"These findings contributed to the change in UK practice suggested in the latest NICE guidelines on management of hypertension (NG136; https://bit.ly/2L5j8hR) for individuals without established cardiovascular disease where risk scoring is used," Dr. Anthony Wierzbicki of Guy's and St. Thomas' Hospitals in London, UK, told Reuters Health by email.
"In the U.S., where the cardiovascular risk score system is slightly different, they provide general support for the lower thresholds suggested in the AHA-ACC guidelines for management of cardiovascular disease," he said. "The European Score risk calculation system is very different to UK QRISK or U.S. ASCVD scores, but the general principle of intervention at lower risk than previously considered in patients with hypertension remains valid."
"Clinicians should consider intervening for raised blood pressure at a similar threshold risk to that for raised cholesterol," he concluded.
As reported in Hypertension, the team aimed to establish the 10-year CVD risk threshold where initiating antihypertensive drug treatment for primary prevention in adults with stage-1 hypertension, becomes cost-effective. A lifetime horizon Markov model was used to compare antihypertensive drug versus no treatment, using a UK National Health Service perspective.
Analyses included 10-year cardiovascular disease (CVD) risks ranging between 5% and 20%. Health status included no CVD event; CVD and non-CVD death; and six nonfatal CVD morbidities.
Interventions were compared using cost-per-quality-adjusted life-years (QALYs). The base-case age was 60, with analyses repeated between ages 40 and 75.
For men and women aged 60, antihypertensive treatment in stage 1 hypertension was associated with improved QALYs but higher costs for all risk thresholds.
In the base case, treatment was cost-effective at 10% CVD risk for both sexes, with an incremental cost-effectiveness ratio (ICER) of $14,542/QALY for men and $12,536 for women. The number needed to treat to avoid one CVD event over 10 years varied from five to 79 for men and seven to 136 for women.
Overall, hypertensive drug treatment was cost-effective for men regardless of age and women over age 60. The population risk profile for younger women was such that some would not reach the minimum threshold above which treatment was cost-effective; this suggested that individual risk calculation might be appropriate.
Dr. Samuel Mann, an internist and hypertension expert at Weill Cornell Medicine in New York City, commented by phone to Reuters Health, "One problem with the study is that they are looking at cardiovascular complications or death over the next five or six years. Most young patients won't show any problems for 20 years or more. That's why we don't rush to treat until it's clear the patient has sustained blood pressure elevation."
"I don't disagree with the findings," he said, "but add the caveat that when clinicians treat, it's to prevent complications, such as vascular dementia, 20, 30 years later."
"In a low-risk category, I would wait a little longer - up to six months - to be sure patients truly have hypertension before committing them to life-long treatment," he said. "During that time, it's important that patients self-measure at home or have 24-hour ambulatory monitoring to confirm that they really do have hypertension, and not just white-coat hypertension, because this is not just a two-week course of treatment; it's lifelong treatment, so you want to be positive that they are hypertensive."
SOURCE: https://bit.ly/3blxUvj Hypertension, online December 21, 2020.
By Marilynn Larkin
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