Focus on blood pressure as a major risk factor

The main risk factor for disease and premature death worldwide is high blood pressure.1Lim SS Vos T Flaxman AD Danaei G et al.A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2224-2260Summary Full Text Full Text PDF PubMed Scopus (8258) Google Scholar The associations between blood pressure and fatal coronary artery disease and fatal stroke have been well demonstrated.2Lewington S Clarke R Qizilbash N Peto R Collins R Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.Lancet. 2002; 360: 1903-1913Summary Full Text Full Text PDF PubMed Scopus (7449) Google Scholar However, little evidence exists from contemporary clinical practice on the associations between blood pressure and morbidity and mortality from specific cardiovascular disease conditions in different age groups. Also missing are results concerning lifetime risk for specific cardiovascular complications associated with hypertension. Eleni Rapsomaniki and colleagues3Rapsomaniki E Timmis A George J et al.Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people.Lancet. 2014; 383: 1899-1911Summary Full Text Full Text PDF PubMed Scopus (887) Google Scholar now report results in The Lancet that extend our knowledge and understanding of blood pressure as a risk factor for cardiovascular disease. This contemporary study in a primary-care setting assessed electronic health records for more than a million patients aged 30 years or older who did not have cardiovascular disease, and recorded initial cardiovascular morbidity during a median of 5·2 years of follow-up. The investigators report that the lifetime burden of hypertension is substantial. In a 30-year-old patient with hypertension, the lifetime risk for a cardiovascular event was 63·3% (95% CI 62·9–63·8), compared with 46·1% (45·5–46·8) in a normotensive individual, with an estimated loss of 5 years free of cardiovascular disease. Whereas patients with moderate or severe hypertension should always be offered antihypertensive treatment, the benefit of treatment in patients with mild hypertension has been subject to discussion.4Diao D Wright JM Cundiff DK Gueyffier F Pharmacotherapy for mild hypertension.Cochrane Database Syst Rev. 2012; 8 (CD006742)PubMed Google Scholar However, the results by Rapsomaniki and colleagues3Rapsomaniki E Timmis A George J et al.Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people.Lancet. 2014; 383: 1899-1911Summary Full Text Full Text PDF PubMed Scopus (887) Google Scholar provide circumstantial support for starting treatment of mild hypertension in younger people. In each age group, the risk for future cardiovascular disease was lowest in people with a systolic blood pressure of 90–114 mm Hg and a diastolic blood pressure of 60–74 mm Hg, and no increase in risk with low values (J-shaped curve) was noted. A novel finding was that the risk associated with an increase in blood pressure differed with age and specific cardiovascular disease conditions. For example, the associations between morbidity and an increase in systolic blood pressure were strongest for stable angina pectoris (hazard ratio for a 20 mm Hg rise in systolic blood pressure 1·41, 95% CI 1·36–1·46), and intracerebral and subarachnoidal haemorrhage (1·44 [1·32–1·58] and 1·43 [1·25–1·63], respectively), whereas the risk of an abdominal aortic aneurysm was more closely related to increased diastolic blood pressure (hazard ratio for a 10 mm Hg rise in diastolic blood pressure 1·45, 1·34–1·56). Furthermore, for patients aged 30 years, coronary artery disease accounted for most of the estimated loss of years free of cardiovascular disease associated with hypertension, whereas heart failure contributed to a substantial part in patients aged 80 years. Most patients with heart failure are old, have an impaired quality of life and poor prognosis, and health-care costs are high.5Mejhert M Lindgren P Schill O et al.Health care consumption and cost expenditure in chronic systolic heart failure during an 8–12 year prospective follow up.Eur J Intern Med. 2013; 24: 260-265Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar The findings by Rapsomaniki and colleagues3Rapsomaniki E Timmis A George J et al.Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people.Lancet. 2014; 383: 1899-1911Summary Full Text Full Text PDF PubMed Scopus (887) Google Scholar indirectly support antihypertensive treatment also in patients 80 years or older.6Beckett NS Peters R Fletcher AE et al.for the HYVET Study GroupTreatment of hypertension in patients 80 years of age or older.N Engl J Med. 2008; 358: 1887-1898Crossref PubMed Scopus (2419) Google Scholar Although the efficacy of antihypertensive drug therapy is undisputed, observational studies suggest that few patients reach target blood pressure.7Qvarnström M Wettermark B Ljungman C et al.Antihypertensive treatment and control in a large primary care population of 21167 patients.J Hum Hypertens. 2011; 25: 484-491Crossref PubMed Scopus (34) Google Scholar Several steps therefore need to be taken to improve antihypertensive treatment and control (panel). First, assessment of global cardiovascular risk is essential to offer the best management to the individual patient. The study by Rapsomaniki and colleagues3Rapsomaniki E Timmis A George J et al.Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people.Lancet. 2014; 383: 1899-1911Summary Full Text Full Text PDF PubMed Scopus (887) Google Scholar provides important new information to improve risk assessment, patient counselling, and decision making for patients with hypertension. Second, improvements are needed in caregiver support and education. Caregivers might think that side-effects with treatment are a problem, or that available evidence to treat is insufficient. Drugs might be prescribed with an inappropriate dosing, or inadequate drug combinations could be used. Caregiver organisation and systematic follow-up might also need improvement.PanelKey issues to improve antihypertensive treatment and control •Assessment of global cardiovascular risk in individual patients•Improve caregiver organisation, support, and education•Increase drug compliance and treatment persistence to prescribed treatment•Expand the use of home blood-pressure monitoring and 24 h ambulatory blood-pressure monitoring•Consider secondary forms of hypertension in difficult-to-treat patients•Consider referral of patients with remaining uncontrolled hypertension to a specialist hypertension centre •Assessment of global cardiovascular risk in individual patients•Improve caregiver organisation, support, and education•Increase drug compliance and treatment persistence to prescribed treatment•Expand the use of home blood-pressure monitoring and 24 h ambulatory blood-pressure monitoring•Consider secondary forms of hypertension in difficult-to-treat patients•Consider referral of patients with remaining uncontrolled hypertension to a specialist hypertension centre Third, factors that can improve drug compliance and treatment persistence to prescribed therapy ought to be better understood than they are at present. We reported that 35% of patients newly initiated on antihypertensive drug therapy discontinued treatment within 2 years.8Qvarnström M Kahan T Kieler H et al.Factors associated with persistence to antihypertensive treatment.Eur J Clin Pharmacol. 2013; 69: 1955-1964Crossref PubMed Scopus (40) Google Scholar Furthermore, many patients referred for apparently treatment-resistant hypertension do not seem to take their prescribed medication.9Strauch B Petrák O Zelinka T et al.Precise assessment of noncompliance with the antihypertensive therapy in patients with resistant hypertension using toxicological serum analysis.J Hypertens. 2013; 12: 2455-2461Crossref Scopus (119) Google Scholar, 10Fadl Elmula FE Hoffmann P Fossum E et al.Renal sympathetic denervation in patients with treatment-resistant hypertension after witnessed intake of medication before qualifying ambulatory blood pressure.Hypertension. 2013; 62: 526-532Crossref PubMed Scopus (103) Google Scholar Fourth, an increased use of home blood-pressure monitoring and 24 h ambulatory blood-pressure monitoring is important. Such use would identify patients susceptible to the white-coat effect, improve risk stratification, and increase patient engagement.11Redon J Campos C Narciso ML et al.Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study.Hypertension. 1998; 31: 712-718Crossref PubMed Scopus (371) Google Scholar Fifth, people with secondary forms of hypertension can often be offered specific treatment and are thus important to identify, in particular those with apparently treatment-resistant disease. Finally, an appreciation is needed that most patients with remaining uncontrolled hypertension can be well controlled when referred to a specialist hypertension centre.10Fadl Elmula FE Hoffmann P Fossum E et al.Renal sympathetic denervation in patients with treatment-resistant hypertension after witnessed intake of medication before qualifying ambulatory blood pressure.Hypertension. 2013; 62: 526-532Crossref PubMed Scopus (103) Google Scholar, 12Persu A Jin Y Baelen M et al.European Network Coordinating research on REnal Denervation (ENCOReD) ConsortiumEligibility for renal denervation: experience at 11 European expert centers.Hypertension. 2014; 63: 1319-1325Crossref PubMed Scopus (63) Google Scholar Blood-pressure control could be improved in patients with hypertension. The clinical benefit of improved risk assessment and appropriate treatment might be substantial. I have received research grants from Celladon, Medtronic, Pfizer, and Servier. Hypertension: an urgent need for global control and preventionThis week's issue is dedicated to hypertension—the biggest contributor to the global burden of disease (GBD) and to global mortality, according to 2010 data from the Institute for Health Metrics and Evaluation. Hypertension is estimated to contribute to 9·4 million deaths each year worldwide. Ahead of the joint meeting of the European Society of Hypertension and the International Society of Hypertension, to be held in Athens, Greece, June 13–16, we publish three research papers on hypertension. These three papers illustrate some of the important areas of uncertainty about treatment. Full-Text PDF Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million peopleThe widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them. Full-Text PDF Open Access