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Journal of Peking University (Health Sciences) ›› 2024, Vol. 56 ›› Issue (3): 441-447. doi: 10.19723/j.issn.1671-167X.2024.03.010

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Comparison of initiation of antihypertensive therapy strategies for primary prevention of cardiovascular diseases in Chinese population: A decision-analytic Markov modelling study

Tianjing ZHOU1,Qiuping LIU1,Minglu ZHANG1,Xiaofei LIU1,Jiali KANG1,Peng SHEN2,Hongbo LIN2,Xun TANG1,3,*(),Pei GAO1,3,4,*()   

  1. 1. Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing 100191, China
    2. Yinzhou District Center for Disease Control and Prevention, Ningbo 315101, Zhejiang, China
    3. Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing 100191, China
    4. Center for Real-world Evidence Evaluation, Peking University Clinical Research Institute, Beijing 100191, China
  • Received:2024-02-17 Online:2024-06-18 Published:2024-06-12
  • Contact: Xun TANG,Pei GAO E-mail:tangxun@bjmu.edu.cn;peigao@bjmu.edu.cn
  • Supported by:
    the National Natural Science Foundation of China(82373662);the National Natural Science Foundation of China(81973132);the National Key Research and Development Program of China(2020YFC2003503)

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Abstract:

Objective: To evaluate the health benefits and intervention efficiency of different strategies of initiating antihypertensive therapy for the primary prevention of cardiovascular diseases in a community-based Chinese population from the Chinese electronic health records research in Yinzhou (CHERRY) study. Methods: A decision-analytic Markov model was used to simulate and compare different antihypertensive initiation strategies, including: Strategy 1, initiation of antihypertensive therapy for Chinese adults with systolic blood pressure (SBP) ≥140 mmHg (2020 Chinese guideline on the primary prevention of cardiovascular diseases); Strategy 2, initiation of antihypertensive therapy for Chinese adults with SBP ≥130 mmHg; Strategy 3, initiation of antihypertensive therapy for Chinese adults with SBP≥140 mmHg, or with SBP between 130 and 140 mmHg and at high risk of cardiovascular diseases (2017 American College of Cardiology/American Heart Association guideline for the prevention, detection, evaluation, and management of high blood pressure in adults); Strategy 4, initiation of antihypertensive therapy for Chinese adults with SBP≥160 mmHg, or with SBP between 140 and 160 mmHg and at high risk of cardiovascular diseases (2019 United Kingdom National Institute for Health and Care Excellence guideline for the hypertension in adults: Diagnosis and management). The high 10-year cardiovascular risk was defined as the predicted risk over 10% based on the 2019 World Health Organization cardiovascular disease risk charts. Different strategies were simulated by the Markov model for ten years (cycles), with parameters mainly from the CHERRY study or published literature. After ten cycles of simulation, the numbers of quality-adjusted life years (QALY), cardiovascular events and all-cause deaths were calculated to evaluate the health benefits of each strategy, and the numbers needed to treat (NNT) for each cardiovascular event or all-cause death could be prevented were calculated to assess the intervention efficiency. One-way sensitivity analysis on the uncertainty of incidence rates of cardiovascular disease and probabilistic sensitivity analysis on the uncertainty of hazard ratios of interventions were conducted. Results: A total of 213 987 Chinese adults aged 35-79 years without cardiovascular diseases were included. Compared with strategy 1, the number of cardiovascular events that could be prevented in strategy 2 increased by 666 (95% UI: 334-975), while the NNT per cardiovascular event prevented increased by 10 (95% UI: 7-20). In contrast to strategy 1, the number of cardiovascular events that could be prevented in strategy 3 increased by 388 (95% UI: 194-569), and the NNT per cardiovascular event prevented decreased by 6 (95% UI: 4-12), suggesting that strategy 3 had better health benefits and intervention efficiency. Compared to strategy 1, although the number of cardiovascular events that could be prevented decreased by 193 (95% UI: 98-281) in strategy 4, the NNT per cardiovascular event prevented decreased by 18 (95% UI: 13-37) with better efficiency. The results were consistent in the sensitivity analyses. Conclusion: When initiating antihypertensive therapy in an economically developed area of China, the strategy combined with cardiovascular risk assessment is more efficient than those purely based on the SBP threshold. The cardiovascular risk assessment strategy with different SBP thresholds is suggested to balance health benefits and intervention efficiency in diverse populations.

Key words: Cardiovascular diseases, Primary prevention, Blood pressure management, Markov model

CLC Number: 

  • R54

Figure 1

Markov model diagram for strategies of antihypertensive therapy initiation for primary prevention of cardiovascular diseases CVD, cardiovascular diseases; P1, probability from CVD-free status to alive with CVD status; P2, probability from CVD-free status to CVD death status; P3, probability from CVD-free status to non-CVD death status; P4, probability to stay alive without CVD; P5, probability from alive with CVD status to CVD death status; P6, probability from alive with CVD status to non-CVD death status; P7, probability to stay alive with CVD."

Table 1

Parameters and data sources in the Markov model"

Items Incidence of CVD Mortality of CVD Data source
35-59 years 60-79 years 35-59 years 60-79 years
Transition probabilities (/100 000) Estimated from this current study
  SBP < 130 mmHg 238 1181 4 36
  130≤SBP < 140 mmHg and non-high risk 311 829 6 14
  130≤SBP < 140 mmHg and high risk 703 1 902 18 100
  140≤SBP < 150 mmHg and non-high risk 374 811 10 18
  140≤SBP < 150 mmHg and high risk 837 2 165 28 134
  150≤SBP < 160 mmHg and non-high risk 385 752 9 1
  150≤SBP < 160 mmHg and high risk 931 1 918 34 111
  SBP≥160 mmHg 527 2 007 23 105
Hazard ratio of intervention, ${\bar x}$±s
  Every 5 mmHg reduction in SBP 0.91±0.01 0.93±0.03 Meta-analysis[11]

Table 2

Baseline characteristics of the study population"

Characteristics Men (n=103 639) Women (n=110 348) P
Age/years, ${\bar x}$±s 54.77±10.86 55.18±10.69 < 0.001
Education (senior high school or higher), n (%) 23 977 (23) 20 730 (19) < 0.001
Urban, n (%) 32 366 (31) 37 694 (34) < 0.001
Current smoker, n (%) 65 143 (63) 6 014 (6) < 0.001
Diabetes, n (%) 10 095 (10) 11 586 (10) < 0.001
SBP/mmHg, ${\bar x}$±s 130.94±14.98 130.68±16.37 0.800
DBP/mmHg, ${\bar x}$±s 81.22±9.23 79.68±9.77 < 0.001
TC/(mmol/L), ${\bar x}$±s 4.79±1.03 5.03±1.03 < 0.001
LDL-C/(mmol/L), ${\bar x}$±s 2.77±0.79 2.88±0.81 < 0.001
HDL-C/(mmol/L), ${\bar x}$±s 1.27±0.35 1.39±0.35 < 0.001
BMI/(kg/m2), ${\bar x}$±s 23.51±2.77 23.13±2.99 < 0.001
CVD risk score/%, M (P25, P75) 6.54 (3.32, 11.64) 4.86 (2.39, 8.83) < 0.001

Table 3

Comparison of health benefits and intervention efficiency of life quality and number of cardiovascular events prevented by different strategies of antihypertensive therapy"

Strategy 1 Strategy 2 Strategy 3 Strategy 4 Strategy 2 vs. Strategy 1 Strategy 3 vs. Strategy 1 Strategy 4 vs. Strategy 1
Total numbers for assessment 213 987 213 987 213 987 213 987
Total numbers eligible for antihypertensive therapy 57 666 114 855 73 321 31 961 57 189 15 655 -25 705
QALY gained/years 1 407 (751, 2 000) 2 275 (1 218, 3 234) 2 014 (1 075, 2 864) 1 219 (646, 1 734) 868 (467, 1 234) 607 (324, 864) -188 (-265, -101)
CVD events could be prevented 944 (473, 1 384) 1 610 (807, 2 359) 1 332 (666, 1 953) 751 (375, 1 102) 666 (334, 975) 388 (194, 569) -193 (-281, -98)
CVD deaths could be prevented 148 (73, 216) 223 (108, 326) 208 (101, 304) 136 (66, 197) 75 (36, 110) 60 (29, 89) -12 (-18, -6)
All deaths could be prevented 209 (109, 299) 328 (172, 469) 302 (158, 433) 190 (99, 272) 119 (63, 170) 93 (49, 134) -19 (-27, -10)
NNT per CVD events prevented 61 (42, 122) 71 (49, 142) 55 (38, 110) 43 (29, 85) 10 (7, 20) -6 (-12, -4) -18 (-37, -13)
NNT per all death prevented 276 (193, 529) 350 (245, 668) 243 (169, 464) 168 (118, 323) 74 (52, 139) -33 (-65, -23) -108 (-206, -75)

Figure 2

Evaluation of health benefit and intervention efficiency of different antihypertensive initiation strategies for cardiovascular diseases prevention NNT, number needed to treat."

Figure 3

One-way sensitivity analyses on the number needed to treat (NNT) per cardiovascular event prevented by different incidence rates of cardiovascular diseases"

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