Gaps in antihypertensive and statin treatments and benefits of optimisation: a modelling study in a 1 million ethnically diverse urban population in UK

ObjectivesTo characterise gaps in antihypertensive treatment in people with hypertension and statin treatment in people with cardiovascular diseases (CVD) in a large urban population and quantify the health and economic impacts of their optimisation.DesignA cross-sectional population study and a long-term CVD decision model.SettingPrimary care, UK.ParticipantsAll adults with diagnosed hypertension or CVD in a population of about 1 million people, served by 123 primary care practices in London, UK in 2019.InterventionsFollowing UK clinical guidelines, all adults with diagnosed hypertension were categorised into optimal, suboptimal and untreated groups with respect to their antihypertensive treatment, and all adults with diagnosed CVD were categorised in the same manner with respect to their statin treatment.OutcomesProportion of patients suboptimally treated or untreated. Projected cardiovascular events avoided, years and quality-adjusted life years (QALYs) gained and healthcare costs saved with optimised treatments.Results21 954 of the 91 828 adults with hypertension (24%; mean age 59 years; 49% women) and 9062 of the 23 723 adults with CVD (38%; mean age 69 years; 43% women) were not optimally treated with antihypertensive or statin treatment, respectively. Per 1000 additional patients optimised over 5 years, hypertension treatment is projected to prevent 25 (95% CI 16 to 32) major vascular events (MVEs) and 7 (3 to 10) vascular deaths, statin treatment, 28 (22 to 33) MVEs and 6 (4 to 7) vascular deaths. Over their lifespan, a patient with uncontrolled hypertension aged 60–69 years is projected to gain 0.64 (95% CI 0.36 to 0.87) QALYs with optimised hypertension treatment, and a similarly aged patient with previous CVD not optimally treated with statin is projected to gain 0.3 (0.24 to 0.37) QALYs with optimised statin treatment. In both cases, the hospital cost savings minus extra medication costs were about £1100 per person over remaining lifespan.ConclusionsOptimising cardiovascular treatments can cost-effectively reduce cardiovascular risk and improve life expectancy.

Arterial Hypertension in Aortic Valve Stenosis: A Critical Update

Aortic stenosis (AS) is a very common valve disease and is associated with high mortality once it becomes symptomatic. Arterial hypertension (HT) has a high prevalence among patients with AS leading to worse left ventricle remodeling and faster degeneration of the valve. HT also interferes with the assessment of the severity of AS, leading to an underestimation of the real degree of stenosis. Treatment of HT in AS has not historically been pursued due to the fear of excess reduction in afterload without a possibility of increasing stroke volume due to the fixed aortic valve, but most recent evidence shows that several drugs are safe and effective in reducing BP in patients with HT and AS. RAAS inhibitors and beta-blockers provide benefit in selected populations based on their profile of pharmacokinetics and pharmacodynamics. Different drugs, on the other hand, have proved to be unsafe, such as calcium channel blockers, or simply not easy enough to handle to be recommended in clinical practice, such as PDE5i, MRA or sodium nitroprusside. The present review highlights all available studies on HT and AS to guide antihypertensive treatment.

Antihypertensive Treatment and Central Arterial Hemodynamics: A Meta-Analysis of Randomized Controlled Trials

Background: Antihypertensive treatment may have different effects on central arterial hemodynamics. The extent of the difference in effects between various antihypertensive drugs remains undefined.Methods: We conducted a systematic review and meta-analysis of randomized controlled trials that explored the effects of antihypertensive agents on both central and peripheral systolic blood pressure (SBP) and pulse pressure (PP) or central augmentation index, with a special focus on the comparison between newer [renin-angiotensin-aldosterone system (RAS) inhibitors and calcium-channel blockers (CCBs)] and older antihypertensive agents (diuretics and β- and α-blockers).Results: In total, 20 studies (n = 2,498) were included. Compared with diuretics (10 studies), β-blockers (16 studies), or an α-blocker (1 study), RAS inhibitors (21 studies), and CCBs (6 studies) more efficaciously (P < 0.001) reduced both central and peripheral SBP by a weighted mean difference of −5.63 (−6.50 to −4.76 mmHg) and −1.97 mmHg (−2.99 to −0.95 mmHg), respectively. Compared with older agents, the newer agents also more efficaciously (P < 0.001) reduced central PP (−3.27 mmHg; −4.95 to −1.59 mmHg), augmentation index (−6.11%; −7.94 to −4.29) and augmentation (−3.35 mmHg; −5.28 to –1.42 mmHg) but not peripheral PP (p ≥ 0.09). Accordingly, the newer agents reduced central-to-peripheral PP amplification significantly less than the older agents (0.11 mmHg; 0.05 to 0.17 mmHg; P < 0.001).Conclusion: Newer agents, such as RAS inhibitors and CCBs, were significantly more efficacious than older agents in their effects on central hemodynamics.

Blood Pressure Levels and Risks of Dementia: a Nationwide Study of 4.5 Million People

There are inconsistent results on the impacts of controlling blood pressure (BP) on the risk of dementia. We investigated the association between BP and risk of dementia subtypes by antihypertensive treatment and comorbidities. Using the Korean National Health Insurance Service-Health Screening Database from 2009 to 2012, a total of 4 522 447 adults aged 60+ years without a history of dementia were analyzed and followed up for a mean of 5.4 years. Individuals were classified according to their baseline systolic BP (SBP) and diastolic BP; SBP 130 to <140 mm Hg and diastolic BP 80 to <90 mm Hg were used as reference groups. The risk of overall dementia and probable Alzheimer disease was significantly higher in the SBP≥160 and lower SBP groups. These U-shaped associations were consistent regardless of antihypertensive use or comorbidities. The risk of probable vascular dementia (VaD) was not higher among lower SBP groups and increased gradually as SBP increased. Although there was a linear association between SBP and the risk of probable VaD in individuals not taking antihypertensives or without comorbidities, there was a U-shaped association in individuals taking antihypertensives or with comorbidities. Patterns of association between diastolic BP and risk of probable Alzheimer disease or probable VaD were similar to those with SBP, except for the risk of probable VaD in individuals taking antihypertensives. In conclusion, risks of probable Alzheimer disease and probable VaD were different among lower BP groups. Although the risk of dementia appears higher in people with lower BP receiving antihypertensives, this finding may be affected by comorbidities.