CRHCP, RICH LIFE, MB-BP, QUARTET USA Trials Explore HTN Management Across Diverse Patient Populations

Innovative strategies for mindful disruption of chronic hypertension management were the focus of a Late-Breaking Science session on Nov. 6 at AHA 2022 in Chicago, with researchers presenting findings from the CRHCP, RICH LIFE, MB-BP and QUARTET USA studies.

In CRHCP, researchers found that village doctor-led hypertension intervention was effective in reducing cardiovascular disease and all-cause mortality in rural villages in China compared with usual care. Researchers implemented a simple stepped-care protocol for hypertension treatment to achieve a target systolic blood pressure (BP) <130 mmHg and diastolic BP <80 mmHg, with village doctors initiating and titrating antihypertensive medications based on the treatment protocol, delivering discounted and free medications to patients, conducting health coaching on lifestyle modification and medication adherence, and instructing patients on home BP monitoring.

At 36 months, the net group differences in systolic and diastolic BP were -23.1 and -9.9 mmHg (P<0.0001), respectively, and the primary composite outcome of myocardial infarction, stroke, heart failure, or cardiovascular disease death was significantly reduced by 31% in the intervention group compared to usual care.

"This cluster-randomized trial demonstrated that a village doctor-led intervention for hypertension control in a low-resource setting is effective in reducing cardiovascular disease and all-cause mortality," said Jiang He, MD, who presented the findings. "Furthermore, it showed that treating all hypertensive adults to a lower BP target is both feasible and beneficial for cardiovascular disease risk reduction."

In RICH LIFE, an enhanced, collaborative and stepped care intervention that included equity-focused leadership training and engagement, BP measurement standardization, hypertension best practices education, and audit/feedback on hypertension disparities, improved BP control significantly among racially and economically diverse primary care patients with hypertension.

Thirty practices were involved in the study and randomized to either standard of care plus or collaborative care/stepped care intervention. According to Lisa A. Cooper, MD, MPH, who presented the findings, "the addition of a collaborative care team including a care manager and a community health worker provided similar benefits for BP control and BP levels, greater improvements in patient experiences of chronic illness care, and greater improvements in BP control for patients with Medicaid insurance and patients with coronary heart disease, than for patients not in those groups.

Based on the findings, Cooper suggests that health system leaders and policymakers should provide support for multi-level interventions to reduce disparities in BP control, with more intensive approaches reserved for those individuals with complex medical and social needs. She adds that future research should further explore the barriers to successful implementation of interventions that would advance equity in hypertension outcomes.

Results from the MB-BP study found that adults with hypertension who participated in a mindfulness behavior program for eight weeks had significantly lower BP levels and greatly reduced sedentary time, at six months follow-up. Compared with participants who received enhanced usual care (a home BP monitor, BP educational information, and facilitated access to a physician if needed), those in the mindfulness program group were more likely to eat heart-healthy foods and to report lower levels of perceived stress.

"The mindfulness program focused on training participants in skills such as attention control, self-awareness and emotion regulation, and then applied that training to health behavior change," said Eric B. Loucks, PhD. "This approach may offer a novel way to improve BP control."

QUARTET USA findings found that initiating a four-drug, quarter-dose BP-lowering combination of candesartan (2 mg), amlodipine (1.25 mg), indapamide (0.625 mg) and bisoprolol (2.5 mg) led to a -4.8/-4.9 mmHg greater reduction in change in BP from baseline to 12 weeks compared with standard-dose ARB monotherapy (candesartan/8 mg daily) in patients with mild to moderate hypertension.

Researchers noted that differences in systolic BP were not statistically significant, which is likely due to limited power related to the sample size. Additionally, while adverse events were more common in the intervention group, the rate of discontinuation was higher in the comparator group.

"New approaches are needed to achieve lower BP targets, especially for patients and communities with a high burden of hypertension and hypertension-related diseases," said Mark D. Huffman, MD, FACC, who presented the findings. He added that the direction and magnitude of BP lowering effect were similar between QUARTET and QUARTET USA, despite different study populations with lower baseline BP in the U.S., "thus strengthening the case for this new approach."

Clinical Topics: Cardiovascular Care Team, Prevention, Hypertension, Stress

Keywords: AHA Annual Scientific Sessions, AHA22, Blood Pressure, Cardiovascular Diseases, Guideline Adherence, Hypertension, Life Style, Meditation, Mindfulness, Patient Reported Outcome Measures, Stress, Psychological, Treatment Outcome, ACC International, Secondary Prevention, Care Team

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