Using benefit-based tailored treatment to improve the use of antihypertensive medications

Effect of Population-Level Blood Pressure Treatment Strategies on Cardiovascular and Cognitive Outcomes

BACKGROUND

The large and increasing number of adults living with dementia is a pressing societal priority, which may be partially mitigated through improved population-level blood pressure (BP) control. We explored how tighter population-level BP control affects the incidence of atherosclerotic cardiovascular disease (ASCVD) events and dementia.

METHODS

Using an open-source ASCVD and dementia simulation analysis platform, the Michigan Chronic Disease Simulation Model, we evaluated how optimal implementation of 2 BP treatments based on the Eighth Joint National Committee recommendations and SPRINT (Systolic Blood Pressure Intervention Trial) protocol would influence population-level ASCVD events, global cognitive performance, and all-cause dementia. We simulated 3 populations (usual care, Eighth Joint National Committee based, SPRINT based) using nationally representative data to annually update risk factors and assign ASCVD events, global cognitive performance scores, and dementia, applying different BP treatments in each population. We tabulated total ASCVD events, global cognitive performance, all-cause dementia, optimal brain health, and years lived in each state per population.

RESULTS

Optimal implementation of SPRINT-based BP treatment strategy, compared with usual care, reduced ASCVD events in the United States by ≈77 000 per year and produced 0.4 more years of stroke- or myocardial infarction-free survival when averaged across all Americans. Population-level gains in years lived free of ASCVD events were greater for SPRINT-based than Eighth Joint National Committee-based treatment. Survival and years spent with optimal brain health improved with optimal SPRINT-based BP treatment implementation versus usual care: the average patient with hypertension lived 0.19 additional years and 0.3 additional years in optimal brain health. SPRINT-based BP treatment increased the number of years lived without dementia (by an average of 0.13 years/person with hypertension), but increased the total number of individuals with dementia, mainly through more adults surviving to advanced ages.

CONCLUSIONS

Tighter BP control likely benefits most individuals but is unlikely to reduce dementia prevalence and might even increase the number of older adults living with dementia.

Development and validation of the Michigan Chronic Disease Simulation Model (MICROSIM)

Strategies to prevent or delay Alzheimer's disease and related dementias (AD/ADRD) are urgently needed, and blood pressure (BP) management is a promising strategy. Yet the effects of different BP control strategies across the life course on AD/ADRD are unknown. Randomized trials may be infeasible due to prolonged follow-up and large sample sizes. Simulation analysis is a practical approach to estimating these effects using the best available existing data. However, existing simulation frameworks cannot estimate the effects of BP control on both dementia and cardiovascular disease. This manuscript describes the design principles, implementation details, and population-level validation of a novel population-health microsimulation framework, the MIchigan ChROnic Disease SIMulation (MICROSIM), for The Effect of Lower Blood Pressure over the Life Course on Late-life Cognition in Blacks, Hispanics, and Whites (BP-COG) study of the effect of BP levels over the life course on dementia and cardiovascular disease. MICROSIM is an agent-based Monte Carlo simulation designed using computer programming best practices. MICROSIM estimates annual vascular risk factor levels and transition probabilities in all-cause dementia, stroke, myocardial infarction, and mortality in a nationally representative sample of US adults 18+ using the National Health and Nutrition Examination Survey (NHANES). MICROSIM models changes in risk factors over time, cognition and dementia using changes from a pooled dataset of individual participant data from 6 US prospective cardiovascular cohort studies. Cardiovascular risks were estimated using a widely used risk model and BP treatment effects were derived from meta-analyses of randomized trials. MICROSIM is an extensible, open-source framework designed to estimate the population-level impact of different BP management strategies and reproduces US population-level estimates of BP and other vascular risk factors levels, their change over time, and incident all-cause dementia, stroke, myocardial infarction, and mortality.

Incorporation of quantitative imaging data using artificial intelligence improves risk prediction in veterans with liver disease

BACKGROUND AND AIMS

Utilization of electronic health records data to derive predictive indexes such as the electronic Child-Turcotte-Pugh (eCTP) Score can have significant utility in health care delivery. Within the records, CT scans contain phenotypic data which have significant prognostic value. However, data extractions have not traditionally been applied to imaging data. In this study, we used artificial intelligence to automate biomarker extraction from CT scans and examined the value of these features in improving risk prediction in patients with liver disease.

APPROACH AND RESULTS

Using a regional liver disease cohort from the Veterans Health System, we retrieved administrative, laboratory, and clinical data for Veterans who had CT scans performed for any clinical indication between 2008 and 2014. Imaging biomarkers were automatically derived using the analytic morphomics platform. In all, 4614 patients were included. We found that the eCTP Score had a Concordance index of 0.64 for the prediction of overall mortality while the imaging-based model alone or with eCTP Score performed significantly better [Concordance index of 0.72 and 0.73 ( p <0.001)]. For the subset of patients without hepatic decompensation at baseline (n=4452), the Concordance index for predicting future decompensation was 0.67, 0.79, and 0.80 for eCTP Score, imaging alone, or combined, respectively.

CONCLUSIONS

This proof of concept demonstrates that the potential of utilizing automated extraction of imaging features within CT scans either alone or in conjunction with classic health data can improve risk prediction in patients with chronic liver disease.

Estimated Population Health Benefits of Intensive Systolic Blood Pressure Treatment Among SPRINT-Eligible US Adults

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated an intensive (<120 mm Hg) vs. standard (<140 mm Hg) systolic blood pressure (SBP) goal lowered cardiovascular disease (CVD) risk. Estimating the effect of intensive SBP lowering among SPRINT-eligible adults most likely to benefit can guide implementation efforts.

METHODS

We studied SPRINT participants and SPRINT-eligible participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study and National Health and Nutrition Examination Surveys (NHANES). A published algorithm of predicted CVD benefit with intensive SBP treatment was used to categorize participants into low, medium, or high predicted benefit. CVD event rates were estimated with intensive and standard treatment.

RESULTS

Median age was 67.0, 72.0, and 64.0 years in SPRINT, SPRINT-eligible REGARDS, and SPRINT-eligible NHANES participants, respectively. The proportion with high predicted benefit was 33.0% in SPRINT, 39.0% in SPRINT-eligible REGARDS, and 23.5% in SPRINT-eligible NHANES. The estimated difference in CVD event rate (standard minus intensive) was 7.0 (95% confidence interval [CI] 3.4-10.7), 8.4 (95% CI 8.2-8.5), and 6.1 (95% CI 5.9-6.3) per 1,000 person-years in SPRINT, SPRINT-eligible REGARDS participants, and SPRINT-eligible NHANES participants, respectively (median 3.2-year follow-up). Intensive SBP treatment could prevent 84,300 (95% CI 80,800-87,920) CVD events per year in 14.1 million SPRINT-eligible US adults; 29,400 and 28,600 would be in 7.0 million individuals with medium or high predicted benefit, respectively.

CONCLUSIONS

Most of the population health benefit from intensive SBP goals could be achieved by treating those characterized by a previously published algorithm as having medium or high predicted benefit.

Cumulative exposure to elevated blood pressure better predicts cardiovascular disease risk in rural Chinese adults

Background

Traditional risk estimations for cardiovascular disease (CVD) are based on current blood pressure (BP); however, whether cumulative exposure to elevated BP among rural individuals has additional prognostic value is unclear. We aimed to validate the association of cumulative BP with CVD occurrence and assess the prognostic value of cumulative BP in CVD risk prediction.

Methods

A total of 13,057 participants who underwent three examinations from 2004 to 2010 were included in this rural epidemiological study and followed up until 2017. Cumulative BP was defined as the sum of the product of the average BP values between consecutive examinations and the time interval for each pair of successive tests prior to the follow-up period. CVD incidents that occurred during the follow-up period were noted and verified by qualified researchers. We used multivariate Cox models to assess the association of cumulative BP with CVD risk. The receiver operating characteristic curve was constructed to determine the predictive differentiation of single baseline BP measurements and cumulative BP values for CVD outcomes.

Results

During the follow-up period, 1,312 participants underwent CVD incidents. We found that cumulative systolic BP (hazard ratio = 1.334, 95% confidence interval: 1.245, 1.430) and cumulative diastolic BP (hazard ratio = 1.253, 95% confidence interval: 1.168, 1.343) were associated with CVD incidence above and beyond that of the current BP. These stronger associations persisted for stroke, myocardial infarction, and CVD mortality. The area under the curve for the model increased significantly (p < 0.001) from 0.735 (0.720, 0.750) to 0.742 (0.728, 0.757) when integrating cumulative systolic BP instead of baseline systolic BP.

Conclusion

Cumulative BP in Chinese rural adults showed a stronger association with CVD incidence than that of current BP. Furthermore, cumulative BP slightly improved the predictive performance for CVD. Our findings underline the incremental predictive value of cumulative BP in CVD risk assessment among Chinese rural adults.

Application of ensemble machine learning algorithms on lifestyle factors and wearables for cardiovascular risk prediction

This study looked at novel data sources for cardiovascular risk prediction including detailed lifestyle questionnaire and continuous blood pressure monitoring, using ensemble machine learning algorithms (MLAs). The reference conventional risk score compared against was the Framingham Risk Score (FRS). The outcome variables were low or high risk based on calcium score 0 or calcium score 100 and above. Ensemble MLAs were built based on naive bayes, random forest and support vector classifier for low risk and generalized linear regression, support vector regressor and stochastic gradient descent regressor for high risk categories. MLAs were trained on 600 Southeast Asians aged 21 to 69 years free of cardiovascular disease. All MLAs outperformed the FRS for low and high-risk categories. MLA based on lifestyle questionnaire only achieved AUC of 0.715 (95% CI 0.681, 0.750) and 0.710 (95% CI 0.653, 0.766) for low and high risk respectively. Combining all groups of risk factors (lifestyle survey questionnaires, clinical blood tests, 24-h ambulatory blood pressure and heart rate monitoring) along with feature selection, prediction of low and high CVD risk groups were further enhanced to 0.791 (95% CI 0.759, 0.822) and 0.790 (95% CI 0.745, 0.836). Besides conventional predictors, self-reported physical activity, average daily heart rate, awake blood pressure variability and percentage time in diastolic hypertension were important contributors to CVD risk classification.

The Need for Brevity During Shared Decision Making (SDM) for Cancer Screening: Veterans' Perspectives on an "Everyday SDM" Compromise

Introduction. Detailed or "full" shared decision making (SDM) about cancer screening is difficult in the primary care setting. Time spent discussing cancer screening is time not spent on other important issues. Given time constraints, brief SDM that is incomplete but addresses key elements may be feasible and acceptable. However, little is known about how patients feel about abbreviated SDM. This study assessed patient perspectives on a compromise solution ("everyday SDM"): 1) primary care provided makes a tailored recommendation, 2) briefly presents qualitative information on key tradeoffs, and 3) conveys full support for decisional autonomy and desires for more information. Methods. We recruited a stratified random sample of Veterans from an academic Veterans Affairs medical center who were eligible for lung cancer screening, oversampling women and minority patients, to attend a 6-hour deliberative focus group. Experts informed participants about cancer screening, factors that influence screening benefits, and the role of patient preferences. Then, facilitator-led small groups elicited patient questions and informed opinions about the everyday SDM proposal, its acceptability, and their recommendations for improvement. Results. Thirty-six Veterans with a heavy smoking history participated (50% male, 83% white). There was a strong consensus that everyday SDM was acceptable if patients were the final deciders and could get more information on request. Participants broadly recommended that clinicians only mention downsides directly related to screening and avoid discussion of potential downstream harms (such as biopsies). Discussion. Although further testing in more diverse populations and different conditions is needed, these patients found the everyday SDM approach to be acceptable for routine lung cancer screening discussions, despite its use of an explicit recommendation and presentation of only qualitative information.

Understanding providers' attitudes and key concerns toward incorporating CVD risk prediction into clinical practice: a qualitative study

Background

Although risk prediction has become an integral part of clinical practice guidelines for cardiovascular disease (CVD) prevention, multiple studies have shown that patients’ risk still plays almost no role in clinical decision-making. Because little is known about why this is so, we sought to understand providers’ views on the opportunities, barriers, and facilitators of incorporating risk prediction to guide their use of cardiovascular preventive medicines.

Methods

We conducted semi-structured interviews with primary care providers (n = 33) at VA facilities in the Midwest. Facilities were chosen using a maximum variation approach according to their geography, size, proportion of MD to non-MD providers, and percentage of full-time providers. Providers included MD/DO physicians, physician assistants, nurse practitioners, and clinical pharmacists. Providers were asked about their reaction to a hypothetical situation in which the VA would introduce a risk prediction-based approach to CVD treatment. We conducted matrix and content analysis to identify providers’ reactions to risk prediction, reasons for their reaction, and exemplar quotes.

Results

Most providers were classified as Enthusiastic (n = 14) or Cautious Adopters (n = 15), with only a few Non-Adopters (n = 4). Providers described four key concerns toward adopting risk prediction. Their primary concern was that risk prediction is not always compatible with a “whole patient” approach to patient care. Other concerns included questions about the validity of the proposed risk prediction model, potential workflow burdens, and whether risk prediction adds value to existing clinical practice. Enthusiastic, Cautious, and Non-Adopters all expressed both doubts about and support for risk prediction categorizable in the above four key areas of concern.

Conclusions

Providers were generally supportive of adopting risk prediction into CVD prevention, but many had misgivings, which included concerns about impact on workflow, validity of predictive models, the value of making this change, and possible negative effects on providers’ ability to address the whole patient. These concerns have likely contributed to the slow introduction of risk prediction into clinical practice. These concerns will need to be addressed for risk prediction, and other approaches relying on “big data” including machine learning and artificial intelligence, to have a meaningful role in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06540-y.

Optimal cholesterol treatment plans and genetic testing strategies for cardiovascular diseases

Atherosclerotic cardiovascular disease (ASCVD) is among the leading causes of death in the US. Although research has shown that ASCVD has genetic elements, the understanding of how genetic testing influences its prevention and treatment has been limited. To this end, we model the health trajectory of patients stochastically and determine treatment and testing decisions simultaneously. Since the cholesterol level of patients is one controllable risk factor for ASCVD events, we model cholesterol treatment plans as Markov decision processes. We determine whether and when patients should receive a genetic test using value of information analysis. By simulating the health trajectory of over 64 million adult patients, we find that 6.73 million patients undergo genetic testing. The optimal treatment plans informed with clinical and genetic information save 5,487 more quality-adjusted life-years while costing $1.18 billion less than the optimal treatment plans informed with clinical information only. As precision medicine becomes increasingly important, understanding the impact of genetic information becomes essential.

Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk

Supplemental Digital Content is available in the text.

Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke.

Effectiveness of blood pressure-lowering treatment by the levels of baseline Framingham risk score: A post hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT)

This was a post hoc analysis of Systolic Blood Pressure Intervention Trial (SPRINT), aimed to investigate whether intensive blood pressure treatment has differential therapeutic outcomes on patients with different baseline Framingham risk score (FRS). The 9298 SPRINT participants were categorized into low-risk (baseline FRS < 10%), intermediate-risk (FRS = 10%-20%), or high-risk (FRS > 20%) arms. The primary outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes. Serious adverse events were defined as hypotension, syncope, and bradycardia. Multiple Cox regression was used to calculate hazard ratios for study outcomes with intensive compared with standard SBP treatment between these three groups. After a median follow-up time of 3.26 years, the primary outcome hazard ratio (HR) for intensive versus standard treatment was 0.73 (95% CI: 0.61-0.88, P = .0044) in the high-risk arm. And, for all-cause mortality, the hazard ratio with intensive SBP treatment was 1.58 (95% CI: 0.55-1.06), 0.9 (95% CI: 0.26-9.50), and 0.53 (95% CI: 0.34-0.82) in three arms (all P values for interaction > 0.05). Effects of intensive versus standard SBP control on serious adverse events were similar among patients with different FRS. Our results suggested that regardless of the FRS level, the intensive blood pressure control was beneficial.

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

BACKGROUND

Worldwide treatment recommendations for lowering blood pressure continue to be guided predominantly by blood pressure thresholds, despite strong evidence that the benefits of blood pressure reduction are observed in patients across the blood pressure spectrum. In this study, we aimed to investigate the implications of alternative strategies for offering blood pressure treatment, using the UK as an illustrative example.

METHODS

We did a retrospective cohort study in primary care patients aged 30-79 years without cardiovascular disease, using data from the UK's Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality. We assessed and compared four different strategies to determine eligibility for treatment: using 2011 UK National Institute for Health and Care Excellence (NICE) guideline, or proposed 2019 NICE guideline, or blood pressure alone (threshold ≥140/90 mm Hg), or predicted 10-year cardiovascular risk alone (QRISK2 score ≥10%). Patients were followed up until the earliest occurrence of a cardiovascular disease diagnosis, death, or end of follow-up period (March 31, 2016). For each strategy, we estimated the proportion of patients eligible for treatment and number of cardiovascular events that could be prevented with treatment. We then estimated eligibility and number of events that would occur during 10 years in the UK general population.

FINDINGS

Between Jan 1, 2011, and March 31, 2016, 1 222 670 patients in the cohort were followed up for a median of 4·3 years (IQR 2·5-5·2). 271 963 (22·2%) patients were eligible for treatment under the 2011 NICE guideline, 327 429 (26·8%) under the proposed 2019 NICE guideline, 481 859 (39·4%) on the basis of a blood pressure threshold of 140/90 mm Hg or higher, and 357 840 (29·3%) on the basis of a QRISK2 threshold of 10% or higher. During follow-up, 32 183 patients were diagnosed with cardiovascular disease (overall rate 7·1 per 1000 person-years, 95% CI 7·0-7·2). Cardiovascular event rates in patients eligible for each strategy were 15·2 per 1000 person-years (95% CI 15·0-15·5) under the 2011 NICE guideline, 14·9 (14·7-15·1) under the proposed 2019 NICE guideline, 11·4 (11·3-11·6) with blood pressure threshold alone, and 16·9 (16·7-17·1) with QRISK2 threshold alone. Scaled to the UK population, we estimated that 233 152 events would be avoided under the 2011 NICE guideline (28 patients needed to treat for 10 years to avoid one event), 270 233 under the 2019 NICE guideline (29 patients), 301 523 using a blood pressure threshold (38 patients), and 322 921 using QRISK2 threshold (27 patients).

INTERPRETATION

A cardiovascular risk-based strategy (QRISK2 ≥10%) could prevent over a third more cardiovascular disease events than the 2011 NICE guideline and a fifth more than the 2019 NICE guideline, with similar efficiency regarding number treated per event avoided.

FUNDING

National Institute for Health Research.

Assessing Patient Interest in Individualized Preventive Care Recommendations

Background. Few Americans obtain all 41 guideline-recommended preventive services for nonpregnant adults. We assessed patient interest in prioritizing their preventive care needs. Methods. We conducted a mixed-methods study, with 4 focus groups (N = 28) at a single institution and a nationwide survey (N = 2,103). Participants were middle-aged and older adults with preventive care needs. We obtained reactions to written materials describing the magnitude of benefit from major preventive services, including both absolute and relative benefits. Recommendations were individualized for patient risk factors (“individualized preventive care recommendations”). Focus groups assessed patient interest, how patients would want to discuss individualized recommendations with their providers, and potential for individualized recommendations to influence patient decision making. Survey content was based on focus groups and analyzed with logistic regression. Results. Patients expressed strong interest in individualized recommendations. Among survey respondents, an adjusted 88.2% (95% confidence interval [CI] = 86.7% to 89.7%) found individualized recommendations very easy to understand, 77.2% (95% CI = 75.3% to 79.1%) considered them very useful, and 64.9% (95% CI = 62.8% to 67.0%) highly trustworthy (each ≥6/7 on Likert scale). Three quarters of participants wanted to receive their own individualized recommendations in upcoming primary care visits (adjusted proportion = 77.5%, 95% CI = 75.6% to 79.4%). Both focus group and survey participants supported shared decision making and reported that individualized recommendations would improve motivation to obtain preventive care. Half of survey respondents reported that they would be much more likely to visit their doctor if they knew individualized recommendations would be discussed, compared with 4.2% who would not be more likely to visit their doctor. Survey respondents already prioritized preventive services, stating they were most likely to choose quick/easy preventive services and least likely to choose expensive preventive services (adjusted proportions, 63.8% and 8.5%, respectively). Results were consistent in sensitivity analyses. Conclusions. Individualized preventive care recommendations are likely to be well received in primary care and might motivate patients to improve adherence to evidence-based care.

Clinic-Based Strategies to Reach United States Million Hearts 2022 Blood Pressure Control Goals

BACKGROUND

The Centers for Disease Control and Prevention's Million Hearts initiative includes an ambitious ≥80% blood pressure control goal in US adults with hypertension by 2022. We used the validated Blood Pressure Control Model to quantify changes in clinic-based hypertension management processes needed to attain ≥80% blood pressure control.

METHODS AND RESULTS

The Blood Pressure Control Model simulates patient blood pressures weekly using 3 key modifiable hypertension management processes: office visit frequency, clinician treatment intensification given uncontrolled blood pressure, and continued antihypertensive medication use (medication adherence rate). We compared blood pressure control rates (using the Seventh Joint National Committee on hypertension targets) achieved over 4 years between usual care and the best-observed values for management processes identified from the literature (1-week return visit interval, 20%-44% intensification rate, and 76% adherence rate). We determined the management process values needed to achieve ≥80% blood pressure control in US adults. In adults with uncontrolled blood pressure, usual care achieved 45.6% control (95% uncertainty interval, 39.6%-52.5%) and literature-based best-observed values achieved 79.7% control (95% uncertainty interval, 79.3%-80.1%) over 4 years. Increasing treatment intensification rates to 62% of office visits with an uncontrolled blood pressure resulted in ≥80% blood pressure control, even when the return visit interval and adherence remained at usual care values. Improving to best-observed values for all 3 management processes would achieve 78.1% blood pressure control in the overall US population with hypertension, approaching the ≥80% Million Hearts 2022 goal.

CONCLUSIONS

Achieving the Million Hearts blood pressure control goal by 2022 will require simultaneously increasing visit frequency, overcoming therapeutic inertia, and improving patient medication adherence. As the relative importance of each of these 3 processes will depend on local characteristics, simulation models like the Blood Pressure Control Model can help local healthcare systems tailor strategies to reach local and national benchmarks.

Income Disparities in Absolute Cardiovascular Risk and Cardiovascular Risk Factors in the United States, 1999-2014

Importance

Large improvements in the control of risk factors for cardiovascular disease have been achieved in the United States, but it remains unclear whether adults in all socioeconomic strata have benefited equally.

Objective

To assess temporal trends in 10-year predicted absolute cardiovascular risk and cardiovascular risk factors among US adults in different socioeconomic strata.

Design, Setting, and Participants

A cross-sectional analysis was conducted using data on adults 40 to 79 years of age without established cardiovascular disease from the 1999 to 2014 National Health and Nutrition Examination Survey.

Exposures

Socioeconomic status was based on the family income to poverty ratio and participants were divided into the following 3 groups: high income (family income to poverty ratio, ≥4), middle income (>1 and <4), or at or below the federal poverty level (≤1).

Main Outcomes and Measures

We assessed predicted absolute cardiovascular risk using the pooled cohort equation. We assessed the following 4 risk factors: systolic blood pressure, smoking status, diabetes, and total cholesterol.

Results

Of the 17 199 adults whose data were included in the study (8828 women and 8371 men; mean age, 54.4 years), from 1999-2014, trends in the percentage of adults with predicted absolute cardiovascular risk of 20% or more, mean systolic blood pressure, and the percentage of current smokers varied by income strata (P ≤ .02 for interaction). For adults with incomes at or below the federal poverty level, there was little evidence of a change in any of these outcomes across survey years (cardiovascular risk ≥20%, 14.9% [95% CI, 12.9%-16.8%] in 1999-2004; 16.5% [95% CI, 13.7%-19.2%] in 2011-2014; P = .41; mean systolic blood pressure, 127.6 [95% CI, 126.1-129.0] mm Hg in 1999-2004; 126.8 [95% CI, 125.2-128.5] mm Hg in 2011-2014; P = .44; and smoking, 36.5% [95% CI, 32.1%-41.0%] in 1999-2004; 36.0% [95% CI, 31.1%-40.8%] in 2011-2014; P = .87). For adults in the high-income stratum, these variables decreased across survey years (cardiovascular risk ≥20%, 12.0% [95% CI, 10.7%-13.3%] in 1999-2004; 9.5% [95% CI, 8.2%-10.7%] in 2011-2014; P = .003; systolic blood pressure, 126.0 [95% CI, 125.0-126.9] mm Hg in 1999-2004; 122.3 [95% CI, 121.3-123.3] mm Hg in 2011-2014; P < .001; and smoking, 14.1% [95% CI, 12.0%-16.2%] in 1999-2004; 8.8% [95% CI, 6.6%-11.0%] in 2011-2014; P = .001). Trends in the percentage of adults with diabetes and the mean total cholesterol level did not vary by income.

Conclusions and Relevance

Adults in each socioeconomic stratum have not benefited equally from efforts to control cardiovascular risk factors.

Personalizing Second-Line Type 2 Diabetes Treatment Selection: Combining Network Meta-analysis, Individualized Risk, and Patient Preferences for Unified Decision Support

BACKGROUND

Personalizing medical treatment often requires practitioners to compare multiple treatment options, assess a patient's unique risk and benefit from each option, and elicit a patient's preferences around treatment. We integrated these 3 considerations into a decision-modeling framework for the selection of second-line glycemic therapy for type 2 diabetes.

METHODS

Based on multicriteria decision analysis, we developed a unified treatment decision support tool accounting for 3 factors: patient preferences, disease outcomes, and medication efficacy and safety profiles. By standardizing and multiplying these 3 factors, we calculated the ranking score for each medication. This approach was applied to determining second-line glycemic therapy by integrating 1) treatment efficacy and side-effect data from a network meta-analysis of 301 randomized trials ( N = 219,277), 2) validated risk equations for type 2 diabetes complications, and 3) patient preferences around treatment (e.g., to avoid daily glucose testing). Data from participants with type 2 diabetes in the U.S. National Health and Nutrition Examination Survey (NHANES 2003-2014, N = 1107) were used to explore variations in treatment recommendations and associated quality-adjusted life-years given different patient features.

RESULTS

Patients at the highest microvascular disease risk had glucagon-like peptide 1 agonists or basal insulin recommended as top choices, whereas those wanting to avoid an injected medication or daily glucose testing had sodium-glucose linked transporter 2 or dipeptidyl peptidase 4 inhibitors commonly recommended, and those with major cost concerns had sulfonylureas commonly recommended. By converting from the most common sulfonylurea treatment to the model-recommended treatment, NHANES participants were expected to save an average of 0.036 quality-adjusted life-years per person (about a half month) from 10 years of treatment.

CONCLUSIONS

Models can help integrate meta-analytic treatment effect estimates with individualized risk calculations and preferences, to aid personalized treatment selection.

Potential Cardiovascular Disease Events Prevented with Adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline

BACKGROUND

Over 10 years, achieving and maintaining 2017 ACC/AHA guideline goals could prevent 3.0 million (UR, 1.1-5.1 million), 0.5 million (UR, 0.2-0.7 million), and 1.4 million (UR, 0.6-2.0 million) cardiovascular disease (CVD) events compared with maintaining current blood pressure (BP) levels, achieving 2003 Seventh Joint National Committee Report goals, and achieving 2014 Eighth Joint National Committee goals, respectively. We estimated the number of cardiovascular disease events prevented and treatment-related serious adverse events incurred over 10 years among US adults with hypertension by achieving 2017 ACC/AHA guideline-recommended BP goals compared with (1) current BP levels, (2) achieving 2003 Seventh Joint National Committee Report BP goals, and (3) achieving 2014 Eighth Joint National Committee panel member report BP goals.

METHODS

US adults aged ≥45 years with an indication for BP treatment were grouped according to recommendations for antihypertensive drug therapy in the 2017 ACC/AHA guideline, 2003 Seventh Joint National Committee Report, and 2014 Eighth Joint National Committee. Population sizes were estimated from the 2011 to 2014 National Health and Nutrition Examination Surveys. Rates for fatal and nonfatal CVD events (stroke, coronary heart disease, or heart failure) were estimated from the REGARDS (REasons for Geographic And Racial Differences in Stroke) study, weighted to the US population. CVD risk reductions with treatment to BP goals and risk for serious adverse events were obtained from meta-analyses of BP-lowering trials. CVD events prevented and treatment-related nonfatal serious adverse events over 10 years were calculated. Uncertainty surrounding main data inputs was expressed in uncertainty ranges (UR).

RESULTS

Over ten years, achieving and maintaining 2017 ACC/AHA guideline goals compared with current BP levels, achieving 2003 Seventh Joint National Committee Report goals, or achieving 2014 Eighth Joint National Committee goals could prevent 3.0 million (UR, 1.1-5.1 million), 0.5 million (UR, 0.2-0.7 million), or 1.4 million (UR, 0.6-2.0 million) CVD events, respectively. Compared with current BP levels, achieving and maintaining 2017 goals could prevent 71.9 (UR, 26.6-122.3) CVD events per 1000 treated. Achieving 2017 guideline BP goals compared with current BP levels could also lead to nearly 3.3 million more serious adverse events over 10 years (UR, 2.2-4.4 million).

CONCLUSIONS

Achieving and maintaining 2017 ACC/AHA BP goals could prevent a greater number of CVD events than achieving 2003 Seventh Joint National Committee Report or 2014 Eighth Joint National Committee BP goals but could also lead to more serious adverse events.

Implications of True and Perceived Treatment Burden on Cardiovascular Medication Use

Background: Clinical decisions require weighing possible risks and benefits, which are often based on the provider's sense of treatment burden. Patients often have a different view of how heavily treatment burden should be weighted. Objective: To examine how much small variations in patient treatment burden would influence optimal use of antihypertensive medications and how much over- and undertreatment can result from clinicians misunderstanding their patients' values. Methods: Analysis-Markov chain model. Data sources-Existing literature, including an individual-level meta-analysis of blood pressure trials. Target population-US representative sample, ages 40 to 85, no history of cardiovascular disease. Time horizon-Effect of 10 years of treatment on estimated lifetime quality-adjusted life-year (QALY) burden. Perspective-Patient.

OUTCOME MEASURES

QALYs gained by treatment. Results: Fairly small differences in true patient burden from blood pressure treatment alter the number of blood pressure medications that should be recommended and alters treatment's potential benefit dramatically. We also found that a clinician misunderstanding the patient's burden could lead to almost 30% of patients being treated inappropriately. Limitations: Our results are based on simulation modeling. Conclusions: Clinical decisions that fail to account for patient treatment burden can mistreat a very large proportion of the public. Successful treatment choices closely depend on a clinician's ability to accurately gauge a patient's treatment burden.

Matching Microsimulation Risk Factor Correlations to Cross-sectional Data: The Shortest Distance Method

BACKGROUND

Microsimulation models often compute the distribution of a simulated cohort's risk factors and medical outcomes over time using repeated waves of cross-sectional data. We sought to develop a strategy to simulate how risk factor values remain correlated over time within individuals, and compare it to available alternative methods.

METHODS

We developed a method using shortest-distance matching for modeling changes in risk factors in individuals over time, which preserves both the cohort distribution of each risk factor as well as the cross-sectional correlation between risk factors observed in repeated cross-sectional data. We compared the performance of the method with rank stability and regression methods, using both synthetic data and data from the Framingham Offspring Heart Study (FOHS) to simulate a cohort's atherosclerotic cardiovascular disease (ASCVD) risk.

RESULTS

The correlation between risk factors was better preserved using the shortest distance method than with rank stability or regression (root mean squared difference = 0.077 with shortest distance, v. 0.126 with rank stability and 0.146 with regression in FOHS, and 0.052, 0.426 and 0.352, respectively, in the synthetic data). The shortest distance method generated population ASCVD risk estimate distributions indistinguishable from the true distribution in over 99.8% of cases (Kolmogorov-Smirnov, P > 0.05), outperforming some existing regression methods, which produced ASCVD distributions statistically distinguishable from the true one at the 5% level around 15% of the time.

LIMITATIONS

None of the methods considered could predict individual longitudinal trends without error. The shortest-distance method was not statistically inferior to rank stability or regression methods for predicting individual risk factor values over time in the FOHS.

CONCLUSIONS

A shortest distance method may assist in preserving risk factor correlations in microsimulations informed by cross-sectional data.

Designing for Clinical Change: Creating an Intervention to Implement New Statin Guidelines in a Primary Care Clinic

Background

Recent clinical practice guidelines from major national organizations, including a joint United States Department of Veterans Affairs (VA) and Department of Defense (DoD) committee, have substantially changed recommendations for the use of the cholesterol-lowering statin medications after years of relative stability. Because statin medications are among the most commonly prescribed treatments in the United States, any change in their use may have significant implications for patients and providers alike. Prior research has shown that effective implementation interventions should be both user centered and specifically chosen to address identified barriers.

Objective

The objectives of this study were to identify potential determinants of provider uptake of the new statin guidelines and to use that information to tailor a coordinated and streamlined local quality improvement intervention focused on prescribing appropriate statins.

Methods

We employed user-centered design principles to guide the development and testing of a multicomponent guideline implementation intervention to improve statin prescribing. This paper describes the intervention development process whereby semistructured qualitative interviews with providers were conducted to (1) illuminate the knowledge, attitudes, and behaviors of providers and (2) elicit feedback on intervention prototypes developed to align with and support the use of the VA/DoD guidelines. Our aim was to use this information to design a local quality improvement intervention focused on statin prescribing that was tailored to the needs of primary care providers at our facility. Cabana’s Clinical Practice Guidelines Framework for Improvement and Nielsen’s Usability Heuristics were used to guide the analysis of data obtained in the intervention development process.

Results

Semistructured qualitative interviews were conducted with 15 primary care Patient Aligned Care Team professionals (13 physicians and 2 clinical pharmacists) at a single VA medical center. Findings highlight that providers were generally comfortable with the paradigm shift to risk-based guidelines but less clear on the need for the VA/DoD guidelines in specific. Providers preferred a clinical decision support tool that helped them calculate patient risk and guide their care without limiting autonomy. They were less comfortable with risk communication and performance measurement systems that do not account for shared decision making. When possible, we incorporated their recommendations into the intervention.

Conclusions

By combining qualitative methods and user-centered design principles, we could inform the design of a multicomponent guideline implementation intervention to better address the needs and preferences of providers, including clear and direct language, logical decision prompts with an option to dismiss a clinical decision support tool, and logical ordering of feedback information. Additionally, this process allowed us to identify future design considerations for quality improvement interventions.

Blood pressure-lowering treatment strategies based on cardiovascular risk versus blood pressure: A meta-analysis of individual participant data

BACKGROUND

Clinical practice guidelines have traditionally recommended blood pressure treatment based primarily on blood pressure thresholds. In contrast, using predicted cardiovascular risk has been advocated as a more effective strategy to guide treatment decisions for cardiovascular disease (CVD) prevention. We aimed to compare outcomes from a blood pressure-lowering treatment strategy based on predicted cardiovascular risk with one based on systolic blood pressure (SBP) level.

METHODS AND FINDINGS

We used individual participant data from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) from 1995 to 2013. Trials randomly assigned participants to either blood pressure-lowering drugs versus placebo or more intensive versus less intensive blood pressure-lowering regimens. We estimated 5-y risk of CVD events using a multivariable Weibull model previously developed in this dataset. We compared the two strategies at specific SBP thresholds and across the spectrum of risk and blood pressure levels studied in BPLTTC trials. The primary outcome was number of CVD events avoided per persons treated. We included data from 11 trials (47,872 participants). During a median of 4.0 y of follow-up, 3,566 participants (7.5%) experienced a major cardiovascular event. Areas under the curve comparing the two treatment strategies throughout the range of possible thresholds for CVD risk and SBP demonstrated that, on average, a greater number of CVD events would be avoided for a given number of persons treated with the CVD risk strategy compared with the SBP strategy (area under the curve 0.71 [95% confidence interval (CI) 0.70-0.72] for the CVD risk strategy versus 0.54 [95% CI 0.53-0.55] for the SBP strategy). Compared with treating everyone with SBP ≥ 150 mmHg, a CVD risk strategy would require treatment of 29% (95% CI 26%-31%) fewer persons to prevent the same number of events or would prevent 16% (95% CI 14%-18%) more events for the same number of persons treated. Compared with treating everyone with SBP ≥ 140 mmHg, a CVD risk strategy would require treatment of 3.8% (95% CI 12.5% fewer to 7.2% more) fewer persons to prevent the same number of events or would prevent 3.1% (95% CI 1.5%-5.0%) more events for the same number of persons treated, although the former estimate was not statistically significant. In subgroup analyses, the CVD risk strategy did not appear to be more beneficial than the SBP strategy in patients with diabetes mellitus or established CVD.

CONCLUSIONS

A blood pressure-lowering treatment strategy based on predicted cardiovascular risk is more effective than one based on blood pressure levels alone across a range of thresholds. These results support using cardiovascular risk assessment to guide blood pressure treatment decision-making in moderate- to high-risk individuals, particularly for primary prevention.

Potential U.S. Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline

BACKGROUND

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults provides recommendations for the definition of hypertension, systolic and diastolic blood pressure (BP) thresholds for initiation of antihypertensive medication, and BP target goals.

OBJECTIVES

This study sought to determine the prevalence of hypertension, implications of recommendations for antihypertensive medication, and prevalence of BP above the treatment goal among U.S. adults using criteria from the 2017 ACC/AHA guideline and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).

METHODS

The authors analyzed data from the 2011 to 2014 National Health and Nutrition Examination Survey (N = 9,623). BP was measured 3 times following a standardized protocol and averaged. Results were weighted to produce U.S. population estimates.

RESULTS

According to the 2017 ACC/AHA and JNC7 guidelines, the crude prevalence of hypertension among U.S. adults was 45.6% (95% confidence interval [CI]: 43.6% to 47.6%) and 31.9% (95% CI: 30.1% to 33.7%), respectively, and antihypertensive medication was recommended for 36.2% (95% CI: 34.2% to 38.2%) and 34.3% (95% CI: 32.5% to 36.2%) of U.S. adults, respectively. Nonpharmacological intervention is advised for the 9.4% of U.S. adults with hypertension who are not recommended for antihypertensive medication according to the 2017 ACC/AHA guideline. Among U.S. adults taking antihypertensive medication, 53.4% (95% CI: 49.9% to 56.8%) and 39.0% (95% CI: 36.4% to 41.6%) had BP above the treatment goal according to the 2017 ACC/AHA and JNC7 guidelines, respectively.

CONCLUSIONS

Compared with the JNC7 guideline, the 2017 ACC/AHA guideline results in a substantial increase in the prevalence of hypertension, a small increase in the percentage of U.S. adults recommended for antihypertensive medication, and more intensive BP lowering for many adults taking antihypertensive medication.

Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline

BACKGROUND

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults provides recommendations for the definition of hypertension, systolic and diastolic blood pressure (BP) thresholds for initiation of antihypertensive medication, and BP target goals.

OBJECTIVES

This study sought to determine the prevalence of hypertension, implications of recommendations for antihypertensive medication, and prevalence of BP above the treatment goal among US adults using criteria from the 2017 ACC/AHA guideline and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).

METHODS

The authors analyzed data from the 2011 to 2014 National Health and Nutrition Examination Survey (N = 9 623). BP was measured 3 times following a standardized protocol and averaged. Results were weighted to produce US population estimates.

RESULTS

According to the 2017 ACC/AHA and JNC7 guidelines, the crude prevalence of hypertension among US adults was 45.6% (95% confidence interval [CI]: 43.6% to 47.6%) and 31.9% (95% CI: 30.1% to 33.7%), respectively, and antihypertensive medication was recommended for 36.2% (95% CI: 34.2% to 38.2%) and 34.3% (95% CI: 32.5% to 36.2%) of US adults, respectively. Nonpharmacological intervention is advised for the 9.4% of US adults with hypertension who are not recommended for antihypertensive medication according to the 2017 ACC/AHA guideline. Among US adults taking antihypertensive medication, 53.4% (95% CI: 49.9% to 56.8%) and 39.0% (95% CI: 36.4% to 41.6%) had BP above the treatment goal according to the 2017 ACC/AHA and JNC7 guidelines, respectively.

CONCLUSIONS

Compared with the JNC7 guideline, the 2017 ACC/AHA guideline results in a substantial increase in the prevalence of hypertension, a small increase in the percentage of US adults recommended for antihypertensive medication, and more intensive BP lowering for many adults taking antihypertensive medication.

Dynamic treatment selection and modification for personalised blood pressure therapy using a Markov decision process model: a cost-effectiveness analysis

OBJECTIVE

Personalised medicine seeks to select and modify treatments based on individual patient characteristics and preferences. We sought to develop an automated strategy to select and modify blood pressure treatments, incorporating the likelihood that patients with different characteristics would benefit from different types of medications and dosages and the potential severity and impact of different side effects among patients with different characteristics.

DESIGN, SETTING AND PARTICIPANTS

We developed a Markov decision process (MDP) model to incorporate meta-analytic data and estimate the optimal treatment for maximising discounted lifetime quality-adjusted life-years (QALYs) based on individual patient characteristics, incorporating medication adjustment choices when a patient incurs side effects. We compared the MDP to current US blood pressure treatment guidelines (the Eighth Joint National Committee, JNC8) and a variant of current guidelines that incorporates results of a major recent trial of intensive treatment (Intensive JNC8). We used a microsimulation model of patient demographics, cardiovascular disease risk factors and side effect probabilities, sampling from the National Health and Nutrition Examination Survey (2003-2014), to compare the expected population outcomes from adopting the MDP versus guideline-based strategies.

MAIN OUTCOME MEASURES

Costs and QALYs for the MDP-based treatment (MDPT), JNC8 and Intensive JNC8 strategies.

RESULTS

Compared with the JNC8 guideline, the MDPT strategy would be cost-saving from a societal perspective with discounted savings of US$1187 per capita (95% CI 1178 to 1209) and an estimated discounted gain of 0.06 QALYs per capita (95% CI 0.04 to 0.08) among the US adult population. QALY gains would largely accrue from reductions in severe side effects associated with higher treatment doses later in life. The Intensive JNC8 strategy was dominated by the MDPT strategy.

CONCLUSIONS

An MDP-based approach can aid decision-making by incorporating meta-analytic evidence to personalise blood pressure treatment and improve overall population health compared with current blood pressure treatment guidelines.

The Veterans Affairs Cardiac Risk Score: Recalibrating the Atherosclerotic Cardiovascular Disease Score for Applied Use

BACKGROUND

Accurately estimating cardiovascular risk is fundamental to good decision-making in cardiovascular disease (CVD) prevention, but risk scores developed in one population often perform poorly in dissimilar populations. We sought to examine whether a large integrated health system can use their electronic health data to better predict individual patients' risk of developing CVD.

METHODS

We created a cohort using all patients ages 45-80 who used Department of Veterans Affairs (VA) ambulatory care services in 2006 with no history of CVD, heart failure, or loop diuretics. Our outcome variable was new-onset CVD in 2007-2011. We then developed a series of recalibrated scores, including a fully refit "VA Risk Score-CVD (VARS-CVD)." We tested the different scores using standard measures of prediction quality.

RESULTS

For the 1,512,092 patients in the study, the Atherosclerotic cardiovascular disease risk score had similar discrimination as the VARS-CVD (c-statistic of 0.66 in men and 0.73 in women), but the Atherosclerotic cardiovascular disease model had poor calibration, predicting 63% more events than observed. Calibration was excellent in the fully recalibrated VARS-CVD tool, but simpler techniques tested proved less reliable.

CONCLUSIONS

We found that local electronic health record data can be used to estimate CVD better than an established risk score based on research populations. Recalibration improved estimates dramatically, and the type of recalibration was important. Such tools can also easily be integrated into health system's electronic health record and can be more readily updated.

Black-White Cardiovascular Disease Disparities After Target-Based Versus Personalized Benefit-Based Lipid and Blood Pressure Treatment

Background: Cardiovascular disease (CVD) remains the leading cause of black-white morbidity and mortality disparities in the United States. Objectives: We sought to compare black-white CVD morbidity and mortality if lipid and blood pressure treatments were prescribed to achieve targeted lipid and blood pressure levels (treat-to-target [TTT]) or personalized CVD risk and treatment benefit estimates (benefit-based tailored treatment [BTT]). Methods: We utilized a microsimulation model of statin and blood pressure treatment based on a TTT approach (Joint National Commission 7; Adult Treatment Panel III) or a BTT approach (treating those with 10-year CVD risk ≥10%, a modification and extension of recent American College of Cardiology/American Heart Association guidelines). We input data from the National Health and Nutrition Examination Survey, isolating adults 40 to 75 years of age without prior CVD events. Results: We observed that TTT would prevent fewer CVD events (17.0 events prevented per 1,000 whites, 22.2 per 1,000 blacks) than the BTT approach (25.9 events prevented per 1,000 whites, 45.4 per 1,000 blacks). TTT could lower the national black-white CVD event rate disparity from 23.1 excess events per 1,000 blacks to 17.9 excess events (-23%), while BTT could lower the disparity to 3.6 excess events (-84% overall). The inferiority of TTT to BTT remained consistent in sensitivity analyses testing alternative treatment targets and either over- or underestimation of risk by commonly used equations. Conclusions: A BTT approach to lipid and blood pressure treatment would be expected to prevent more CVD events in the overall population and more effectively reduce national black-white CVD disparities than a traditional TTT approach.

Using Predicted Cardiovascular Disease Risk in Conjunction With Blood Pressure to Guide Antihypertensive Medication Treatment

Using cardiovascular disease (CVD) risk instead of or in addition to blood pressure (BP) to guide antihypertensive treatment is an active area of research. The purpose of this review is to provide an overview of studies that could inform this treatment paradigm. We review data from randomized trials on relative and absolute CVD risk reduction that can occur when antihypertensive treatment is guided by CVD risk. We also review population-level data on using CVD risk in conjunction with BP to guide antihypertensive treatment, the broad distribution in CVD risk for people with similar BP levels, and the use of CVD risk for guiding antihypertensive treatment among subgroups including older adults, young adults, and those with diabetes mellitus or chronic kidney disease. In addition, we review potential challenges in implementing antihypertensive treatment recommendations that incorporate CVD risk. In closing, we provide recommendations for using CVD risk in combination with BP to guide antihypertensive treatment.

Cardiovascular Risk Assessment

Cardiovascular risk assessment is fundamental to prevention of cardiovascular disease, because it helps determine the size of the potential benefits that might accrue to individual patients from use of statins, aspirin, and other preventive interventions. Current guidelines recommend specific algorithms for cardiovascular risk assessment that combine information from traditional risk factors including blood pressure, lipids, and smoking, along with age and sex and other factors. These algorithms are the subject of active research and controversy. This article addresses the rationale, current guidelines and use, and potential future directions of cardiovascular risk assessment.

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Personalized Management of Cardiovascular Disorders

Personalized management of cardiovascular disorders (CVD), also referred to as personalized or precision cardiology in accordance with general principles of personalized medicine, is selection of the best treatment for an individual patient. It involves the integration of various "omics" technologies such as genomics and proteomics as well as other new technologies such as nanobiotechnology. Molecular diagnostics and biomarkers are important for linking diagnosis with therapy and monitoring therapy. Because CVD involve perturbations of large complex biological networks, a systems biology approach to CVD risk stratification may be used for improving risk-estimating algorithms, and modeling of personalized benefit of treatment may be helpful for guiding the choice of intervention. Bioinformatics tools are helpful in analyzing and integrating large amounts of data from various sources. Personalized therapy is considered during drug development, including methods of targeted drug delivery and clinical trials. Individualized recommendations consider multiple factors - genetic as well as epigenetic - for patients' risk of heart disease. Examples of personalized treatment are those of chronic myocardial ischemia, heart failure, and hypertension. Similar approaches can be used for the management of atrial fibrillation and hypercholesterolemia, as well as the use of anticoagulants. Personalized management includes pharmacotherapy, surgery, lifestyle modifications, and combinations thereof. Further progress in understanding the pathomechanism of complex cardiovascular diseases and identification of causative factors at the individual patient level will provide opportunities for the development of personalized cardiology. Application of principles of personalized medicine will improve the care of the patients with CVD.

Applying the Systolic Blood Pressure Intervention Trial Results to Older Adults

The Systolic Blood Pressure Intervention Trial (SPRINT; ClinicalTrials.gov, NCT01206062) was stopped early because of significantly lower risk of cardiovascular disease in participants randomized to a systolic blood pressure target of 120 mmHg (intensive) than in those randomized to 140 mmHg (standard). The cardiovascular outcome benefit was also identified in subjects aged 75 and older assigned to the intensive arm-34% lower than in the standard arm-in addition to 33% lower all-cause mortality at 3.14 years of follow-up. These beneficial outcomes held in older participants characterized as frail or with impaired gait speed. This article addresses several questions that need to be considered in applying the SPRINT results to the clinical care of older adults: Why are the SPRINT results discordant from those of epidemiological studies? Do the SPRINT findings generalize to the frail, older adults that I care for? Were there more adverse events in the intensive treatment group? What about cognitive and kidney outcomes? What are future considerations, and how low should we go?

Comparative effectiveness and cost-effectiveness of treat-to-target versus benefit-based tailored treatment of type 2 diabetes in low-income and middle-income countries: a modelling analysis

BACKGROUND

Optimal prescription of blood pressure, lipid, and glycaemic control treatments for adults with type 2 diabetes remains unclear. We aimed to compare the effectiveness and cost-effectiveness of two treatment approaches for diabetes management in five low-income and middle-income countries.

METHODS

We developed a microsimulation model to compare a treat-to-target (TTT) strategy, aiming to achieve target levels of biomarkers (blood pressure <130/80 mm Hg, LDL <2·59 mmol/L, and HbA1c <7% [ie, 53·0 mmol/mol]), with a benefit-based tailored treatment (BTT) strategy, aiming to lower estimated risk for complications (to a 10 year cardiovascular risk <10% and lifetime microvascular risk <5%) on the basis of age, sex, and biomarker values. Data were obtained from cohorts in China, Ghana, India, Mexico, and South Africa to span a spectrum of risk profiles.

FINDINGS

The TTT strategy recommended treatment to a larger number of people-who were generally at lower risk of diabetes complications-than the BTT. The BTT strategy recommended treatment to fewer people at higher risk. Compared with the TTT strategy, the BTT strategy would be expected to avert 24·4-30·5% more complications and be more cost-effective from a societal perspective (saving US$4·0-300·0 per disability-adjusted life-year averted in the countries simulated). Alternative treatment thresholds, matched by total cost or population size treated, did not change the comparative superiority of the BTT strategy, nor did titrating treatment using fasting plasma glucose (for areas without HbA1c testing). However, if insulin were unavailable, the BTT strategy would no longer be superior for preventing microvascular events and was superior only for preventing cardiovascular events.

INTERPRETATION

A BTT strategy is more effective and cost-effective than a TTT strategy in low-income and middle-income countries for prevention of both cardiovascular and microvascular complications of type 2 diabetes. However, the superiority of the BTT strategy for averting microvascular complications is contingent on insulin availability.

FUNDING

Rosenkranz Prize for Healthcare Research in Developing Countries and US National Institutes of Health (U54 MD010724, DP2 MD010478).

Data-Driven Markov Decision Process Approximations for Personalized Hypertension Treatment Planning

Background: Markov decision process (MDP) models are powerful tools. They enable the derivation of optimal treatment policies but may incur long computational times and generate decision rules that are challenging to interpret by physicians. Methods: In an effort to improve usability and interpretability, we examined whether Poisson regression can approximate optimal hypertension treatment policies derived by an MDP for maximizing a patient's expected discounted quality-adjusted life years. Results: We found that our Poisson approximation to the optimal treatment policy matched the optimal policy in 99% of cases. This high accuracy translates to nearly identical health outcomes for patients. Furthermore, the Poisson approximation results in 104 additional quality-adjusted life years per 1000 patients compared to the Seventh Joint National Committee's treatment guidelines for hypertension. The comparative health performance of the Poisson approximation was robust to the cardiovascular disease risk calculator used and calculator calibration error. Limitations: Our results are based on Markov chain modeling. Conclusions: Poisson model approximation for blood pressure treatment planning has high fidelity to optimal MDP treatment policies, which can improve usability and enhance transparency of more personalized treatment policies.

Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial

IMPORTANCE

The appropriate treatment target for systolic blood pressure (SBP) in older patients with hypertension remains uncertain.

OBJECTIVE

To evaluate the effects of intensive (<120 mm Hg) compared with standard (<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension but without diabetes.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, randomized clinical trial of patients aged 75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.

INTERVENTIONS

Participants were randomized to an SBP target of less than 120 mm Hg (intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard treatment group, n = 1319).

MAIN OUTCOMES AND MEASURES

The primary cardiovascular disease outcome was a composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes. All-cause mortality was a secondary outcome.

RESULTS

Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%) provided complete follow-up data. At a median follow-up of 3.14 years, there was a significantly lower rate of the primary composite outcome (102 events in the intensive treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66 [95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67 [95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI, 0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs 2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for injurious falls (HR, 0.91 [95% CI, 0.65-1.29]).

CONCLUSIONS AND RELEVANCE

Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120 mm Hg compared with an SBP target of less than 140 mm Hg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01206062.

Alternative Strategies to Achieve Cardiovascular Mortality Goals in China and India: A Microsimulation of Target- Versus Risk-Based Blood Pressure Treatment

BACKGROUND

The World Health Organization aims to reduce mortality from chronic diseases including cardiovascular disease (CVD) by 25% by 2025. High blood pressure is a leading CVD risk factor. We sought to compare 3 strategies for treating blood pressure in China and India: a treat-to-target (TTT) strategy emphasizing lowering blood pressure to a target, a benefit-based tailored treatment (BTT) strategy emphasizing lowering CVD risk, or a hybrid strategy currently recommended by the World Health Organization.

METHODS AND RESULTS

We developed a microsimulation model of adults aged 30 to 70 years in China and in India to compare the 2 treatment approaches across a 10-year policy-planning horizon. In the model, a BTT strategy treating adults with a 10-year CVD event risk of ≥ 10% used similar financial resources but averted ≈ 5 million more disability-adjusted life-years in both China and India than a TTT approach based on current US guidelines. The hybrid strategy in the current World Health Organization guidelines produced no substantial benefits over TTT. BTT was more cost-effective at $205 to $272/disability-adjusted life-year averted, which was $142 to $182 less per disability-adjusted life-year than TTT or hybrid strategies. The comparative effectiveness of BTT was robust to uncertainties in CVD risk estimation and to variations in the age range analyzed, the BTT treatment threshold, or rates of treatment access, adherence, or concurrent statin therapy.

CONCLUSIONS

In model-based analyses, a simple BTT strategy was more effective and cost-effective than TTT or hybrid strategies in reducing mortality.

Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus

IMPORTANCE

Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm.

OBJECTIVE

To examine the rate of BP- and blood glucose-lowering medicine deintensification among older patients with type 1 or 2 diabetes mellitus who potentially receive overtreatment.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study conducted using data from the US Veterans Health Administration. Participants included 211 667 patients older than 70 years with diabetes mellitus who were receiving active treatment (defined as BP-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride) from January 1 to December 31, 2012. Data analysis was performed December 10, 2013, to July 20, 2015.

EXPOSURES

Participants were eligible for deintensification of treatment if they had low BP or a low hemoglobin A1c (HbA1c) level in their last measurement in 2012. We defined very low BP as less than 120/65 mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolic BP (DBP) less than 65 mm Hg, very low HbA1c as less than 6.0%, and moderately low HbA1c as 6.0% to 6.4%. All other values were not considered low.

MAIN OUTCOMES AND MEASURES

Medication deintensification, defined as discontinuation or dosage decrease within 6 months after the index measurement.

RESULTS

The actively treated BP cohort included 211,667 participants, more than half of whom had moderately or very low BP levels. Of 104,486 patients with BP levels that were not low, treatment in 15.1% was deintensified. Of 25,955 patients with moderately low BP levels, treatment in 16.0% was deintensified. Among 81,226 patients with very low BP levels, 18.8% underwent BP medication deintensification. Of patients with very low BP levels whose treatment was not deintensified, only 0.2% had a follow-up BP measurement that was elevated (BP ≥140/90 mm Hg). The actively treated HbA1c cohort included 179,991 participants. Of 143,305 patients with HbA1c levels that were not low, treatment in 17.5% was deintensified. Of 23,769 patients with moderately low HbA1c levels, treatment in 20.9% was deintensified. Among 12,917 patients with very low HbA1c levels, 27.0% underwent medication deintensification. Of patients with very low HbA1c levels whose treatment was not deintensified, fewer than 0.8% had a follow-up HbA1c measurement that was elevated (≥7.5%).

CONCLUSIONS AND RELEVANCE

Among older patients whose treatment resulted in very low levels of HbA1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment. Low HbA1c or BP values or low life expectancy had little association with deintensification events. Practice guidelines and performance measures should place more focus on reducing overtreatment through deintensification.

The U.S. prevention of cardiovascular disease guidelines and implications for implementation in LMIC

The 2013 guidelines for the Prevention of Cardiovascular Disease released by the American College of Cardiology and the American Heart Association included guidelines of assessment of cardiovascular disease (CVD) risk, lifestyle management, management of overweight and obesity, and treatment of blood cholesterol. In addition, there were also 2014 guidelines on hypertension management released by members appointed to the Eighth Joint National Committee. Taken together, these guidelines, though extensively discussed and disseminated in the United States, have not been widely recognized beyond the United States, nor have their implications been considered for lower- and middle-income developing countries. With an estimated 80% of the global burden in CVD occurring in developing countries, it is important to develop strategies to adequately detect those at increased CVD risk and to manage their risk through lifestyle and where appropriate, pharmacologic means. Though certain aspects of each guideline may be suitable for implementation globally, including in developing countries, other recommendations would be unrealistic for many countries based on local epidemiology and resources. CVD prevention priorities can be set using guidance from recently published CVD prevention guidelines if appropriately modified to the context of lower- and middle-income developing countries. Establishment of global CVD prevention standards and rapid adaptation and dissemination of clinical guidelines are of paramount importance if we are to make significant progress into achieving World Health Organization 2025 goals to reduce the burden from CVD and other noncommunicable diseases.

Identifying Individuals at Risk for Cardiovascular Events Across the Spectrum of Blood Pressure Levels

BACKGROUND

We determined the proportion of atherosclerotic cardiovascular disease (ASCVD) events that occur across the spectrum of systolic blood pressure (SBP) and assessed whether multivariable risk assessment can identify persons who experience ASCVD events at all levels of SBP, including those with goal levels.

METHODS AND RESULTS

Participants aged 45 to 64 years from the Framingham Offspring and Atherosclerosis Risk in Communities studies were stratified based on treated and untreated SBP levels (<120, 120 to 129, 130 to 139, 140 to 149, 150 to 159, ≥160 mm Hg). We determined the number of excess ASCVD events in each SBP stratum by calculating the difference between observed and expected events (ASCVD event rate in untreated SBP <120 mm Hg was used as the reference). We categorized participants into 10-year ASCVD risk groups using the Pooled Cohort risk equations. There were 18 898 participants (78% white; 22% black) who were followed for 10 years. We estimated 427 excess ASCVD events, of which 56% (109 of 197) and 50% (115 of 230), respectively, occurred among untreated and treated participants with elevated SBP who were not recommended for antihypertensive therapy. Among untreated participants, 10-year ASCVD risk ≥7.5% identified 64% of those who experienced an ASCVD at 10 years and 30% of those who did not. Multivariable risk assessment was less useful in baseline-treated participants.

CONCLUSIONS

Half of excess ASCVD events occurred in persons with elevated SBP who were not currently recommended for antihypertensive therapy. Multivariable risk assessment may help identify those likely to benefit from further risk-reducing therapies. These findings support consideration of multivariable risk in guiding prevention across the spectrum of SBP.

Physical activity and better medication compliance improve mini-mental state examination scores in the elderly

In addition to hypertension, dyslipidemia, atherosclerosis, and diabetes, a sedentary lifestyle plays a pivotal role in cerebro- and cardiovascular disease and progressive cognitive decline, including vascular dementia and Alzheimer's disease. The present study investigated whether controlling the key risks and participating in physical activity have a beneficial impact on these disorders. Elderly volunteers were enrolled in a 3-month program that consisted of structured exercise three times per week. The daily routine, medical treatment, and vital parameters were evaluated and correlated with the subjects' neuropsychiatric status. High blood pressure was found in 40% of the participants, with no significant differences between the sexes. A higher proportion of females (55%) than males (18%) forgot to take their medication during the observation period. Significant negative correlations were found between Mini-Mental State Examination (MMSE) scores and age, lack of a caregiver, and increased pulse rate before or after exercise. These results suggest that the presence of home assistance and subsequent improvement in medication compliance, vital parameter optimization, and regular physical activity may yield better MMSE results and a lower risk for cerebro- and cardiovascular disease.

Blood pressure targets and absolute cardiovascular risk

In the Eighth Joint National Committee guideline on hypertension, the threshold for the initiation of blood pressure-lowering treatment for elderly adults (≥60 years) without chronic kidney disease or diabetes mellitus was raised from 140/90 mm Hg to 150/90 mm Hg. However, the committee was not unanimous in this decision, particularly because a large proportion of adults ≥60 years may be at high cardiovascular risk. On the basis of Eighth Joint National Committee guideline, we sought to determine the absolute 10-year risk of cardiovascular disease among these adults through analyzing the National Health and Nutrition Examination Survey (2005-2012). The primary outcome measure was the proportion of adults who were at ≥20% predicted absolute cardiovascular risk and above goals for the Seventh Joint National Committee guideline but reclassified as at target under the Eighth Joint National Committee guideline (reclassified). The Framingham General Cardiovascular Disease Risk Score was used. From 2005 to 2012, the surveys included 12 963 adults aged 30 to 74 years with blood pressure measurements, of which 914 were reclassified based on the guideline. Among individuals reclassified as not in need of additional treatment, the proportion of adults 60 to 74 years without chronic kidney disease or diabetes mellitus at ≥20% absolute risk was 44.8%. This corresponds to 0.8 million adults. The proportion at high cardiovascular risk remained sizable among adults who were not receiving blood pressure-lowering treatment. Taken together, a sizable proportion of reclassified adults 60 to 74 years without chronic kidney disease or diabetes mellitus was at ≥20% absolute cardiovascular risk.

The health system and population health implications of large-scale diabetes screening in India: a microsimulation model of alternative approaches

BACKGROUND

Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India.

METHODS AND FINDINGS

We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25-65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as "high risk" for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be "false positives." The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening.

CONCLUSIONS

Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes.