Looking Beyond Targets for Blood Pressure Medications

Heart disease and stroke treatment may depend on multiple factors besides blood pressure readings

(RxWiki News) When prescribing high blood pressure medication, doctors often focus on getting their patients to reach a blood pressure target. A more individualized approach, looking at multiple factors, may be more effective.

High blood pressure (hypertension) is a risk factor for heart attack and stroke, and it’s common practice for healthcare providers to prescribe blood pressure medication solely on these readings.

Recently, researchers found that a person's blood pressure level was often not the most important factor in determining if a blood pressure medication would prevent heart attack and strokes — several risk factors may need to be taken into consideration.

"Get your blood pressure checked regularly."

Jeremy Sussman, MD, assistant professor of internal medicine in the Division of General Medicine at the University of Michigan Medical School and research scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System in Michigan, served as lead author on this study.

Using the National Health and Nutrition Examination Survey III (which contains health data on 34,000 individuals), Dr. Sussman and colleagues developed a sample of American adults, ages 30 to 85 years, with no history of heart attack, stroke or severe congestive heart failure.

These researchers then created a simulation model to compare results from two approaches to antihypertensive medication management after five years. The approaches were a treat-to-target treatment (TTT) focusing on specific blood pressure goals and a benefit-based tailored treatment (BTT) based on estimated reduction of cardiovascular disease events.

Medical guidelines today use a one-size-fits-all TTT approach, according to the authors of this study. They say that this TTT way of using blood pressure medication is based on blood pressure values only, and that leads to some patients being on too many medications and others being on too few.

BTT is an approach tailored to each individual, and it takes into account multiple factors to determine a person’s risk of heart disease. These factors include age, gender, whether a person smokes and blood pressure.

Based on their analysis, the researchers estimated that 55 percent of the overall population of 176 million Americans would be treated identically under the two treatment approaches.

They theorized that BTT outcomes in this population would be much better than TTT. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more quality-adjusted life years (a measure taking into account both quantity and quality of life), despite using 6 percent fewer medications.

In the 45 percent of those treated differently by the strategies, BTT would save 159 quality-adjusted life years per 1,000 treated versus 74 quality-adjusted life years per 1,000 treated by TTT.

Based on their calculations, the BTT approach could prevent more than one-fourth of heart attacks.

Dr. Sussman told dailyRx News, “The point of blood pressure-lowering medications is to stop heart disease, stroke and other related diseases. If you remember that, then blood pressure immediately stops being the only factor in deciding whether or not to take these medications. For example, someone who smokes and has a family history of stroke has a much greater chance of having a stroke prevented by these medications than someone who does not.

"In this paper we asked, ‘What would happen if we used these medications by the chance that they'd prevent a heart attack or stroke, rather than by the blood pressure itself?’ It turned out that this would be a much more efficient way of using these very common medications and that the driving factor of benefit is actually the patient's cardiovascular risk, which is a summary of all of a patient's risk factors (age, blood pressure, tobacco use, etc)," Dr. Sussman said. 

In a press release, he added, "Drugs that lower blood pressure are among the most effective and commonly used medications in the country, but we believe they can be used dramatically more effectively.”

While medications can reduce high blood pressure, other measures may help as well, including eating a healthy diet with reduced salt, exercising regularly, lowering stress, stopping smoking and maintaining a healthy weight.

The authors concluded that “[Cardiovascular disease] events can be prevented more effectively with a more comprehensive accounting for all available factors that contribute to net patient benefit...rather than chiefly basing decisions on whether the observed blood pressure level is above or below a prespecified blood pressure target.”

This study was published online on November 4 in the journal Circulation. Funding was provided by the US Department of Veterans Affairs Quality Enhancement Research Initiative and the Methods Core of the Michigan Center for Diabetes and Translational Research of the National Institutes of Health.

Review Date: 
November 11, 2013