Long-term event rates, risk factors, and treatment pattern in 1.4 million individuals qualifying for dual blood pressure lowering therapy

OBJECTIVES: We assessed rates of cardiovascular events, all-cause death, baseline risk factors, and treatment patterns in a population qualifying for initiation of dual combination blood pressure (BP)-lowering therapy. We also evaluated the association between dual versus monotherapy during follow-up and incidence of cardiovascular events. METHODS: This study utilized integrated databases in England: Clinical Practice Research Datalink, Hospital Episode Statistics, and Office for National Statistics. Individuals aged at least 18 years qualifying for dual therapy were identified during 15-year period (2005-2019). The primary endpoint was composite of nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, and cardiovascular death. The secondary endpoint was all-cause death. RESULTS: Total 1 426 079 individuals met selection criteria. The 15-year event rates for the primary and secondary endpoints were 27.1 and 32.6%, respectively. Atherosclerotic cardiovascular disease, diabetes on insulin therapy, heart failure, atrial fibrillation, chronic kidney disease, and advanced age were associated with two to four-fold higher risk of primary and secondary endpoints. The estimated hazard ratio for dual versus monotherapy as a time-varying covariate was 0.82 (95% confidence interval 0.81-0.83) for the primary endpoint. At variance with guidelines, monotherapy was most common treatment pattern over 5-year follow-up. CONCLUSION: Baseline characteristics conveying a multifold higher risk for cardiovascular events and all-cause death mostly represented nonmodifiable risk factors. Treatment with dual therapy as compared to monotherapy was associated with reduction in cardiovascular events. Monotherapy remained most common BP-lowering treatment indicating substantial opportunity for risk reduction by treatment intensification.