30-year cardiovascular disease risk may inform blood pressure treatment decisions

“Although many people may not have a heart attack or stroke or develop heart failure for the next few years, lowering their blood pressure may help prevent future heart attacks, strokes and heart failure,” said lead study author Paul Mantner, PhD, visiting professor in the Department of Epidemiology at the University of Alabama at Birmingham. “Experts writing cardiovascular disease guidelines need to consider both short-term and lifetime risks of heart disease, stroke and heart failure when recommending lifestyle changes and treatments.”

This study compared predicted risks estimated by the American Heart Association's PREVENT program.^TM Released in 2023, this risk calculator replaces a previous risk prediction tool, the Pooled Cohort Equations (PCE). PREVENT (an acronym for Prediction of Risk of Cardiovascular Disease CVD Events) uses sex-specific equations, incorporates markers of kidney disease in addition to HbA1c measurements to monitor metabolic health, and can estimate 10- and 30-year risk of heart failure as well as heart attack and stroke, and takes into account additional risk factors from social deprivation indices. The Pooled Cohort Equations do not calculate 30-year risk and do not include additional risk factor predictors such as heart failure or kidney function or statin use.

Pooled cohort equations are designed to assess the 10-year risk of heart attack and stroke in individuals aged 40-79 years, while PREVENT can assess CVD risk in individuals aged 30-79 years and predict the risk of heart attack, stroke, and/or heart failure over the next 10 and 30 years. According to the 2017 ACC/AHA Guidelines for Prevention, Detection, Evaluation, and Management of Hypertension in Adults, a predicted risk of heart attack or stroke over the next 10 years estimated by PCE of 10% or more, along with other criteria, is considered high risk and health care professionals should discuss blood pressure lowering medications with the patient. Blood pressure lowering therapy for stage 1 hypertension includes diet and physical activity modifications and appropriate drug therapy.

In this study, the researchers used the PREVENT calculator to consider high risk as a 10-year risk of heart attack, stroke, and/or heart failure of 15% or more. In contrast, the pooled cohort equation considers high risk as a 10-year risk of heart attack and/or stroke of 10% or more. The researchers analyzed data from the 2013 to 2020 U.S. National Health and Nutrition Examination Survey (NHANES) of 1,703 adults aged 30 to 79 years with stage 1 hypertension (130-139 mmHg/80-89 mmHg). The analysis compared participants' predicted risk estimates of CVD using both calculation methods.

• The participants' average estimated 10-year risk of heart attack and stroke calculated by the PREVENT calculator was 2.9%, while the pooled cohort equation estimate was 5.4%. This means that if treatment guidelines use the same thresholds for PREVENT and PCE, some people may not be advised to start blood pressure-lowering drug therapy based on PREVENT predictions.
• However, some of these people are at increased risk of heart attack, stroke, and heart failure over the next 30 years, which can be estimated with the PREVENT calculator. 55.3% of adults who had a high 10-year risk in the pooled cohort equations had a lower 10-year risk using PREVENT; however, their 30-year risk was 30% or higher and could be considered high risk. This indicates that clinicians may need to consider both short-term and long-term cardiovascular risk for patients with high blood pressure (BP), the authors note.

“Many people with stage 1 high blood pressure who are unlikely to have a heart attack, stroke or heart failure within the next 10 years may be at higher risk over the next 30 years,” Muntner said. “Even if your short-term risk is low, we encourage you to consider and speak with your doctor about taking antihypertensive medications to lower your blood pressure to reduce your lifelong risk of heart attack, stroke and heart failure.”

Study design, background and details:

• The average age of study participants with stage 1 hypertension was 49.6 years old, 55% identified as male and 45% as female. Of this group, 65.8% were white adults, 15.5% were Hispanic adults, 10.1% were black adults, 5.8% were Asian adults, and 2.7% identified as other races or ethnicities.
• Additionally, 17.2% of participants were current smokers, 9.6% were taking statin medication to lower cholesterol, 8.4% had type 1 or type 2 diabetes, and 9.1% had chronic kidney disease.
• All study participants were determined to have stage 1 hypertension based on up to three blood pressure measurements taken at a single visit during the NHANES data collection period from 2013 to 2020. Because the study was cross-sectional, blood pressure was measured at a single visit.
• Participants answered questions about age, sex, race, ethnicity, smoking status, and medical history of coronary artery disease, heart attack, heart failure, stroke, type 1 or type 2 diabetes, or hypertension during the NHANES enrollment period. Participants who reported having a history of coronary artery disease, heart attack, stroke, or heart failure were excluded from the analysis.

“Preventing cardiovascular disease is important for people of all racial and ethnic groups. In the United States, non-Hispanic black adults are at higher risk of stroke and heart failure compared to other groups, including non-Hispanic white adults,” Muntner said. “However, we know that treatments for these groups are equally effective. Therefore, ensuring equal access to blood pressure lowering treatments is important for all adults.”

The study had several limitations. Participants' blood pressure values ​​were measured at one NHANES visit during the study period, rather than two or more visits at different visits, as recommended by the American Heart Association's 2017 Adult Hypertension Prevention, Detection, Evaluation, and Management Guideline. The researchers pooled NHANES data from 2013 to 2020 to obtain a sufficient sample study size to generate statistical estimates of predicted risk. The 10-year risk of cardiovascular disease using pooled cohort equations was stable over the 5-year period for which data were included. Also, because the data used were cross-sectional, meaning they examined the characteristics of the study population at one point in time, and did not include data on CVD outcomes, the study results cannot state with certainty which model is better at predicting the risk of developing cardiovascular disease.

“Emerging and growing evidence from clinical trials knows that lowering blood pressure is effective in reducing CVD risk, with the benefit greater for those with higher baseline risk. This study highlights the high burden of stage 1 hypertension and our goal as clinicians, health care systems and society should be focused on keeping blood pressure optimal for as long as possible, either through lifestyle or through initiation of blood pressure medications when lifestyle alone is not enough. The question of when to initiate blood pressure lowering medications arises from clinical trial data such as the SPRINT trial and the recently published ESPRIT trial, which showed benefit from intensive blood pressure lowering for those with CVD or at high risk for CVD. By using the most accurate and precise models to focus on those at higher predicted risk, we can most effectively and efficiently improve population health outcomes,” said Sadiya S. Khan, MD, MS, FAHA, chair of the writing group for the Society's 2023 Scientific Statement, “New Predictions.” “Total Cardiovascular Disease Absolute Risk Assessment Equation that Accounts for Cardiovascular, Renal and Metabolic Health” Khan is the Magerstadt Professor of Cardiovascular Epidemiology and an associate professor of medicine and preventive medicine at Northwestern University Feinberg School of Medicine in Chicago, and a preventive cardiologist at Northwestern Medicine, who was not involved in the study.

“The authors should be commended for looking at both 10- and 30-year risk, the latter being a valuable addition to the PREVENT model to enhance risk communication discussions with patients,” said Khan. “As we know from the guidelines for blood pressure, cholesterol, and primary prevention, risk estimation is the first step to initiate a patient-physician discussion that should also include other risk-increasing factors. For example, people who develop high blood pressure during pregnancy (preeclampsia) have a roughly two-fold increased risk of CVD and should be considered for more intensive preventive measures, such as early initiation of blood pressure-lowering medications. This study also highlights the importance of clinical trials in younger populations at increased 30-year risk, as well as in specific populations, such as preeclampsia patients, to better understand thresholds for initiation of medication and goals for blood pressure treatment with medication.”