Treating to New Blood Pressure Goals Could Prevent Millions of CVD Events

Approximately 3 million cardiovascular disease (CVD) events could be prevented over the next 10 years by achieving and maintaining the recommendations set forth in the updated hypertension guideline released last year by the American College of Cardiology (ACC), the American Heart Association (AHA), and nine other partnering organizations, according to a new analysis of population data. The researchers theorize that the impact on public health from compliance with the update would be significantly greater than achieving the blood pressure goals set forth in previous US guidelines.

“We estimate that 20% more events will be prevented by complying with the newer guidelines compared with JNC 7 . . . and 90% more than JNC 8,” the study’s lead author Adam P. Bress, PharmD, (University of Utah School of Medicine, Salt Lake City), told TCTMD.

The analysis is similar to a study published earlier this year that used population data to create models for predicting how achieving the treatment goals of the new ACC/AHA guideline recommendation of < 130/80 mm Hg affected annual morbidity and mortality compared with the JNC 8 recommendation of < 140/90 mm Hg. That study found that over 300,000 lives per year could be saved with full compliance of the treatment goals in the 2017 guideline, and that even at lower levels of compliance (ie, 50%) the savings in lives and CVD events was still much greater than under the older standards.

“The thing that I think is important about both of these studies is that we know that we have safe, effective, and inexpensive antihypertensive medications and we have proven implementation strategies that can control blood pressure more effectively than usual care,” Bress said. “Now it’s about will and investment on a public health ‘best buy’ in terms of high-quality [BP] measurement, initiating treatment, and using those proven implementation strategies. [These papers] set the bounds for what we could achieve if we invested in the work.”

Bress added that although prediction models have their drawbacks and limitations, they “can give you estimates when you don't have the data you wish you did.”

Big Reductions but More Adverse Events

For the new analysis, Bress and colleagues used data from the REGARDS study of 29,218 black and white adults age 45 years and older from all 48 contiguous US states and the District of Columbia. The contemporary database was chosen because it includes rigorous adjudication of CVD events. The data from REGARDS were pooled with National Health and Nutrition Examination Surveys (NHANES) conducted between 2011 and 2014.

We know that we have safe, effective, and inexpensive antihypertensive medications and we have proven implementation strategies that can control blood pressure more effectively than usual care. Adam P. Bress

Of the 3 million cardiovascular disease events predicted to be prevented by achieving the 2017 ACC/AHA guideline-recommended BP goals, 83% would result from treatment in adults with a current BP of ≥ 140/90 mm Hg. Further, approximately one-third of all the events prevented would be in those initiating antihypertensive treatment and 65% in those intensifying their current antihypertensive treatment.

The analysis also looked at the effect of the newer treatment goals on patient subgroups and found that they would prevent more CVD than the JNC 7 in patients who have a current BP of ≥ 140/90 mm Hg but do not have diabetes or chronic kidney disease. Compared with the JNC 8, however, the newer treatment goals were predicted to prevent more CVD across all patient categories.

In all cases, the event reductions included patients intensifying current treatment to reach their goal as well as those initiating treatment, which is important, Bress and colleagues note, since some investigators have voiced concern that the new guideline overextended the reach of hypertension diagnosis and drug therapy.

In a sensitivity analysis that assumed only a 75% compliance rate with the new guideline, the number of projected CVD events prevented was still greater than under the JNC 7 or JNC 8 guidelines.

At the same time, however, achieving the new targets for BP would lead to an estimated 3.3 million treatment-related serious adverse events, which is 1.2 million more than maintaining the JNC 7 recommendations and 2.4 million more than following the JNC 8.

Future Directions

According to Bress, the researchers were not able to break down the adverse events according to how they occurred or which events were most common, due to limitations of the database. SPRINT and ACCORD are two of the few data sets with carefully adjudicated serious adverse events related to hypertension medications, he noted, adding that future trials need to “carry the baton forward” by including better documentation about these events.

Another potential criticism of the current study is that REGARDS does not include data on Hispanic or Asian patients, limiting the generalizability with regard to the US population.

“That's fair and important to note,” Bress said. “The one thing that helps dial back this concern is when you look at CVD risk between Asian Americans, whites, and Hispanics from the multiethnic cohort studies, they are more similar than different, whereas for blacks versus whites the difference is very pronounced.”

Bress said some important next steps for this type of research will be identifying high-benefit subgroups to enable clinicians to more appropriately tailor treatment to patients who will have the greatest absolute benefit in terms of CVD event reduction and also the lowest risk of safety events.

“This is something we are working on right now,” Bress observed. “Our models are going to try to discriminate people who are ‘high benefit-high risk’ or ‘high benefit-low risk’ or ‘low benefit-high risk,’ with the goal of creating something like the DAPT score for blood pressure.”