Long-term Cardiovascular Risk to Guide Blood Pressure Treatment Decisions

Introduction: Rethinking Cardiovascular Risk Assessment

Recent research published in the American Heart Association’s journal Hypertension has highlighted the importance of assessing a person’s long-term cardiovascular health when managing stage 1 hypertension, commonly known as high blood pressure. Traditionally, healthcare providers have relied on evaluating a 10-year risk of cardiovascular disease (CVD) to guide treatment decisions. However, this study suggests that considering a 30-year risk of CVD may provide a more comprehensive understanding of an individual’s potential for developing heart-related conditions over time. By taking into account this extended risk assessment, doctors can better tailor treatment strategies, potentially leading to more effective long-term outcomes for patients with stage 1 hypertension.

The research underscores the evolving approach to hypertension management, which increasingly recognizes that short-term assessments may not fully capture the cumulative effects of high blood pressure on cardiovascular health. Stage 1 hypertension, often characterized by slightly elevated blood pressure levels, can have significant long-term consequences if not adequately managed. The study advocates for integrating both 10-year and 30-year risk evaluations into clinical practice, offering a more robust framework for predicting and preventing future cardiovascular events. This approach could lead to earlier and more personalized interventions, ultimately improving patient prognosis and reducing the overall burden of CVD.

The Importance of Long-term Risk Prediction

Current Practices and Shortcomings

Current guidelines typically focus on short-term, 10-year risk assessments to determine when to begin medication therapy for high blood pressure. However, this approach may overlook the benefits of lowering blood pressure to prevent long-term cardiovascular events such as heart attacks, strokes, and heart failure.

Insights from Dr. Paul Muntner

“Many people may not have a heart attack or stroke, or develop heart failure in the next few years, yet they may benefit from lowering their blood pressure to protect them against having a heart attack, stroke, or heart failure later in life,” said Paul Muntner, Ph.D., M.H.S., FAHA, lead study author and visiting professor in the department of epidemiology at the University of Alabama at Birmingham.

Comparing Risk Prediction Tools

The PREVENT Calculator

The study compared the American Heart Association’s newly released PREVENT™ risk calculator with the older Pooled Cohort Equations (PCE). The PREVENT tool uses sex-specific equations, incorporates markers of kidney disease and HbA1c measures, and considers social deprivation indices. It can estimate both 10-year and 30-year risks for heart attack, stroke, and heart failure.

The Pooled Cohort Equations

In contrast, the PCE only calculates 10-year risk for heart attack and stroke and does not include factors like kidney function or statin use. It was designed for individuals aged 40 to 79, whereas PREVENT covers ages 30 to 79.

Key Findings of the Study

Higher Threshold for Long-term Risk

The study used data from the U.S. National Health and Nutrition Examination Survey (NHANES) from 2013 to 2020, analyzing 1,703 adults aged 30 to 79 with stage 1 hypertension. The researchers considered a 10-year risk of 15% or higher as high-risk using the PREVENT calculator, compared to a 10% threshold with the PCE.

Significant Discrepancies in Risk Assessment

Findings revealed that participants’ average 10-year estimated risk for heart attack and stroke was 2.9% with the PREVENT calculator, compared to 5.4% with the PCE. Furthermore, 55.3% of adults deemed high-risk by the PCE had a low 10-year risk using PREVENT, but their 30-year risk was 30% or higher, suggesting the need for clinicians to consider both short- and long-term risks.

Implications for Blood Pressure Management

“Many people with stage 1 high blood pressure who are not likely to have a heart attack, stroke, or heart failure within the next 10 years may have a high risk over the next 30 years,” Muntner said. “People may want to discuss this with their doctors and consider starting antihypertensive medication to lower their blood pressure to reduce their risk for heart attack, stroke, and heart failure across their lifetime even if they have a low short-term risk.”

Detailed Study Analysis

Demographics and Health Status

The average age of participants was 49.6 years. Among them, 55% identified as men, 45% as women, 65.8% as white, 15.5% as Hispanic, 10.1% as Black, 5.8% as Asian, and 2.7% as other races. Additionally, 17.2% smoked, 9.6% were on statins, 8.4% had diabetes, and 9.1% had chronic kidney disease.

Study Design and Limitations

Blood pressure was measured during a single visit, unlike the multiple readings recommended by guidelines. The cross-sectional nature of the data means it only captures a snapshot in time and cannot conclusively determine which model better predicts CVD outcomes.

Expert Commentary

Insights from Dr. Sadiya S. Khan

“We know from emerging evidence that blood pressure-lowering is effective at reducing CVD risk, especially among those at higher baseline risk,” said Sadiya S. Khan, M.D., M.Sc., FAHA, chair of the writing group for the American Heart Association’s 2023 scientific statement on risk assessment. “This study highlights the burden of stage 1 hypertension and the need to keep BP as optimal as possible for as long as possible, whether through lifestyle changes or medication.”

Enhancing Patient-Clinician Discussions

“The authors should be commended for examining both 10- and 30-year risk,” Khan continued. “This is a valuable addition to the PREVENT models for enhancing risk communication discussions with patients. Estimating risk is the first step in initiating a patient-clinician discussion, and including other risk-enhancing factors is also crucial.”

Broader Implications for Public Health

Importance of Equal Access to Treatment

“Cardiovascular prevention is important for all race and ethnic groups,” Muntner emphasized. “Non-Hispanic Black adults have a higher risk of stroke and heart failure in the U.S. compared to other groups, but treatments are equally effective. Ensuring equal access to treatments that lower blood pressure is important for all adults.”

Future Research Directions

Further research should focus on validating these findings in diverse populations and exploring how best to integrate long-term risk assessments into clinical practice to optimize cardiovascular health outcomes.

Conclusion: Towards Better Risk Management in Hypertension

This study underscores the importance of considering both short-term and long-term cardiovascular risks when making treatment decisions for high blood pressure. By using comprehensive tools like the PREVENT calculator, healthcare providers can better tailor interventions to reduce the lifetime risk of cardiovascular events, ultimately improving patient outcomes and advancing public health.