Intensive blood pressure lowering by non-physician healthcare providers significantly reduces the risk of cardiovascular disease

1. A significant reduction in all-cause mortality was seen among patients in the intervention group compared to usual care.

2. Over 36 months, the net group difference in systolic blood pressure was -23.1 mmHg while the difference in diastolic blood pressure was -9.9 mmHg, favouring the intervention group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Hypertension is a leading cause of mortality worldwide. While multiple trials have shown the effectiveness of intensive blood pressure titration in patients with known hypertension in various settings, the effectiveness of non-physician healthcare provider-led blood pressure intervention on cardiovascular disease has not been studied. This randomized controlled trial aimed to assess the effectiveness of intensive blood pressure monitoring versus standard treatment on the risk of cardiovascular disease and all-cause mortality among adults with hypertension. Patients were assigned to either the intervention group (where trained non-physician providers titrated antihypertensives according to a preset protocol to achieve blood pressure ≤ 130/80) or usual care. The primary endpoint was a composite of myocardial infarction (MI), stroke, heart failure requiring hospitalization, and cardiovascular disease death. In summary, after 36 months, the intervention group demonstrated significantly reduced blood pressure readings compared to the usual care group. In addition, all-cause mortality was reduced in the intervention group. This study was well done and included patients from multiple demographics across various villages in China, thus strengthening its validity. However, as each non-physician provider was supervised by a local physician, there may be varying levels of involvement depending on the geographic site. Additionally, the provision of discounted or free medication may potentially have an impact on the findings and future studies may look to control this variable.

Click to read the study in The Lancet

Relevant Reading: Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

In-depth [randomized-controlled trial]: Between May 8 and Nov 28, 2018, 33 995 patients were enrolled in the study across 326 villages in China. Included were patients ≥ 40 years with hypertension (≥ 140/90 without comorbidities or ≥ 130/80 with cardiovascular disease, diabetes, kidney disease or those taking antihypertensives). The primary outcome of all-cause mortality was significantly reduced in the intervention group compared to usual care (1.62% vs. 2.40% per year, respectively, hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.61-0.73, p<0.0001). This risk reduction was consistent irrespective of age, sex, education, and antihypertensive use, and yielded a net group difference in systolic blood pressure reduction of 23.1 mmHg (p<0.0001) as well as a difference in diastolic blood pressure reduction of 9.9 mmHg (p<0.0001). Key secondary outcomes including MI (HR 0.77, 95% CI 0.60-0.98, p=0.037), stroke (HR 0.66, 95% CI 0.60-0.73, p<0.0001), and all-cause mortality (HR 0.85, 95% CI 0.76-0.95, p=0.0037) were also reduced in the intervention group. Findings from this study suggest that intensive blood pressure monitoring effectively reduces the risk of cardiovascular disease and all-cause mortality.

Image: PD

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