A comprehensive model of care designed to address community-specific barriers and primarily driven by locally-trained nonphysician health workers (NPHWs) substantially reduced cardiovascular disease risk in 30 communities in Colombia and Malaysia. The findings of the HOPE 4 trial were presented Sept. 2 by Jon-David Schwalm, MD, at ESC Congress 2019 and published in The Lancet.

In designing the intervention with the goal of improving detection and control of high blood pressure – with a particular focus on low- and middle-income countries, which suffer the greatest disease burden – the researchers first identified barriers to treatment at the level of the patient, health care provider and health system.

The intervention strategy consisted of: community screening, detection, treatment, and control of cardiovascular disease risk factors by NPHWs (in collaboration with local physicians) guided by tablet-based simplified management algorithms, decision support, and counselling programs; provision of free locally available combination antihypertensive medications and a statin recommended by NPHWs, but supervised by local physicians; and support from a participant-nominated treatment supporter (friend or family member) to improve adherence to medications and health behaviors.

After enrollment in each community was completed, community clusters were randomized to either the intervention or usual care and followed for 12 months. Usual care included being given health literature on cardiovascular disease that was available locally and a recommendation to see their health care provider as usual.

In total, 14 (n=644) communities were assigned to the intervention and 16 communities (n=727) to usual care. Most of the participants (n=1,008; 73.5 percent) had a history of hypertension and were taking antihypertensive medications, but their blood pressure was not controlled.

Results showed a greater reduction in the primary endpoint of 10-year cardiovascular risk as measured by the Framingham Risk Score at 12 months in the intervention group vs. the control group (–11.17 percent vs. –6·40 percent), with a difference of change of –4.78 percent; p<0·0001. In the intervention group, there was a 34.2 percent relative reduction in the FRS estimate compared with baseline.

Greater absolute reductions were also seen in the intervention group compared with the control group for systolic blood pressure (11.45 mm Hg) and for LDL-C (15.85 mg/dL) (p<0.001 for both). More patients in the intervention group achieved blood pressure control, defined as <140 mm Hg systolic, than in the control group (69 percent vs. 30 percent; p<0.001). Medication adherence was higher with the intervention.

The community-based intervention was successful in urban and rural settings in two different countries and continents, with widely varying health systems and cultural backgrounds, wrote the authors, "which suggests our findings are widely applicable." They also noted the high degree of agreement in clinical decision-making between the NPHWs and physicians.

"Adoption of the HOPE 4 strategy could substantially enhance reduction in cardiovascular disease risk in those with hypertension, and in doing so help achieve the UN's General Assembly target that calls for a one-third reduction in premature cardiovascular disease mortality by 2030," said the researchers.

Clinical Topics: Prevention, Stable Ischemic Heart Disease, Hypertension, Chronic Angina

Keywords: ESC 19, ESC Congress, Hypertension, Risk Factors, Primary Prevention, Angina, Stable

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