Association Hypertension Guidelines Research Articles

Abstract P482: Long-term Health and Cost Impact of the 2017 American College of Cardiology/American Heart Association (2017 Acc/aha) Hypertension Guidelines for Low-risk Adults

Introduction: The 2017 ACC/AHA guidelines redefined stage 1 hypertension to include blood pressure 130-139 mmHg/80-89 mmHg and recommended non-pharmacologic interventions (e.g., DASH diet, physical activity) for those with stage 1 hypertension and a low 10-year risk of cardiovascular disease (CVD). The cost-effectiveness of achieving target blood pressure in this low risk population in the clinical setting (via identification, diagnosis, and counseling on diet and exercise) has not been assessed. Methods: We used the Cardiovascular Disease Policy Model (CVDPM), a dynamic state-transition model of CVD in US adults to simulate achieving blood pressure control in low-risk adults aged 35-64 years with untreated stage 1 hypertension based on the 2017 ACC/AHA guidelines. Outcomes included incident CVD (coronary heart disease and stroke), CVD healthcare costs (2018 dollars), and quality-adjusted life years (QALYs) over 10 years. We projected outcomes assuming all low-risk young adults achieve control. We then varied the degree to which patients would change behaviors following diagnosis, using low uptake (20%) and high uptake (70%) estimates sourced from literature. We tested the sensitivity of health gains to decrements in QALYs associated with receiving a diagnosis using estimates from the Global Burden of Disease. Results: An estimated 7.0 million men and 6.6 million women age 35-64 years would be newly diagnosed with stage 1 hypertension and indicated for non-pharmacologic interventions according to 2017 ACC/AHA. Achieving targets of <130/80 mmHg is projected to prevent 63,200 incident CVD events and 4,800 CVD deaths and lower CVD related healthcare costs by $3.6 billion (2018 USD) over 10 years compared to no BP change. Assuming less than complete control (because of variable uptake of non-pharmacologic interventions) resulted in lower rates of CVD prevention (low uptake - 13,900 events prevented and $0.8 billion lower costs; high uptake 41,000 events prevented and $2.3 billion lower costs). In all scenarios, the magnitude of QALYs gained from preventing CVD was highly sensitive to decrements associated with anxiety from receiving a diagnosis. Conclusions: Achieving 2017 ACC/AHA stage 1 hypertension goals in newly diagnosed low-risk adults would result in substantial CVD benefit and reductions in CVD-related healthcare costs. . If these goals are to be achieved in the clinical setting, gains are likely to be offset by degree of uptake of counseling regarding non-pharmacologic interventions and anxiety related to a new diagnosis of hypertension.

New 2017 ACC/AHA Hypertension Guidelines—Cost-Effectiveness among U.S. Adults with Type 2 Diabetes

Introduction: The new 2017 American College of Cardiology (ACC) and American Heart Association (AHA) hypertension guideline defines hypertension as either systolic blood pressure (SBP) > 130 mmHg or diastolic blood pressure (DBP) > 80 mmHg, compared with the old guideline of SBP >140 mmHg or DBP > 90 mmHg. The new definition would increase number of persons eligible for hypertension treatment. Our objectives were to estimate how many more persons with type 2 diabetes would be eligible for hypertension treatment under the new guideline and to assess the cost-effectiveness (CE) of treating this newly eligible population. Method: Data from the 2011-2016 National Health and Nutrition Examination Survey and the 2015 Census were used to estimate the numbers of persons with diabetes who would be eligible for hypertension treatment under the new and old guidelines. The CDC-RTI cost-effectiveness diabetes simulation model was used to project the lifetime health and cost (2017 USD) consequences of treating newly eligible persons. Two hypertension treatments were modeled: moderate BP treatment as defined in the guidelines and intensive BP treatment using multiple antihypertensive drugs as implemented in the UK Prospective Diabetes Study trial. The CE of the new guideline was measured using costs per quality-adjusted life year (QALY). Results: The number of persons with diabetes eligible for hypertension treatment would increase from 8.4 (27.7%) to 15.7 million (51.9%) under the new ACC/AHA guideline. Treating hypertension persons defined by new guideline would result in $3038/QALY if the moderate BP treatment were implemented and would be cost-saving if intensive BP treatment were implemented, compared to treating persons defined through old guideline. Conclusion: The new ACC/AHA hypertension guideline would nearly double the number of persons with diabetes who would be eligible for hypertension treatment. Treating those newly eligible is likely to be cost-effective or even cost-saving. Disclosure H. Shao: None. M. Laxy: None. D.B. Rolka: None. E.W. Gregg: None. P. Zhang: None.

HYPE and TENSION in Hypertension. Debating the latest hypertension guidelines

Background: The latest American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines promote radical changes to hypertension management - achieving a normal blood pressure (BP) defined as <120 mm Hg systolic and <80 mm Hg diastolic in all. The “rationale” for this re-definition of hypertension remains hotly debated and has been rejected by a variety of bodies.Method: This article approaches the hype and the tensions in hypertension from five different perspectives: (1) Physiology - pressure and flow in a pipe are related to the 4th power of the radius, hence very small changes in radius require a significant pressure increase to maintain the same flow to maintain oxygen distribution to tissues - the cardinal function of the heart. Chronic SNS and HPA-axis activation results in persistent vasoconstriction and thus chronically elevated BP. (2) Epidemiology - BP is non-linearly distributed across the community and increases with inflammaging across the lifespan. Ethnic as well as socioeconomic factors are associated with elevated BP levels, most likely to the chronic activation of the SNS and HPA-axis with increasing disadvantage. (3) Disease, an emergent phenomenon - A complex adaptive systems understanding shows that health and disease are a “whole of system” phenomenon with a high degree of robustness. Its underlying physiological mechanisms mostly maintain a healthy functional state and only occasionally result in dysfunctional disease states. (4) Overselling risks and benefits - what matters is absolute risk and absolute benefit/harm. The misunderstanding of basic statistics, namely that large studies are required to demonstrate small differences rather than an indicator of magnitude and veracity of benefit shown by it, allows ‘snake oil merchants’ to promote interventions tapping into fear. While risk perception varies, most people regard treatments with an NNT of >30 as not worth the effort. (5) The need for wisdom in clinical care.Results and Discussion: Peter Drucker emphasised there is a distinction between doing things right and doing the right thing. Doing the right thing requires contextualisation of data and information gleaned from clinical trials in the context of the patient in front of the clinician; many elderly people require “high BP” to maintain cerebral perfusion that allows them to think, not fall, and to maintain their independence. Hence, we should come to terms with the fact that non-linear physiological phenomena cannot be approached with a cause-and-effect mindset; that quality of life is often more important to people than the label of their morbidities and that after all the sum of all causes of mortality always add up to 100%. Conclusion: Wisdom has no easy answers, doing the right thing entails taking account of the best available data and information, being honest about the magnitude of the real benefits and the real risks of treatments, contextualising those for the context of every person and valuing his/her best-informed choice without resentment or fear.