Study Reveals Cost-Effectiveness Strategy of 2017 American Heart Association Guidelines on Hypertension

A cost-effectiveness study exploring how to best implement 2017 guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) was presented at the AHA Scientific Session 2019 in Philadelphia, PA, from November 16 to 18, 2019.

The guidelines lowered blood pressures that define hypertension, from readings of 140/90 mm Hg or higher to 130/80 mm Hg or higher. These also suggest treating all adults with blood pressures 140/90 mm Hg or higher as well as recommending medication therapy for selected patients with blood pressures ranging from 130-139/80-89 mm Hg if they have had a cardiovascular event, such as a heart attack or stroke, or are at high risk for a first event within 10 years.

“Compared with hypertension guidance from the 2003 Seventh Report of the Joint National Committee, the 2017 ACC/AHA guidelines increased the number of people diagnosed and eligible for hypertension treatment and recommended blood pressure targets of <130/80 mm Hg for all patients,” said Joanne M. Penko, MS, MPH, the study’s first author and a research data analyst at the University of California, in a press release.

In the study, the researchers evaluated the cost-effectiveness of implementing the 2017 ACC/AHA guidelines over 10 years compared with the 2003 Seventh Report guidelines, including hypertension treatment costs incurred (prescription medications and monitoring visits) along with health care costs avoided by preventing heart disease and stroke events.

The study authors used quality-adjusted life years (QALYs) to quantify health that would be gained by implementing the 2017 hypertension guidelines. The ACC and the AHA consider health care strategies with a cost per QALY gained below $50,000 to have a high value, those ranging from $50,000 to $150,000 per QALY to have intermediate value, and those with costs higher than $150,000 per QALY to be low value.

In the analysis that compared the 2017 guidelines to the 2003 guidelines, the researchers found that:

• Treating all patients from 35 to 84 years of age according to the 2017 hypertension guidelines was a high to intermediate value treatment in some, but not all men, and a generally lower value strategy for women.
• Adding the more aggressive treatment goals of the 2017 guidelines was highly cost-effective over 10 years in men 65 to 84 years old and women 75 to 84 years old with existing cardiovascular disease, for which costs per QALY gained were below $50,000.
• Treating high-risk patients without prior cardiovascular disease was only intermediately cost-effective in most adults with baseline blood pressures 140/90 mm Hg or higher and not cost-effective in those with baseline blood pressures measuring 130-139/80-89 mm Hg.

“Previous studies have shown that compared with no treatment, treating high blood pressure according to the 2003 Seventh Report is cost-effective over 10 years. We were surprised to learn in our study that wasn’t the case for all patients indicated for medication treatment in the 2017 guidelines,” Penko said.

The findings suggest an incremental approach to implementing the 2017 ACC/AHA hypertension guidelines, first focusing limited resources on treating the oldest, highest-risk adults to intensive blood pressure goals, according to Penko. She noted that more research is needed to better understand the balance of benefits and consequences over a lifetime of treatment, particularly in younger adults.

The researchers used a long-tested computer simulation, the Cardiovascular Disease Policy Model, to estimate treatment costs over a decade and the benefits to patients’ health by applying the 2017 guidelines first to US adults with the highest risk of heart disease. Then, step-by-step, they applied the guidelines to lower-risk groups until they were fully implemented.

Risk level was determined based on patients’ baseline blood pressure, history of heart disease, stroke, high risk score for a future cardiovascular problem, or sex and age groups.

“This was a really neat simulation study. What they found in their analysis was that by reducing blood pressure to these new targets, there were some benefits that came about — reduction of cardiovascular events like stroke and heart attack, but there are also costs,” noted Mitchell S.V. Elkind, MD, AHA president-elect, chair of the Advisory Committee of the ASA, and professor of neurology and epidemiology at Columbia University in New York.

“And, so there's always this balancing act. We'd like to lower blood pressure in as many people as possible, but we have to balance that with the costs, especially if you think about it on the population level. The benefits in terms of health outweighed the costs significantly, particularly for those who were older and had evidence of cardiovascular disease,” Elkind said.

Reference

• Studies explore potential benefits and costs of increased treatment to achieve lower blood pressure targets [press release]. American Heart Association website. Published November 11, 2019. https://newsroom.heart.org/news/studies-explore-potential-benefits-and-costs-of-increased-treatment-to-achieve-lower-blood-pressure-targets. Accessed November 14, 2019.