Treating overall risk more effective at reining in heart disease

Targeting specific blood pressure numbers may not be as effective as tailoring therapy to reduce the risk of cardiovascular disease (CVD) events in hypertensive patients, according to a study published online Nov. 4 in Circulation. Benefit-based tailored treatment (BTT) was more effective and required less antihypertensive medication than therapy geared toward lowering blood pressure.

“By basing decision-making on an individual’s estimated absolute risk reduction from treatment, and by explicitly including estimates of treatment harm, treatment decisions can be made based on the net benefit of treatment, which is the factor that is most likely to matter most to patients,” wrote the authors, led by Jeremy Sussman, MD, MS, of the University of Michigan Medical School in Ann Arbor, when describing their rationale behind the study.

Using data from the National Health and Nutrition Examination Survey III (NHANES), the researchers created a nationally representative sample of Americans ages 30 to 85 with no prior heart attacks, strokes or severe congestive heart failure. They next estimated the effects of five years of treatment with both the BTT approach and the treat-to-target (TTT) approach that aimed to lower blood pressure. Estimates came from meta-analyses of randomized trials.

Based on their analyses, treatment using either BTT or TTT would be the same for 55 percent of the overall population of 176 million Americans. However, compared with TTT, BTT would prevent 900,000 more CVD events, save 2.8 million quality-adjusted life years (QALYs) and use about 6 percent fewer medications in a five-year period. In the remainder of the population treated differently by BTT and TTT, BTT saves more QALYs than TTT (159 per 1,000 treated vs. 74 per 1,000 treated).

The authors acknowledged that their study’s main limitation is the use of simulated data. However, they argued that there is strong evidence from previous studies to back up their analyses. They also explained that they are not suggesting a move away from guidelines to prevent CVD.

"Drugs that lower blood pressure are among the most effective and commonly used medications in the country, but we believe they can be used dramatically more effectively," Sussman said in a press release.

In an accompanying editorial, Kazem Rahimi, MRCP, MPH, DM, and Stephen MacMahon, DSc, FMedSci, of the University of Oxford in the U.K., wrote that Sussman et al’s research as well as previous studies “support the concept of treating cardiovascular risk as opposed to individual risk factors, such as blood pressure and cholesterol.”

“The findings are very timely,” they added, “given that some of the international blood pressure guidelines have recently departed from such risk-based strategies.”