▎ WuXi AppTec content team editor
Antihypertensive therapy has been a cornerstone of cardiovascular disease prevention for decades. Most clinical guidelines recommend hypotensive therapy in patients with confirmed hypertension (blood pressure ≥140/90 mmHg).
But over the past 20 years, as the evidence has been updated, the decision to initiate antihypertensive therapy has been renewed to treat "patients who are likely to benefit the most" rather than just those with "high" blood pressure. This contains two significant changes, one in combination with cardiovascular disease risk predictors, and the other being that the ACC/AHA guidelines have recommended a reduction in the blood pressure threshold for initiating antihypertensive therapy from 140/90 mmHg to 130/80 mmHg.
So, in the decision of antihypertensive therapy, which is more important, the two factors of risk prediction value and blood pressure threshold, the degree of influence on the risk of future cardiovascular disease?
Screenshot source: The Lancet Healthy Longevity
Recently, Lancet- Aging Health published an important study found that long-term follow-up data covering millions of people showed that the incidence of cardiovascular disease and the effectiveness of antihypertensive drug therapy depended mainly on the patient's cardiovascular disease risk prediction value in a fairly wide range of blood pressure ranges.
For clinical practice, this means that while emphasizing blood pressure control target values, attention to the overall risk of cardiovascular disease should not be overlooked. By treating a large number of patients with a high predictive risk, the burden of cardiovascular disease can be significantly reduced. If the patient's medium-term predictive risk is low, it is also possible to start pharmacotherapy without rushing to start pharmacological therapy, and try non-pharmacological antihypertensive first.
Image credit: 123RF
This is a cohort study conducted in the UK population that included 1,099,000 patients aged 30-79 years (median age 52 years at the time of joining the study) and 57.3% were women since 1 January 2011. The median follow-up was 4.3 years (IQR 2.6-6.0 years; total follow-up was 46,000 person-years) until 31 November 2018.
The study focused on the effects of 10-year cardiovascular disease risk predictors (QRISK2 algorithm) and systolic blood pressure on three health outcomes: cardiovascular disease, potential target organ damage (including damage to the brain, heart, eyes, and kidneys), and dementia without known cause.
At the time of inclusion in the study, these patients had a median 10-year cardiovascular disease risk prediction of 4.6% (IQR 1.4%–12.0%) and an average systolic blood pressure of 129.1 mmHg. A total of 51,996 cardiovascular disease events were reported during the follow-up period, and the overall incidence of cardiovascular disease was 11.2 cases per 1000 person-years.
Data analysis shows that:
First of all, it is expected that the increase in blood pressure generally increases the incidence of cardiovascular disease and target organ damage; the 10-year cardiovascular disease risk prediction value is also positively correlated with the incidence of various disease events.
But the impact of the 10-year cardiovascular disease risk prediction is more pronounced.
In the same range of predicted risk, elevated systolic blood pressure had a relatively small effect on the health outcomes described above. For example, for this group of patients with a predicted risk of 10.0%–19.9%, the incidence of cardiovascular disease was 20.1 cases per 1000 person-years when the systolic blood pressure < 110 mmHg, the systolic blood pressure rose to ≥180 mmHg, and the incidence of cardiovascular disease was 23.6 cases/1000 person-year.
Conversely, people with different 10-year cardiovascular disease risk predictions in the same blood pressure range are very different. For example, in this group of patients with systolic blood pressure of 140.0 mmHg–149.9 mmHg, the 10-year cardiovascular disease risk predictor value < 10.0% and the ≥ 30.0%, the incidence of cardiovascular disease was 6.9 cases/1000 person-year and 52.3 cases/1000 person-year, respectively.
▲Incidence of health outcomes during follow-up in people with different systolic blood pressure and 10-year cardiovascular disease risk predictions (as measured in the time of inclusion). From left to right, top to bottom, all cardiovascular diseases, acute coronary syndrome, stroke, peripheral arterial disease, heart failure, hemorrhagic stroke, chronic kidney disease, and dementia. (Image source: References[1])
A more intuitive comparison of the data set is that patients with a low predictive risk (low systolic blood pressure) (but a high predictive risk (20% ≥) have higher incidences of a variety of diseases, except for hemorrhagic stroke.
▲Low predictive risk but high systolic blood pressure vs low systolic blood pressure but high predictable risk, incidence of various health outcomes during follow-up. (Table source: References[1])
The paper concludes that this study data and evidence to date suggest that in order to better prevent cardiovascular disease, the focus of antihypertensive therapy needs to shift from blood pressure thresholds and antihypertensive goals to managing blood pressure in the overall context of cardiovascular risk prediction.