The hypertension-based chronic disease model in a primary care setting

Abstract

Background: Driver-based chronic disease models address the public health challenge of cardiometabolic risk. However, there is no data available about the novel Hypertension-Based Chronic Disease (HBCD) model. This study investigates the prevalence, characteristics, and prognostic significance of HBCD Stages in a primary care cohort.

Methods: This study included participants aged ≥45 years, randomly selected from the primary care program of a Brazilian medium-sized city. Participants underwent electrocardiogram, tissue Doppler echocardiogram and were followed for a median of 6 years. Participants were classified into HBCD Stages as follows: Stage 1: hypertension risk factors; Stage 2: pre-hypertension; Stage 3: hypertension; and Stage 4: hypertension complications.

Results: Overall, 633 participants were included in the cross-sectional analysis and 560 that had follow-up data were included in the prognostic analysis. From 633 participants, 1.3% had no identifiable risk factors for HBCD, 10.0% were Stage 1, 14.7% Stage 2, 51.5% Stage 3, and 22.5% Stage 4. Increasing HBCD stages had worse glomerular filtration rates, echocardiographic markers, and higher body mass index, waist circumference, blood glucose levels, and prevalence of type 2 diabetes. Rates of all-cause mortality or cardiovascular hospitalization increased across HBCD Stages: Stage 1: 3.6%; Stage 2: 4.8%, Stage 3: 7.6%; and Stage 4: 39.5%. Kaplan-Meier curves showed composite outcome worsened across HBCD Stages 1-4 (p < 0.001).

Conclusions: HBCD is a conceptually and prognostically valid model. Remarkably, HBCD stages were associated with progressively worsening markers of heart disease, declining kidney function and higher rates of all-cause mortality or cardiovascular hospitalization.

Keywords: Blood pressure; Cardiometabolic disease; Hypertension; Prehypertension.

Fig. 1

The Cardiometabolic-Based Chronic Disease Model with the addition of the Hypertension-Based Chronic Disease Driver. Each driver stage can progress to the right stepwise, leapfrog to the right over adjacent steps, or in certain conditions (e.g., prediabetes), revert to the left. Metabolic drivers can also contribute to risks (Stage 1) of other metabolic drivers. Importantly, each of the progression steps can be a prevention target. Currently, Lipid-Based Chronic Disease is under development and indicated for model completeness. Abbreviations: ABCD – Adiposity-Based Chronic Disease; ABNL – abnormal; AF – atrial fibrillation; B-CELL – pancreatic β-cell; CAD – coronary artery disease; CMBCD- Cardiometabolic-Based Chronic Disease; DBCD- Dysglycemia-Based Chronic Disease; HBCD – Hypertension-Based Chronic Disease; HF – heart failure; LA – left atrial; LBCD – Lipid-Based Chronic Disease; LV – left ventricular; WC – waist circumference. Adapted from Ref. [9].

Fig. 2

Flow chart of the inclusion and exclusion of study participants.

Fig. 3

Prevalence of Hypertension-Based Chronic Disease Stages according to sex and age categories. Percentages of participants without risk factors for HBCD are illustrated in green, Stage 1 in orange, Stage 2 in grey, Stage 3 in yellow, and Stage 4 in blue. HBCD – Hypertension-Based Chronic Disease.

Fig. 4

Kaplan-Meier survival curve and hazard ratios for the composite outcome of all-cause mortality or cardiovascular hospitalization by Hypertension-Based Chronic Disease Stage. HBCD - Hypertension-Based Chronic Disease.