"Tailored" Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
The purpose of prescribing blood pressure (BP) therapy is not to treat hypertension, but to reduce the risk of clinical outcomes associated with hypertension – primarily, cardiovascular disease (heart attacks and strokes). Most current BP guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual's net absolute benefit from treatment – taking into account the patient's estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Using a probability model based on the best available evidence in the literature, investigators examined how many quality-adjusted life years (QALYs) would be saved with each of the two treatment strategies. Constructing a large simulated population (176 million) from a nationally representative survey of American adults aged 30 to 85 years with no history of myocardial infarction, stroke, or severe congestive heart failure, investigators estimated the effects of 5 years of treatment with TTT compared to BTT. Marginal patients (those treated substantially differently by one guideline versus another) were specifically examined in regard to how many were treated differently and what the clinical implications were of that treatment difference. Multiple sensitivity analyses were performed to assess the reliability of outcomes.
- BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more QALYs, despite using 6% fewer medications, compared to TTT.
- While 55% of the 176 million "simulated" patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
- Because the study design was based on the best available evidence in the literature, it also was limited by the current evidence in the literature.
- Caution is always advised when interpreting simulation models because a model is only as good as its inputs and assumptions; however, this study is based on "very strong evidence."
- This study suggests that making more individualized BP treatment decisions based on a patient's overall cardiovascular disease risk, as well as the estimated benefits of advancing treatment can prevent well over 100,000 more heart attacks and strokes a year than current guidelines that emphasize treating to specific BP goals.
This study was funded through VA/HSR&D's Quality Enhancement Research Initiative (Diabetes QUERI). All authors are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI.
Sussman J, Vijan S, and Hayward R. Using Benefit-Based Tailored Treatment to Improve the Use of Anti-hypertensive Medications. Circulation November 19, 2013;128(21):2309-17.