Updated Reasons and Clinical Implications of New Korean Hypertension Guidelines for Cardiologists

Sex differences in the applicability of Western cardiovascular disease risk prediction equations in the Asian population

AIMS

Cardiovascular diseases (CVDs) are the most common cause of death, but they can be effectively managed through appropriate prevention and treatment. An important aspect in preventing CVDs is assessing each individual's comprehensive risk profile, for which various risk engines have been developed. The important keys to CVD risk engines are high reliability and accuracy, which show differences in predictability depending on disease status or race. Framingham risk score (FRS) and the atherosclerotic cardiovascular disease risk equations (ASCVD) were applied to the Korean population to assess their suitability.

METHODS

A retrospective cohort study was conducted using National Health Insurance Corporation sample cohort from 2003 to 2015. The enrolled participants over 30 years of age and without CVD followed-up for 10 years. We compared the prediction performance of FRS and ASCVD and calculated the relative importance of each covariate.

RESULTS

The AUCs of FRS (men: 0.750; women: 0.748) were higher than those of ASCVD (men: 0.718; women: 0.727) for both sexes (Delong test P <0.01). Goodness of fits (GOF) were poor for all models (Chi-square P < 0.001), especially, underestimation of the risk was pronounced in women. When the men's coefficients were applied to women's data, AUC (0.748; Delong test P<0.01) and the GOF (chi-square P = 0.746) were notably improved in FRS. Hypertension was found to be the most influential variable for CVD, and this is one of the reasons why FRS, having the highest relative weight to blood pressure, showed better performance.

CONCLUSION

When applying existing tools to Korean women, there was a noticeable underestimation. To accurately predict the risk of CVD, it was more appropriate to use FRS with men's coefficient in women. Moreover, hypertension was found to be a main risk factor for CVD.

Health-related physical fitness and blood pressure in people with intellectual disabilities in Korea

Hypertension is one critical health issue causing cardiovascular diseases. There has been a common concern among health researchers that the prevalence of hypertension, known as high blood pressure, has been more frequently observed among people with intellectual disabilities, compared to the general population. Thus, this study aims to identify which health-related physical fitness and body composition factors are significantly related to both systolic and diastolic blood pressures among people with intellectual disabilities. The data from 2180 people with intellectual disability who conducted the physical fitness tests from 2019 to 2020 were used for this study. Four physical fitness tests (i.e., 3-min step, grip strength, sit-up, and sit and reach) and two body compositions (i.e., body mass index and body fat %) used as predictors, and two blood pressures (i.e., systolic blood pressure and diastolic blood pressure) were used as outcome variables. A regression analysis was performed to examine the proposed associations. The regression test revealed that 3-min step, body mass index, and body fat % were significantly associated with both systolic blood pressure and diastolic body pressure. This research contributes to our understanding of the roles of body compositions and aerobic endurance in preventing hypertension among people with intellectual disability.

A clinical algorithm to determine target blood pressure in the elderly: evidence and limitations from a clinical perspective

As the elderly population is growing rapidly, management of hypertension in South Korea faces major challenges because the proportion of elderly hypertension patients is also increasing. The characteristics of this population are also much more complex than younger patients. Elderly hypertension is characterized by wide variations in (1) fitness or biological age, (2) white-coat effect, (3) poor functional status or frailty, (4) dependency in activities of daily living or institutionalization, (5) orthostatic hypotension, and (6) multiple comorbidities. All of these should be considered when choosing optimal target blood pressure in individual patients. Recent randomized clinical trials have shown that the benefits of intensive blood pressure control for elderly patients is greater than previously thought. For generalization of these results and implementation of the guidelines based on these studies, defining the clinician's role for individualization is critically important. For individualized decisions for target blood pressure (BP) in the elderly with hypertension, four components should first be checked. These consist of (1) the minimum requirement of functional status and capability of activities of daily living, (2) lack of harmful evidence by the target BP, (3) absence of white-coat hypertension, and (4) standing systolic BP ≥ 110 mmHg without orthostatic symptoms. Risk of decreased organ perfusion by arterial stenosis should be screened before starting intensive BP control. When the target BP differs among comorbidities, the lowest target BP should be given preference. After starting intensive BP lowering therapy, tolerability should be monitored, and the titration should be based on the mean level of blood pressure by office supplemented by out-of-office BPs. Applications of the clinical algorithms will be useful to achieve more standardized and simplified applications of target BP in the elderly.

Cost-Effectiveness Analysis of Hypertension Screening in the Korea National Health Screening Program

We evaluated the cost-effectiveness of routine hypertension (HTN) screening as a part of the national health-screening program. Compared with no screening, the costs per quality adjusted life years of the following screening strategies were below the incremental cost-effectiveness ratio threshold (approximately Korean won 30.5 million in Korea): first screening examination with the second confirmatory examination in adults aged 40 years or older every 3 years, every 2 years, or annually. The most cost-effective HTN screening strategy was the first screening examination with the second confirmatory examination in aged 40 years or older every 3 years.

Background and Objectives

To evaluate the cost-effectiveness of routine hypertension (HTN) screening as a part of the national health-screening program.

Methods

Two aspects of cost-effectiveness were examined using the national general health-screening program. First, the cost of case-finding was computed for 5-year interval age groups. Second, the cost per quality adjusted life years (QALYs) gained were estimated for 12 different scenarios varying examination starting age, pattern and interval compared with no screening.

Results

The cost of finding one new HTN case was low as 26,284 Korean won (KRW) (approximately [approx.] United States Dollar 21) for 70–79 years old to as high as 70,552 KRW for 40–44 years old. Compared with no screening, the costs per QALYs of the following screening strategies were below the incremental cost-effectiveness ratio threshold (approx. KRW 30.5 million): first screening examination with the second confirmatory examination in adults aged ≥40 years every 3 years (KRW 10.2 million), every 2 years (KRW 13.2 million), or annually (KRW 19.9 million). One-way sensitivity analyses suggest that the results were mostly influenced by the sensitivity of the first screening examination, followed by the examination rate of the second confirmatory examination.

Conclusions

HTN screening as a part of routine national health screening program was cost-effective for adults aged 40 years or older. The most cost-effective HTN screening strategy was the first screening examination with the second confirmatory examination in aged 40 years or older every 3 years.

Suboptimal Management Status of Younger Hypertensive Population in Korea

BACKGROUND AND OBJECTIVES

Hypertension (HTN) is the most contributable risk factor for cardiovascular disease. May Measurement Month (MMM) is a global initiative to raise awareness of HTN and act as a temporary solution to the lack of screening programs worldwide.

METHODS

An opportunistic cross-sectional survey of participants aged ≥18 was carried out in May 2019. Over 10,000 participants were recruited in the MMM 2019 Korea, with a slogan of "A simple measure to save lives - #checkyourpressure."

RESULTS

A total of 9,950 participants with valid clinical blood pressure (BP) data were used for analysis. All participants were Korean in ethnicity. The mean age was 57.2±21.2 years, 57.8% were females, and the mean body mass index was 23.4±3.3 kg/m². Among the enrolled population, 20.1% were less than 30 years old, and 5.0% were 30-39 years old. 37.0% of the participants reported a previous diagnosis of HTN, and 91.3% of those diagnosed were on antihypertensive medications. Notably, more than 20% of the participants had not measured their BP during the last 12 months, and the awareness rate in the young hypertensive participants (aged <40) was less than 10%. Among hypertensive participants, the treatment rate was 69.3%, and the control rate among those taking medications was 61.2%.

CONCLUSION

MMM 2019 Korea campaign reported high BP control rates in individuals with HTN, reaching 60%. However, the awareness rate in young hypertensive participants was less than 10% along with suboptimal management status. The MMM 2019 Korea again raised the importance of regular BP measurement in the younger population.

Intensive blood pressure lowering: a practical review

According to the last Hypertension guideline recommendations, it may be concluded that intensive BP lowering is only advisable in a subgroup of patients where there is a clear net benefit of targeting to lower BP goals. However, taking into account the relevance of correct BP measurement, estimates of the benefits versus the harm should be based on reliable office BP measurements and home BP measurements.

There is still debate about which BP goals are optimal in reducing morbidity and mortality in uncomplicated hypertensives and in those with associated comorbidities. In recent years, trials and meta-analyses have assessed intensive BP lowering, with some success. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population.

This article reviews the evidence on and controversies about intensive BP lowering in general and in specific clinical situations, and the importance of obtaining reliable BP readings in patients with hypertension and comorbidities.

Association between Use of Hydrochlorothiazide and Nonmelanoma Skin Cancer: Common Data Model Cohort Study in Asian Population

Although hydrochlorothiazide (HCTZ) has been suggested to increase skin cancer risk in white Westerners, there is scant evidence for the same in Asians. We analyzed the association between the use of hydrochlorothiazide and non-melanoma in the Asian population using the common data model.

METHODS

A retrospective multicenter observational study was conducted using a distributed research network to analyze the effect of HCTZ on skin cancer from 2004 to 2018. We performed Cox regression to evaluate the effects by comparing the use of HCTZ with other antihypertensive drugs. All analyses were re-evaluated using matched data using the propensity score matching (PSM). Then, the overall effects were evaluated by combining results with the meta-analysis.

RESULTS

Positive associations were observed in the use of HCTZ with high cumulative dose for non-melanoma skin cancer (NMSC) in univariate analysis prior to the use of PSM. Some negative associations were observed in the use of low and medium cumulative doses.

CONCLUSION

Although many findings in our study were inconclusive, there was a non-significant association of a dose-response pattern with estimates increasing in cumulative dose of HCTZ. In particular, a trend with a non-significant positive association was observed with the high cumulative dose of HCTZ.