Tailored community intervention effective in reducing CV risk in patients with hypertension
A comprehensive model of care delivered by nonphysician health workers (NPHWs), involving primary care physicians and families that was informed by local context, substantially improved blood pressure (BP) control and cardiovascular disease (CVD) risk, according to results of the HOPE 4 trial reported at the European Society of Cardiology (ESC) Congress 2019 and World Congress of Cardiology (WCC) 2019.
Hypertension is the leading cause of CVD worldwide, with a majority of the disease burden in low- and middle-income countries. Despite clear benefits and recommendations for the use of antihypertensive medications and statins in patients, control of BP and use of statins remain low.
“In our study, the reduction in CV risk was 75 percent greater in the intervention group with a comprehensive model of care that addressed multiple barriers to implementation,” said Dr Jon-David Schwalm, Population Health Research Institute, McMaster University, Hamilton, Canada.
In this parallel-arm, cluster-randomized controlled trial, a total of 1,371 patients from 30 communities in Colombia and Malaysia who had new or uncontrolled hypertension (systolic BP [SBP], >140 mm Hg) were randomized to receive usual care (n=727; mean age, 65.8 years; female, 54 percent) or the intervention (n=644; mean age, 65.1 years; female, 58 percent) for 12 months. [Lancet 2019, doi: 10.1016/S0140-6736(19)31949-X]
The intervention entailed community screening to identify individuals with hypertension, treatment of CVD risk factors by NPHWs (supervised by local physicians) using tablet-based simplified management algorithms, provision of free antihypertensive and statin medications recommended by NPHWs (supervised by physicians), and treatment supporters (friends or families) to improve adherence to medications and healthy behaviours.
At baseline, a majority of participants (n=1,008; 73.5 percent) were on antihypertensives but had poor control of BP (SBP/ diastolic BP [DBP], 152/85 mm Hg in both groups).
There was high agreement between NPHWs and physicians in terms of CV risk assessment, identification of contraindications to antihypertensives and initial treatment recommendations (99 percent, 98 percent and 93 percent, respectively). Similarly, a high attendance rate to scheduled NPHW visits (94 percent) was noted, with treatment supporters present at 74 percent of visits. Adherence to prescribed antihypertensives was higher in the intervention vs control group at 12 months (61 percent vs 40 percent; p<0.0001) .
An absolute risk reduction of 4.78 percent in Framingham Risk Score (FRS) 10-year CVD risk (mean FRS, 11.17 percent vs 6.40 percent; 95 percent confidence interval [CI], -12.88 to -9.47 vs -7.11 to -2.44; p<0.0001) was demonstrated with the intervention.
“This is consistent with a more than 40 percent greater reduction in those receiving the intervention,” commented Schwalm. The effect on the primary outcome was consistent in all predefined subgroups in both countries, with no evidence of heterogeneity of intervention.
An absolute reduction in SBP by 11.45 mm Hg (95 percent CI, -14.94 to -7.97), total cholesterol by 0.45 mmol/L (95 percent CI, -0.62 to -0.28), and LDL-cholesterol by 0.41 mmol/L (95 percent CI, -0.60 to -0.23) was shown with the intervention (p<0.0001). At 12 months, the proportion of patients with SBP controlled at <140 mm Hg more than doubled in the intervention vs control group (68.9 percent vs 30.4 percent; 95 percent CI, 64.9 to 72.9 vs 25.8 to 34.9; p<0.0001).
Most health behaviours improved with the intervention, resulting in a substantial reduction in overall INTERHEART Risk Score (-4.9 vs -1.9; p<0.001) at 12 months. There were no safety concerns with the intervention.
“This strategy is pragmatic, effective, and scalable, and has the potential to substantially reduce CVD globally. This could help achieve the Union Nation’s target for a one-third reduction in premature CV mortality by 2030,” commented Professor Salim Yusuf, McMaster University Faculty of Health Science, Canada.