Medication not recommended for low-risk patients with mild hypertension
Initiating pharmacologic interventions in low-risk patients with mild hypertension may lead to a higher risk of adverse events, such as syncope and electrolyte abnormalities, according to a recent study.
While no link in elevated mortality risks was observed, “[t]he findings suggest that physicians should be cautious when initiating treatment in low-risk patients with mild hypertension, particularly because such an approach may affect millions of individuals with little evidence of benefit,” said researchers.
Accessing an electronic health records database, researchers enrolled 19,143 mildly hypertensive patients (mean age 54.7±11.8 years; 55.9 percent female) with low cardiovascular disease (CVD) risk and who had been exposed to any antihypertensive medication. Over a median follow-up of 5.8 years, the overall mortality rate in this group was 4.08 percent. [JAMA Intern Med 2018;doi:10.1001/jamainternmed.2018.4684]
This was not significantly different from that of the nonexposed control group (4.49 percent, risk difference, 0.41 percent; 95 percent CI, 0.02–0.85 percent; hazard ratio [HR], 1.02; 0.88–1.17; p=0.81), which was similar in size and demographic composition (mean age 54.9±12.2 years; 55.5 percent female).
Similarly, the risks of CVD (HR, 1.08; 0.96–1.25; p=0.23), stroke (HR, 0.97; 0.78–1.21; p=0.76), myocardial infarction (MI; HR, 1.00; 0.80–1.25; p=0.98), non-MI acute coronary syndrome (ACS; HR, 1.19; 0.74–1.91; p=0.47) and heart failure (HR, 1.34; 0.96–1.86; pp=0.09) were statistically comparable between those with and without antihypertensive exposures.
The effect of baseline antihypertensive treatment remained mostly null upon sensitivity analysis, except for its effect on non-MI ACS, which reached statistical significance upon adjusting for baseline cardiovascular risk (HR, 0.54; 0.33–0.89; p=0.02).
“Even in sensitivity analyses adjusting the propensity score for previous or imputed risk score, the observed treatment benefit for cardiovascular outcomes was minimal, with only non-MI ACS associated with a significant risk reduction with treatment,” said researchers.
On the other hand, antihypertensive medication use was associated with significantly elevated risks of adverse events such as hypotension (HR, 1.69; 1.30–2.20; p<0.001), syncope (HR, 1.28; 1.10–1.50; p=0.02), electrolyte abnormalities (HR, 1.72; 1.12–2.65; p=0.01) and acute kidney injury (HR, 1.37; 1.00–1.88; p=0.048).
“There was evidence to suggest that baseline treatment exposure may be associated with an increased risk of adverse events, with a number needed to harm after 5 years of treatment of 135 for syncopal outcomes,” said researchers.
In the present study, low CVD risk was defined according to comorbidities. Patients with a history of CVD, diabetes, atrial fibrillation, chronic kidney disease or left ventricular hypertrophy were not eligible for inclusion. Those with family histories of premature heart disease were also excluded.
“Physicians should therefore be cautious when initiating new treatment in this population, and patients should be made aware of the limited evidence of efficacy for treatment in low-risk individuals,” said researchers.
“These findings may be particularly relevant for younger patients with mild hypertension, because as these individuals age, they are likely to develop higher risk and moderate or severe hypertension, for which the benefits of treatment are more established,” they added.