Long-Term Event Rates, Risk Factors, and Treatment Pattern in Patients Qualifying for Dual Blood Pressure-Lowering Therapy: An Observational Study in 1.4 Million Individuals

Abstract

Objective: Elevated blood pressure (BP) is a major risk factor for cardiovascular (CV) morbidity and mortality. This study assessed CV event rates, their predictive factors, and treatment patterns for BP-lowering therapy in a population qualifying for dual BP-lowering therapy, over a long-term follow-up. Design and method: This study utilized the Clinical Practice Research Datalink, Hospital Episode Statistics, and Office for National Statistics databases in England. Individuals aged > = 18 years with hypertension, qualifying for dual BP-lowering therapy as per the European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines were identified during a 15-year period (2005 to 2019). Primary endpoint was composite of non-fatal myocardial infarction (MI), non-fatal stroke, hospitalization for heart failure, and CV death. Secondary endpoint was all-cause death. Main subgroups of interest were atherosclerotic cardiovascular disease (ASCVD) and diabetes. Event rates and association of risk factors with primary endpoint and all-cause death were evaluated using Kaplan-Meier method and Cox-proportional hazards model, respectively. Treatment patterns were summarized via percent of patient-time on a given therapy during each year of follow-up. Results: Overall, 1,426,079 patients were included. The mean (SD) age was 62.9 (14.1) years and ∼50% were male. The 15-year event rates for the primary composite endpoint and all-cause death were 27.1% and 32.6%, respectively (Table 1) with CV event rates being ∼2.5-fold and ∼1.5-fold in those with ASCVD and diabetes, respectively (unadjusted analyses). Risk factors strongly associated with primary composite endpoint (hazard ratio >1.50) were age > = 65 years, heart failure, atrial fibrillation, chronic kidney disease 4 – 5, chronic obstructive pulmonary disease, coronary heart disease, stroke, and peripheral arterial disease (P < 0.0001 for all). At variance with guidelines, BP-lowering monotherapy was the most common treatment pattern (42.6% – 56.7% of patient-time) over 5–year follow-up period. Conclusions: Patients with hypertension qualifying for dual BP-lowering therapy are at high risk of major CV events and death, with the risk being substantially elevated in those with ASCVD or diabetes. These findings highlight an opportunity for further risk reduction in this population via timely initiation of dual BP-lowering therapy, especially in patients with comorbidities.