%, and 15%, respectively.

They say that giving 1000 patients in each group BP-lowering treatment for 5 years would prevent 14, 20, 24, and 38 cardiovascular events, respectively. Therefore, the number-needed-to-treat to prevent an event would decrease accordingly.

In an accompanying commentary, Paolo Verdecchia ( Hospital of Assisi, Italy) and Gianpaolo Reboldi (University of Perugia, Italy) say: “This study is reminiscent of a landmark analysis undertaken by the Cholesterol Treatment Trialists that showed the absolute benefit of cholesterol reduction with statin treatment to be proportional to the baseline absolute cardiovascular risk.”

They add that the present analysis “is timely and important because its findings could affect future revisions of hypertension guidelines that seem to be reluctant to consider total cardiovascular risk, instead of blood pressure alone”.

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