HOPE 4: Hypertension Screening in Community Reduces CV Risk

September 06, 2019

PARIS — A community-based initiative, in which nonphysician healthcare workers screened individuals for hypertension in their own homes and community centers in two middle-income countries, resulted in a substantial reduction in cardiovascular disease risk, primarily through improvements in blood pressure, low-density lipoprotein (LDL) cholesterol, medication adherence, and some health behaviors in the HOPE 4 study.

"We showed a large reduction in blood pressure and cardiovascular disease risk by reaching out to people in their own communities," Jon David Schwalm, MD, McMaster University, Hamilton, Canada, told theheart.org | Medscape Cardiology.

"We believe that a major reason for the success of this project is that our intervention package explicitly targeted barriers that prevent people accessing care, such as having to take time off work, traveling more than 1 hour to attend a public health clinic, and paying for expensive medications."

Schwalm said he hopes the research will be acted upon by governments to reduce cardiovascular risk in countries around the world.

"If we look at how the reductions in blood pressure and cholesterol translate into reduction in CV events, disability, and time off work, we feel this will show a health economic benefit, and it will be something that will be implemented," he added.

The study was presented at the ESC Congress 2019 and published online in the Lancet on September 2.

"The HOPE 4 strategy could help to attain the UN General Assembly Action Plan for a one-third reduction in premature mortality from cardiovascular disease," the researchers conclude in their publication. "On the basis of the substantial reductions in cardiovascular disease risk and the improvements in blood pressure control shown (as well as the additional benefits of community screening), this target is achievable if health system strategies, such as the one evaluated here, are adapted to local contexts and then adopted."

Schwalm noted that fewer than 20% of individuals with hypertension have their blood pressure controlled. And despite compelling evidence of the benefits of statins in those with hypertension, uptake is extremely low in most parts of the world.

The current study was conducted in 30 townships in Colombia and Malaysia and used auxiliary nurses or research assistants as community health workers. They were given a week's training and supplied with tablets containing management algorithms.

Patients were recruited from their community. "One of the key factors in this study is that we didn't do screening in medical settings, as that's where people are already getting treatment. We wanted to get out into the community to identify individuals who were not being treated by a doctor," Schwalm said. "We used a combination of door-to-door household screening and community outreach centers or local events in public spaces."

If individuals met age and eligibility criteria (older than 50 years with elevated blood pressure), they were invited to participate in the study. Community clusters were then randomly assigned to usual care or to participate in an active cardiovascular disease risk detection and management program, also facilitated by nonphysician health workers. for 12 months.

Study medications were provided free of charge. These included a generic single-pill combination of two antihypertensives (at half or full doses). Combinations included an angiotensin receptor blocker or ACE inhibitor coupled with a diuretic or calcium-channel blocker. A separate generic cholesterol-lowering agent (atorvastatin at 20 mg or rosuvastatin at 10 mg) was also provided.

Patients were reviewed at 1, 3, 6, and 12 months, and a family member or close friend was encouraged to accompany the patient to appointments to help with compliance.

There were 1371 participants in the final analysis. Results showed that the nonphysician healthcare workers were consistently accurate in their ability to identify cardiovascular risk, to recommend appropriate therapies, and to identify contraindications to drug therapies. The nonphysician health workers and physicians agreed on the need to initiate antihypertensive and statin medications based on the simplified management algorithms in 93% of cases.

The major finding of the study was that after 12 months, 10-year Framingham risk score was reduced more in the intervention group (11.2%) than in the control group (6.4%) — a difference of 4.78%.

In addition, there was a greater absolute reduction in systolic blood pressure of 11.45 mm Hg in the intervention group and a greater reduction in LDL cholesterol of 0.41 mmol/L. Furthermore, the change in blood pressure control (<140 mm Hg) status was more than double that in the intervention group (69% vs 31%) at 12 months.

Schwalm said the idea can be adapted to include Western countries. "Blood pressure is just as badly controlled in Western countries as it is in low- and middle-income countries," he noted.

The researchers conducted a similar pilot in Canada but did not provide the medications. "It was more of an effort of going into the community and trying to get people to see their family physicians, and we targeted the lower socioeconomic classes," Schwalm said.

"Just getting out there and identifying these patients is the first step. The healthcare workers in our study were just as effective as physicians at identifying and treating hypertension, showing that if we rethink our healthcare delivery strategies, we can reach a lot more people," he added.

Discussant of the HOPE 4 study at the ESC Hotline session, Eva Prescott, MD, Bispebjerg Hospital, Copenhagen, pointed out that the trial was important given that 80% of cardiovascular deaths occur in low- and middle-income countries, probably because of an increased prevalence of lifestyle factors and the poor detection and treatment of risk factors such as hypertension.

She said the reductions in blood pressure and LDL were "impressive," but the intervention was complex, with three main components: training the healthcare workers; providing free medication; and getting input from family and friends. "We don't know which of these interventions were effective."

She added that it is not known if the results will be sustainable in the long term without regular contact with health workers.

The authors of an accompanying comment point out that integration of this strategy into the current healthcare systems will be of paramount importance.

The healthcare workers used in HOPE 4 were private contractors and hired exclusively for the trial, they note.

"If staff were employees in existing health systems, rather than private contractors, competing tasks might compromise the acceptability, fidelity, effectiveness, and sustainability of the HOPE 4 intervention strategies when scaled up in the real world," they conclude.

The HOPE 4 study was funded by the Canadian Institutes of Health Research; Grand Challenges Canada; Ontario SPOR Support Unit and the Ontario Ministry of Health and Long-Term Care; Boehringer Ingelheim; Department of Management of Non-Communicable Diseases, WHO; and Population Health Research Institute. Schwalm reports no disclosures.

Lancet. Published online September 2, 2019. Abstract, Comment

European Society of Cardiology (ESC) Congress 2019: Presented September 2, 2019.

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