Treatment patterns in a population of 1.4 million individuals qualifying for initiation of dual-combination blood pressure lowering therapy representing usual clinical practice

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Abstract Background Guidelines recommend dual-combination therapy (DCT) in most hypertensive patients requiring initiation of blood pressure (BP)-lowering treatment. This strategy is proven to be more effective as compared to monotherapy in achievement of BP goals, is associated with improved adherence, persistence and reduces risk of cardiovascular (CV) events. Purpose To describe the patterns of treatment with BP-lowering therapies in a large hypertensive population qualifying for initiation of DCT. Methods The study utilized following linked databases in England: Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics. Adults qualifying for DCT as per the 2018 ESC/ESH guidelines were identified during a 15-year period (2005-2019). The index date is the first date when patient became eligible for initiation of DCT as per the guidelines-based criteria. Patients were followed for 5 years from the index date and were categorized into 4 groups: (1) no treatment, (2) monotherapy, (3) combination therapy with 2 agents, (4) combination therapy with ≥3 agents. For each year during follow-up, the percent of patient-time (Pt) on these categories was summarized for the overall population and two main subgroups i.e., atherosclerotic cardiovascular disease (ASCVD) and diabetes at baseline. In addition, we estimated the 15-year event rate for the composite endpoint of nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, and CV death via the Kaplan Meier method. Results Overall, 1,426,079 individuals met the selection criteria. Mean (SD) age was 62.9 (14.1) years and ∼50% were male. Approximately 15.9% and 13.8% had ASCVD and diabetes at baseline, respectively. In overall population during 5-year follow-up (Table 1), nearly 25% of Pt during follow-up reported non-treatment with any BP-lowering therapy. Monotherapy was most common treatment pattern accounting for nearly 50% of Pt while only 25% of Pt represented DCT. Percent of Pt on monotherapy decreased from 56.7% to 42.6% (year-1 to -5), and the percent of Pt on dual-combination therapy increased from 14.9% to 25.5% (year-1 to -5). Percent of Pt on any combination therapy (≥2 agents) increased from 17.5% to 32.4% (year-1 to -5). Similar pattern was observed in ASCVD and diabetes subgroups. The 15-year event rate for the composite endpoint was 27.1% for the overall population and was 57.5% and 40.1% in ASCVD and diabetes subgroups, respectively (Table 2). Conclusion Our findings indicate an opportunity for substantial improvement in BP control and CV risk reduction in this population, by ensuring appropriate guideline-based initiation, of dual combination BP-lowering therapy.Table 1Table 2