Eligibility and subsequent burden of cardiovascular disease under four strategies for blood pressure lowering treatment: a cohort study

Background: Worldwide treatment recommendations for blood pressure lowering continue to be guided predominantly by blood pressure thresholds, despite strong evidence that the benefits of blood pressure reduction are observed across the blood pressure spectrum. This study investigated the implications of alternative strategies for offering blood pressure treatment, using the UK as an illustrative example.
Methods: This cohort study used data from 1.2 million UK primary care patients without cardiovascular disease , followed from 2011 for a median 4.3 years in the Clinical Practice Research Datalink, linked to Hospital Episode Statistics and Office for National Statistics mortality. The strategies compared were (i) 2011 UK National Institute for Health and Care Excellence (NICE) guidelines, (ii) proposed 2019 NICE guidelines, (iii) using blood pressure alone (≥140/90mmHg), (iv) using predicted ten year cardiovascular risk alone (QRISK2 ≥10%). For each strategy, we estimated the proportion of patients eligible for treatment and number of cardiovascular events that could be prevented with treatment.
Findings: 271,963 individuals (22.2% of the cohort) were eligible for treatment under the 2011 NICE guideline, 327,429 (26.8%) based on 2019 guideline, 481,859 (39.4%) based on blood pressure ≥140/90mmHg, and 357,840 (29.3%) for QRISK2 ≥10%. The cardiovascular event rates among those eligible for each strategy were 15.5, 14.9, 11.6 and 17.1 per 1000 person years, respectively. Scaled to the UK population, we estimated that 233,153 events would be avoided under the 2011 NICE strategy (28 patients treated for ten years per event avoided), 270,233 using 2019 NICE strategy (29 treated/event avoided), 301,523 using blood pressure (38 treated/event avoided); and 322,921 using QRISK2 (27 treated/event avoided).
Interpretation: A cardiovascular risk-based strategy (QRISK2 ≥10%) could prevent over one third more CVD events than 2011 NICE guidance and one-fifth more than NICE 2019, with similar efficiency in terms of number treated per event avoided.