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Multicenter Study
. 2015 Feb 5:350:h158.
doi: 10.1136/bmj.h158.

Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study

Wenxin Xu  1 , Saveli I Goldberg  2 , Maria Shubina  3 , Alexander Turchin  4
Affiliations
Multicenter Study

Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study

Wenxin Xu et al. BMJ. .

Abstract

Objectives: To investigate the optimal systolic blood pressure goal above which new antihypertensive medications should be added or doses of existing medications increased ("systolic intensification threshold") and to determine the relation between delays in medication intensification and follow-up and the risk of cardiovascular events or death.

Design: Retrospective cohort study.

Setting: Primary care practices in the United Kingdom, 1986-2010.

Participants: 88 756 adults with hypertension from The Health Improvement Network nationwide primary care research database.

Main outcome measures: Rates of acute cardiovascular events or death from any cause for patients with different hypertension treatment strategies (defined by systolic intensification threshold, time to intensification, and time to follow-up over the course of a 10 year treatment strategy assessment period) after adjustment for age, sex, smoking status, socioeconomic deprivation, history of diabetes, cardiovascular disease or chronic kidney disease, Charlson comorbidity index, body mass index, medication possession ratio, and baseline blood pressure.

Results: During a median follow-up of 37.4 months after the treatment strategy assessment period, 9985 (11.3%) participants had an acute cardiovascular event or died. No difference in risk of the outcome was seen between systolic intensification thresholds of 130-150 mm Hg, whereas systolic intensification thresholds greater than 150 mm Hg were associated with progressively greater risk (hazard ratio 1.21, 95% confidence interval 1.13 to 1.30; P<0.001 for intensification threshold of 160 mm Hg). Outcome risk increased progressively from the lowest (0-1.4 months) to the highest fifth of time to medication intensification (hazard ratio 1.12, 1.05 to 1.20; P=0.009 for intensification between 1.4 and 4.7 months after detection of elevated blood pressure). The highest fifth of time to follow-up (>2.7 months) was also associated with increased outcome risk (hazard ratio 1.18, 1.11 to 1.25; P<0.001).

Conclusions: Systolic intensification thresholds higher than 150 mm Hg, delays of greater than 1.4 months before medication intensification after systolic blood pressure elevation, and delays of greater than 2.7 months before blood pressure follow-up after antihypertensive medication intensification were associated with increased risk of an acute cardiovascular event or death. These findings support the importance of timely medical management and follow-up in the treatment of patients with hypertension.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no financial support from any third party organization for the submitted work; no relationships with companies that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Study patients and exclusion criteria. THIN=The Health Improvement Network
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Fig 2 Effects of systolic blood pressure intensification threshold, time to antihypertensive intensification, and time to follow-up after intensification on risk of acute cardiovascular event or death. Top panel: hazard ratio for acute cardiovascular event or death in relation to systolic blood pressure intensification threshold. Middle panel: hazard ratio for acute cardiovascular event or death in relation to mean months elapsed between systolic blood pressure elevation above minimum intensification threshold and either antihypertensive medication intensification or censoring of unintensified period (via spontaneous normalization of blood pressure). Bottom panel: hazard ratio for acute cardiovascular event or death in relation to mean months elapsed between each antihypertensive medication intensification and next blood pressure measurement. Solid lines indicate hazard ratios; dashed lines indicate 95% confidence intervals calculated using natural cubic spline regression. Reference points are placed at means of respective distributions for time to intensification and time to follow-up. Knots are placed at 5th, 25th, 75th, and 95th centiles of each variable. Multivariable model was adjusted for age, sex, body mass index, smoking status, socioeconomic deprivation, history of cardiovascular disease or diabetes, other chronic medical conditions as represented by Charlson comorbidity index, minimum systolic intensification threshold, mean initial blood pressure elevation above intensification threshold, and medication possession ratio
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Fig 3 Censoring of time to intensification versus length of treatment strategy assessment period (highest fifth: >15.32 months)
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