Using Benefit-Based Tailored Treatment to Improve the Use of Antihypertensive Medications

Abstract

Background Current guidelines for prescribing antihypertensive medications focus on reaching specific blood pressure targets. We sought to determine if antihypertensive medications could be used more effectively by a treatment strategy based on tailored estimates of cardiovascular disease (CVD) events prevented. Methods and Results We developed a nationally representative sample of American adults aged 30 to 85 years with no history of myocardial infarction, stroke, or severe congestive heart failure using the National Health and Nutrition Examination Survey III. We then created a simulation model to estimate the effects of 5 years of treatment with a treat-to-target (TTT, treatment to specific blood pressure goals) and benefit-based tailored treatment (BTT, treatment based on estimated CVD event reduction) approaches to antihypertensive medication management. All effect size estimates were directly derived from meta-analyses of randomized trials. We found that 55% of the overall population of 176 million Americans would be treated identically under the two treatment approaches. BTT would prevent 900,000 more CVD events and save 2.8 million more QALYs, despite using 6% fewer medications over 5 years. In the 45% of the population treated differently by the strategies, BTT saves 159 QALYs per 1000 treated vs. 74 QALYs per 1000 treated by TTT. The findings were robust to sensitivity analyses. Conclusions We found that benefit-based tailored treatment was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals.

Blood Pressure Targets and Absolute Cardiovascular Risk

“…14 Similarly, in a comparative modeling analysis of the provision of blood pressure-lowering treatment in the US adult population, the use of blood pressure-lowering treatment based on absolute risk would reduce the number of total cardiovascular events (coronary heart disease and stroke) by 900 000 over 5 years relative to traditional treat to target approach for the initiation of blood pressure-lowering treatment. 15 There is also good evidence on the use of blood pressure lowering from <150 to <140 mm Hg. An earlier meta-analysis of 32 trials by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC), which included adults with a wide range of baseline systolic blood pressures (128-194 mm Hg), assessed whether the relative risk reduction associated with blood pressure lowering varied by baseline blood pressure.…”

Letter by Hayward Regarding Article, “Hyperlipidemia in Early Adulthood Increases Long-Term Risk of Coronary Heart Disease”

“…This information, combined with the associated hazard ratio for how this increases or decreases a patient's estimated cardiovascular risk obtained by current risk calculators, would be a major advance in guideline primary cardiovascular prevention, not just for lipid therapies. [3][4][5] However, it is the relative impact of any risk factor that is important, not the average risk of all people with that risk factor. 3 Even if being in the top cumulative non-HDL cholesterol risk category doubles the estimated atherosclerotic cardiovascular disease risk score on average, this is still not important for the 55-year-old woman with a 10-year atherosclerotic cardiovascular disease risk estimate of 1% (her 10-year risk is still only ≈2%).…”

“…However, finding heterogeneity in the relative risk reduction (RRR) of statin in a patient's cumulative non-HDL cholesterol, which was not examined in the authors' study, would challenge the American College of Cardiology/American Heart Association risk-based approach. 4,5 Although all currently available clinical trial evidence suggests that the RRR of a statin does not vary by a person's baseline low-density lipoprotein level (ie, RRR is the same whether LDL is 200 or 100 mg/dL), if the RRR of a statin is greater in those with higher versus lower cumulative non-HDL cholesterol, that would necessitate a change to a full benefit-based tailored treatment approach in which both overall cardiovascular risk and heterogeneity in the RRR of the treatment must be considered. …”

Predicting the Effects of Blood Pressure–Lowering Treatment on Major Cardiovascular Events for Individual Patients With Type 2 Diabetes Mellitus

“…17,18 Although some benefit from BP lowering may be seen across the entire range of background risk, it is to be expected that, in some cases, this benefit may be reduced by costs or adverse effects. 19 Clinicians thus need to identify those individual patients where benefit from BP-lowering therapy outweighs potential treatment disadvantages, such as cough and hypotension, the inconvenience of daily taking a drug and the monetary costs of treatment.…”