Delayed BP-Treatment Intensification Linked With CV Events, Mortality

February 05, 2015

BOSTON, MA — Waiting until a patient's systolic blood pressure exceeds 150 mm Hg before intensifying antihypertensive medication is associated with an increased risk of acute cardiovascular events and death, according to the results of a large analysis[1].

In addition, delaying 6 weeks or so before ramping up treatment in these hypertensive individuals, as well as delaying a follow-up appointment after the medication has been adjusted, is also associated with an increased risk of cardiovascular events and mortality.

Lead investigator Dr Wenxin Xu (Beth Israel Deaconess Medical Center, Boston, MA) and colleagues, in a report published online February 5, 2015 in the BMJ, say the present study was designed to determine the optimal time between the detection of high blood pressure and the escalation of antihypertensive therapy, as well as optimal time between medication intensification and follow-up blood-pressure measurements. At present, there are little data on the impact of delays between the detection of hypertension and its management, or even the optimal time to intervene in patients with stage 1 hypertension.

"The treatment of patients with systolic blood pressure between 140 and 149 mm Hg is particularly controversial," write Xu and colleagues.

The researchers analyzed data from 88 756 adults with hypertension and access to a primary-care physician in the UK's Health Improvement Network database. The individuals were followed for just over 3 years after the treatment-strategy assessment period, which was defined as the lowest systolic blood pressure in which antihypertensive medication was intensified. Treatment intensification was defined as an increase in dose or the addition of another medication.

Overall, once a need was identified, a shorter time to medication intensification was associated with a decreased risk of cardiovascular events or death. For example, a delay greater than 1.4 months after identifying systolic-blood-pressure elevation above the intensification threshold was associated with a significant 12% increase in the risk of cardiovascular events or death. Following the intensification of therapy, waiting more than 2.7 months before following up with a primary-care physician was also associated with a significant 18% increased risk in the composite end point.

As noted, systolic blood pressure thresholds greater than 150 mm Hg were associated with progressively greater risk in adverse outcomes. In patients with blood pressures between 130 and 150 mm Hg, there was no increase in risk.

The findings, say researchers, support the "timely achievement of blood-pressure targets," noting that regular follow-up is an "important factor for minimizing the risk of adverse cardiovascular outcomes."

"Hypertension is treatable—the right medical treatment can mitigate a person's risk. But we need to know the optimal blood pressure, the optimal time to intensify treatment, and the optimal time to reassess," senior investigator Dr Alexander Turchin (Brigham and Women's Hospital, Boston, MA) commented in a press release. "Our research supports the importance of avoiding delays in treatment and having follow-up appointments for patients with hypertension."

The Eighth Joint National Committee (JNC 8) guidelines for the management of hypertension and the European Society of Hypertension/European Society of Cardiology both recommend a goal of <140 mm Hg for younger patients and <150 mm Hg for older patients while differing on the definition of "elderly." The National Institute for Health and Clinical Excellence (NICE) guidelines, however, recommend treating patients with a blood pressure between 140 and 160 mm Hg only when other cardiovascular disease risk factors are present (or the patient has end-organ damage).

The study was funded by the Harvard Center for Primary Care. The authors have reported no relevant financial relationships.

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