Cardiac risk is not associated with hypertension treatment intensification

Abstract

Objectives: Considering cardiovascular (CV) risk could make clinical care more efficient and individualized, but most practice guidelines focus on single risk factors. We sought to determine if hypertension treatment intensification (TI) is more likely in patients with elevated CV risk.

Study design: Prospective cohort study of 856 US veterans with diabetes and elevated blood pressure (BP).

Methods: We used multilevel logistic regression to compare TI across 3 CV risk groups: those with history of heart disease, a high-risk primary prevention group (10-year event risk >20% but no history of heart disease), and those with low/ medium CV risk (10-year event risk <20%).

Results: There were no significant differences in TI rates across risk groups, with adjusted odds ratios (ORs) of 1.19 (95% confidence interval 0.77-1.84) and 1.18 (0.76-1.83) for high-risk patients and those with a history of CVD, respectively, compared with those of low/medium risk. Several individual risk factors were associated with higher rates of TI: systolic BP, mean BP in the prior year, and higher glycated hemoglobin. Self-reported home BP <140/90 mm Hg was associated with lower rates of TI. Incorporating CV risk into TI decision algorithms could prevent an estimated 38% more cardiac events without increasing the number of treated patients.

Conclusions: While an individual's BP alters clinical decisions about TI, overall CV risk does not appear to play a role in clinical decision making. Adoption of TI decision algorithms that incorporate CV risk could substantially enhance the efficiency and clinical utility of CV preventive care.

Conflict of interest statement

Conflict of Interest: None

Figures

Figure

Comparison of 10-year estimated event rate reduction by currently observed treatment intensification vs. possible benefit if treatment were based on risk, among primary prevention patients. ‘Intensified’ is the rate reduction among those 55% who received treatment intensification in actual practice vs. those who would in a risk-based treatment. ‘Full population’ is the risk reduction among the entire population likely from the observed intensification vs. the same benefit if only the highest-risk patients were treated.