Treatment of Mild HTN: What’s the Benefit?

Study Questions:

Do adults with mild hypertension (HTN) who are at low risk for cardiovascular disease (CVD) benefit from antihypertensive therapy?

Methods:

This was a longitudinal cohort study using data from the Clinical Practice Research Datalink, which includes data for electronic medical records across England. Data were extracted between January 1, 1998, through September 30, 2015, from adults ages 18-74 years who had mild hypertension (defined as untreated blood pressure of 140/90-159/99 mm Hg) and no previous treatment. Patients with a history of CVD or CVD risk factors were excluded from the present analysis. Also excluded were patients with missing data during follow-up. The primary exposure was defined as prescription of antihypertensive medication. The primary outcomes of interest were death and CVD events. Adverse events among patients prescribed antihypertensive medications compared to those who were not prescribed treatment were also examined.

Results:

A total of 19,143 treated patients (mean age, 54.7 years; 55.9% women; 55.5% white) were matched to 19,143 similar untreated patients (mean age, 54.9 years; 55.5% female; 55.7% white). Over a median follow-up period of 5.8 years, no significant association was found between antihypertensive treatment and mortality (hazard ratio [HR], 1.02; 95% confidence interval [CI], 0.88-1.17) or between antihypertensive treatment and CVD (HR, 1.09; 95% CI, 0.95-1.25). However, antihypertensive treatment was associated with an increased risk of adverse events, including hypotension (HR, 1.69; 95% CI, 1.30-2.20; number needed to harm at 10 years [NNH10] was 41) and syncope (HR, 1.28; 95% CI, 1.10-1.50; NNH10 was 35). Additional adverse events observed for use of antihypertensive therapy included electrolyte abnormalities (HR, 1.72; 95% CI, 1.12-2.65; NNH10 was 111) and acute kidney injury (HR, 1.37; 95% CI, 1.00-1.88; NNH10 was 91).

Conclusions:

The authors concluded that this prespecified analysis found no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension. There was evidence of an increased risk of adverse events, which suggests that physicians should exercise caution when following guidelines that generalize findings from trials conducted in high-risk individuals to those at lower risk.

Perspective:

These data suggest that a large-scale trial to examine use of antihypertensive pharmacologic therapies among patients at low CVD risk who have mild hypertension is warranted. In the meantime, lifestyle modification is perhaps the most important management of such patients and would likely prevent progression of blood pressure elevation.

Clinical Topics: Prevention, Hypertension

Keywords: Acute Kidney Injury, Antihypertensive Agents, Blood Pressure, Blood Pressure Determination, Cardiovascular Diseases, Electrolytes, Electronic Health Records, Hypertension, Hypotension, Life Style, Primary Prevention, Risk Factors, Syncope


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