July 25, 2019

expert reaction to paper on identifying those eligible for blood pressure treatment and subsequent burden of cardiovascular disease

Research, published in The Lancet, reports that prescribing blood pressure drugs based on cardiovascular risk, rather than blood pressure alone, could prevent an additional 85,000 cardiovascular disease events over 10 years.

Dr Sonya Babu-Narayan, Associate Medical Director at the British Heart Foundation, said:

“This study suggests that choosing to lower blood pressure in people based on their overall risk of developing cardiovascular disease over the next 10 years, would prevent more heart attacks and strokes than current guidelines. These are important findings that may influence future NHS recommendations.

“Whilst the study suggests that the introduction of the 2019 NICE guideline will prevent more cardiovascular disease than the 2011 NICE guidelines, the authors believe that an overall risk score for developing heart disease or stroke which is not confined to blood pressure measurement would be even more effective. 

“A limitation of the study is that it did not look at the potential harms of not treating patients with high blood pressure whose overall risk of cardiovascular disease was low.

“This research adds to the evidence on who should be recommended treatment. Meanwhile, we estimate that as many as 5 million people in the UK are living with undiagnosed high blood pressure at a level we know significantly increases their risk of a heart attack or stroke and which can be successfully treated with lifestyle changes and medication where needed.”

Prof Paul Leeson, Professor of Cardiovascular Medicine, University of Oxford, said:

“This is an interesting study that tries to understand whether it is better to target blood pressure treatment to all those at high risk of cardiovascular events or just those with high blood pressure. Not surprisingly the risk score is the most accurate at predicting who will have a cardiovascular event but this does not necessarily mean these are the people who will benefit most from drugs targeted specifically at blood pressure. A method just based on risk score would result in more people with low blood pressure being started on treatment and some people with high blood pressures not being offered medication.  The analysis also does not help understand how much you should try to lower someone’s blood pressure when you use a pure risk score approach. Nevertheless, the study highlights that we need to develop more sophisticated ways to identify the people who are most at risk of developing problems because of their blood pressure, so that we can ensure they receive treatment to prevent later disease.”

Prof Naveed Sattar, Professor of Metabolic Medicine, University of Glasgow, said:

“I like this new paper which is challenging long held beliefs with regards to blood pressure.  In the same way that overall risk for heart disease and stroke dictates when we recommend statins for most patients (unless cholesterol levels are very high), it makes sense that the same ought to be true for blood pressure and indeed this excellent work seems to confirm this.  Guideline committees should give this new paper detailed consideration as they weigh up future recommendations.”  

* ‘Eligibility and subsequent burden of cardiovascular disease of four strategies for blood pressure-lowering treatment: a retrospective cohort study’ by Emily Herrett et al. was published in The Lancet at 23:30 UK time on Thursday 25th July. 

DOI: 10.1016/S0140-6736(19)31359-5

Declared interests

Dr Sonya Babu-Narayan: Dr Sonya Babu-Narayan is associate medical director at BHF

Prof Paul Leeson: None relevant to this paper. 

Prof Naveed Sattar: Prof Sattar was Chair of the cardiovascular prevention guideline for SIGN 2017.