According to a recent study, it’s crucial to consider both the 30-year and 10-year risk for cardiovascular disease when determining the appropriate time to start high blood pressure medication.
An investigation comparing two tools used to predict an individual’s risk of developing cardiovascular disease suggests that in addition to the short-term 10-year risk, long-term 30-year risk should also play a role in deciding when to initiate medication therapy for stage 1 hypertension or high blood pressure. This research was published in Hypertension, a journal of the American Heart Association.
“Even if someone may not be at immediate risk of a heart attack, stroke, or heart failure in the next few years, lowering their blood pressure can still be beneficial in preventing these conditions in the long run,” explained Paul Muntner, Ph.D., M.H.S., FAHA, who is the lead author of the study and a visiting professor in the department of epidemiology at the University of Alabama at Birmingham. “Considering both short-term and lifetime risk of developing heart disease, stroke, or heart failure is important for guiding lifestyle changes and treatment recommendations in cardiovascular disease guidelines.”
The study compared the risk estimates provided by the American Heart Association’s PREVENTTM risk calculator, introduced in 2023, with the previous tool known as the Pooled Cohort Equations (PCE). The PREVENT tool accounts for sex-specific equations, includes markers for kidney disease and HbA1c levels to monitor metabolic health, can calculate both 10-year and 30-year risks for heart attack, stroke, and heart failure, and incorporates additional risk factors such as the social deprivation index. On the other hand, the Pooled Cohort Equations only assess the 10-year risk of heart attack and stroke for individuals aged 40 to 79 and excludes heart failure, additional risk factors like kidney function, and statin use.
The Pooled Cohort Equations focus on estimating the 10-year risk of heart attack and stroke, while PREVENT can predict CVD risks in individuals aged 30 to 79 and project risks over both 10 and 30 years. According to the 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, a 10-year risk of heart attack or stroke exceeding 10% using the PCEs criteria was considered high risk, prompting healthcare professionals to discuss blood pressure-lowering medication with their patients. Treatment for stage 1 hypertension involves lifestyle changes like diet and physical activity modifications along with medication as necessary.
In the study, researchers considered a 10-year risk of heart attack, stroke, and/or heart failure of 15% or higher as high-risk using the PREVENT calculator. In contrast, the Pooled Cohort Equations considered a 10% or higher risk of heart attack and/or stroke as high-risk. The analysis included data from 1,703 adults with stage 1 hypertension aged 30 to 79 who participated in the U.S. National Health and Nutrition Examination Survey (NHANES) from 2013 to 2020. The results revealed:
- The average 10-year estimated risk for heart attack and stroke was 2.9% when calculated using the PREVENT calculator, compared to the Pooled Cohort Equations’ estimate of 5.4%. This indicates that under the same threshold used for PCEs, some individuals may not be advised to start blood pressure-lowering medication based on the PREVENT prediction.
- Although some people were classified as low risk over the next 10 years by PREVENT despite being at high risk using PCEs, these individuals had a 30-year risk of heart attack, stroke, and heart failure equal to or greater than 30%, as estimated by the PREVENT calculator. This underscores the importance of considering both short-term and long-term cardiovascular risks for individuals with high blood pressure.
“Even individuals with stage 1 high blood pressure who are not anticipated to experience a heart attack, stroke, or heart failure within the next decade may still face significant risks over the next 30 years,” Muntner emphasized. “It’s advisable for people to consult with their healthcare providers and contemplate starting antihypertensive medication to reduce the likelihood of heart attack, stroke, and heart failure throughout their lifetime, even if their short-term risk is low.”
The study’s design, background, and participant details revealed:
- The average age of participants with stage 1 high blood pressure was 49.6 years, with men comprising 55% and women 45% of the group. The racial distribution among participants was as follows: 65.8% white adults, 15.5% Hispanic adults, 10.1% Black adults, 5.8% Asian adults, and 2.7% from other racial or ethnic backgrounds.
- Furthermore, 17.2% of participants smoked, 9.6% were using statins to lower cholesterol, 8.4% had Type 1 or Type 2 diabetes, and 9.1% had chronic kidney disease.
- All study participants exhibited stage 1 hypertension, determined by up to three blood pressure measurements taken during a single NHANES data collection period from 2013 to 2020. As the study was cross-sectional, blood pressure readings were obtained during a single office visit.
- Participants provided information during NHANES enrollment about their age, sex, race, ethnicity, smoking habits, and any prior diagnoses of coronary heart disease, heart attack, heart failure, stroke, Type 1 or Type 2 diabetes, or high blood pressure. Individuals with a history of coronary disease, heart attack, stroke, or heart failure were excluded from the analysis.
“Preventing cardiovascular disease is crucial for individuals of all racial and ethnic backgrounds. Non-Hispanic Black adults exhibit a higher risk of stroke and heart failure in the U.S. compared to other groups, including non-Hispanic white adults,” noted Muntner. “However, treatments are similarly effective across these diverse populations. Ensuring equitable access to blood pressure-lowering treatments is essential for all adults.”
The study had certain limitations. Blood pressure levels were measured during a single NHANES visit, in contrast to the two or more readings at different visits recommended by the American Heart Association’s guideline. Five years included in the study showed stable 10-year CVD risk using the Pooled Cohort Equations. The data used was cross-sectional, providing a snapshot of the study population at a specific time without outcomes data related to CVD. Hence, the study results do not definitively determine which model better predicts cardiovascular disease risk.
Evidence from ongoing clinical trials emphasizes the importance of lowering blood pressure. High Blood Pressure Management for Cardiovascular Health
A recent study has shown that managing high blood pressure effectively can significantly reduce the risk of cardiovascular disease, especially for individuals with a higher baseline risk. The findings emphasize the importance for healthcare professionals, health systems, and society as a whole to prioritize maintaining optimal blood pressure levels for as long as possible. This may involve lifestyle modifications and potentially the use of blood pressure medication when lifestyle changes alone are not sufficient.
Deciding when to start medication for lowering blood pressure is informed by clinical trial data, such as the SPRINT and ESPRIT trials, which demonstrated the benefits of intensive blood pressure management for individuals with existing cardiovascular disease or those at an elevated risk. By focusing on individuals with a higher predicted risk using accurate prediction models, health outcomes can be improved more effectively and efficiently.
Dr. Sadiya S. Khan, an expert in cardiovascular epidemiology and preventive medicine, commended the study for considering both short-term (10-year) and long-term (30-year) cardiovascular risk assessments. The addition of 30-year risk assessment can enhance discussions with patients regarding their risk profile. Calculating risk is crucial in initiating discussions between patients and healthcare providers, and additional risk factors need to be taken into account. For instance, individuals who experienced high blood pressure during pregnancy (preeclampsia) are at a significantly higher risk of cardiovascular disease and may require more aggressive preventive measures, including earlier initiation of blood pressure medication.
The study underscores the importance of clinical trials in younger populations with a high long-term risk of cardiovascular disease, as well as specific groups like those with a history of preeclampsia, to determine optimal thresholds for medication initiation and treatment targets for managing blood pressure using medications.
