Large-Scale Intensive BP Intervention Proves Sustainable for CVD Prevention

A community-based intensive blood pressure (BP) intervention was safe and effective for both older and younger adults with hypertension, a randomized trial conducted in rural China showed.

Among participants ages 60 and older in the intervention group compared with a usual-care group, there was a significantly lower rate of total cardiovascular disease (CVD; 2.7% vs 3.5% per year, HR 0.75, 95% CI 0.69-0.81) and all-cause mortality (2.5% vs 2.8% per year, HR 0.90, 95% CI 0.83-0.98) during a median 4 years, reported Yingxian Sun, MD, PhD, of First Hospital of China Medical University in Shenyang, and colleagues.

Similarly, participants younger than 60 in the intervention group also showed reductions in total CVD (1.3% vs 2%, HR 0.64, 95% CI 0.56-0.75), as well as stroke (HR 0.64, 95% CI 0.55-0.76), heart failure (HR 0.39, 95% CI 0.18-0.87), and cardiovascular death (HR 0.54, 95% CI 0.37-0.77), they wrote in JAMA Cardiology.

“The benefit of intensive BP control was consistent among patients in both age ranges regardless of their baseline BP level, CVD risk category, or diabetes status,” Sun’s group noted. Additionally, the incidence of injurious falls, symptomatic hypotension, syncope, and kidney outcomes were not different between the two groups.

“An effective, safe, and sustainable strategy for hypertension management among the older population with higher CVD burden will have a substantial public health impact,” they stressed, adding that the strategy “should be integrated into hypertension control programs in low-resource settings in China and worldwide.”

In an accompanying editorial, Daniel Jones, MD, of the University of Mississippi Medical Center in Jackson, agreed that this kind of strategy should be applied broadly.

“Today, all the tools necessary to improve hypertension control rates are available: effective and safe medications, access to healthy foods, collective wealth, and overwhelming evidence of benefit (now including reduction of dementia risk). Add to this the evidence that a safe, effective, and feasible approach to patient management that can be implemented anywhere — including in the U.S.,” he wrote.

This study, a 48-month follow-up to the China Rural Hypertension Control Project, adds credence to reports that nurse- and pharmacist-led hypertension clinics can get BP to goal — or close to goal — quickly.

This study differs from the SPRINT and STEP trials that had excluded patients with diabetes and prior stroke to find evidence favoring intensive hypertension treatment.

“Making up for all these deficiencies, our trial for the first time, per our knowledge, provided strong evidence to support a BP treatment goal of less than 130/80 mm Hg in the older general population with hypertension in a community-based setting,” Sun and colleagues wrote.

Jones noted that “a key question is whether the U.S. healthcare community is willing to embrace this evidence.”

“Can the mindset of forcing chronic disease management into healthcare systems designed for management of acute illnesses be changed?” he posed. “Can federal and state government agencies, insurers, and healthcare executives make the necessary changes to allow something so simple yet effective to be integrated into systems of care?”

This multifaceted intervention treating participants to a BP goal of <130/80 mm Hg was tested in an open-cluster randomized trial in which “village doctors” with junior medical education were instructed to initiate or titrate antihypertensive medications under the supervision of primary care physicians.

The trial was conducted from 2018 to 2023 and included participants from 326 villages in rural China who met criteria for untreated BP ≥140/90 mm Hg and treated BP ≥130/80 mm Hg.

The randomization phase included participants ages 60 and older (n=22,386) and younger than 60 (n=11,609) who were assigned to either the intervention or usual care.

Participants saw the village doctors monthly until they met the BP goal, then quarterly.

Altogether, mean age of participants was 63 years, and 61.3% were women. Over 20% were current smokers. Approximately half had baseline systolic/diastolic BP in the 140-159/90-99 mm Hg range.

The primary endpoint of incident CVD was defined as a composite of myocardial infarction, stroke, heart failure requiring hospitalization, and cardiovascular disease death.

Sun and team cautioned that they had no measures of serum creatinine at 48 months. Another limitation was the lack of analysis among a frail subgroup.

Notably, outside of this study, the ESPRIT trialists took BP targeting even lower in Chinese patients ages 50 and older — down to 120 mm Hg systolic — and recently reported that such intensive treatment safely reduced cardiovascular events at 3 years.

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