What are the financial implications of the 2017 AHA/ACC High Blood Pressure Guideline?

Since the publication of the 2017 High Blood Pressure Guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA),1 commentaries have been published debating medical perspectives on the usefulness, appropriateness, feasibility and scientific nature thereof. The critical point that most are deliberating on is the implementation of a new definition for hypertension. It was almost 25 years ago that the cut-offs for Stage 1 Hypertension were changed from 160/90 mmHg to 140/90 mmHg.2 In 2017 the AHA/ACC Guideline once again moved away from the globally accepted cut-offs, defining Stage 1 Hypertension based on the lower thresholds of 130–139/80–89 mmHg. Whilst it is important to reflect on the scientific grounds of these guidelines, as well as the feasibility thereof, it is the financial implications that would eventually result in governments adopting the guidelines. Cardiovascular diseases clearly represent a major economic burden on health care systems, and with hypertension being the most important contributor, targeting better prevention, treatment and control makes sense. The concept of early treatment is also aligned with the lifecourse approach proposed by the Lancet Commission of Hypertension.3 An important next step for health economists is to establish whether the new AHA/ACC Guideline will result in improvement of direct cost reduction in terms of health care systems (such as fewer events, hospitalisations, rehabilitation services, physician visits), as well as indirect costs associated with morbidity and mortality (such as loss in productivity and disabilities). With findings from the SPRINT trial embedded in the AHA/ACC Guidelines, cost-effectiveness analysis from SPRINT is important. The SPRINT Research Group thus performed this analysis (in adults at high risk for cardiovascular disease), and found that intensive blood pressure (BP) control was cost-effective and below common willingness-to-pay thresholds in the United States.4 A similar study modelling a cost-effective analysis of lifetime benefits and costs among 68-year-old high-risk adults with hypertension, but not diabetes, also confirmed that intensive BP management provides ‘excellent value’.5 The authors further stated that it remains cost-effective even with substantially higher adverse event rates. An economic analysis by the PAST-BP study in England evaluated the cost-effectiveness of a systolic BP target of <130 mmHg in people with a history of stroke or transient ischaemic attacks.6 Findings again confirmed that intensive systolic pressure lowering is cost-effective in those with a history of stroke, although they pointed out that it was difficult to tease out whether this benefit was due to the lower BP target, or due to more active BP management. Collectively these studies, which were performed in high income countries, clearly point to cost-effectiveness of the lower BP thresholds. However, it seems that the feasibility of implementing the targets remains at the core of the debate. The adoption of the new AHA/ACC Guideline in the rest of the world therefore remains controversial. This may be due to weaker health systems in low- and middle-income countries, where the burden of hypertension is the greatest,7 and hypertension management at the current 140/90 mmHg targets remains inadequate. These realities have spurred several new approaches to improve hypertension management, such as the introduction of self-management8 and the polypill,9,10 which have the potential to be cost-effective. Where the abovementioned analyses focus on the overall and long-term effects of the new AHA/ACC Guidelines, the immediate consequence is that more patients will qualify for antihypertensive medication. For the United States this increase was reportedly a minor increase when moving from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) to the new guidelines, namely from 34.3% to 36.2%.11 In the European Journal of Preventive Cardiology a cost estimation was also done by Vaucher et al. for the population of Switzerland – specifically for those aged 45 to 85 years.12 They have estimated that when moving from the 2013 European Society of Hypertension/European Society of Cardiology Guideline13 to the AHA/ACC Guideline, patients eligible for antihypertensive treatment will increase by 9% (from 31.3% to 40.3%), translating to an additional 250,000 patients, and an annual cost of €63 m. A high-income country such as Switzerland is unlikely to consider adopting the AHA/ACC Guideline – particularly since the release of the 2018 European Guideline is anticipated to be in June 2018. Nevertheless, the actual long term financial gains in direct and indirect costs by treating raised BP early are awaited – particularly in high-income countries where resources allow, and where the adoption of these guidelines is potentially possible. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The article is funded by the DST/NRF South African Research Chair Initiative programme and the South African Medical Research Council.