Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions: A quantitative benefit-harm assessment

Hélène E. Aschmann, Cynthia M. Boyd, Craig W. Robbins, Richard A. Mularski, Wiley V. Chan, Orla C. Sheehan, Renée F. Wilson, Wendy L. Bennett, Elizabeth A. Bayliss, Tsung Yu, Bruce Leff, Karen Armacost, Carol Glover, Katie Maslow, Suzanne Mintz, Milo A. Puhan

Research output: Contribution to journalArticle

Abstract

Objective Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance. Design Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey. Setting Outpatient care. Participants Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus. Interventions SBP target of 120 versus 140 mm Hg for patients without history of stroke. Primary and secondary outcome measures Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach. Results Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment. Conclusions For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.

Original languageEnglish
Article number028438
JournalBMJ open
Volume9
Issue number8
DOIs
Publication statusPublished - 2019 Aug 1

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Blood Pressure
Patient Preference
Stroke
Chronic Renal Insufficiency
Multiple Chronic Conditions
National Cancer Institute (U.S.)
Ambulatory Care
Type 2 Diabetes Mellitus
Antihypertensive Agents
Decision Making
Heart Failure
Outcome Assessment (Health Care)
Hypertension
Morbidity
Weights and Measures
Therapeutics

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

Aschmann, H. E., Boyd, C. M., Robbins, C. W., Mularski, R. A., Chan, W. V., Sheehan, O. C., ... Puhan, M. A. (2019). Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions: A quantitative benefit-harm assessment. BMJ open, 9(8), [028438]. https://doi.org/10.1136/bmjopen-2018-028438
Aschmann, Hélène E. ; Boyd, Cynthia M. ; Robbins, Craig W. ; Mularski, Richard A. ; Chan, Wiley V. ; Sheehan, Orla C. ; Wilson, Renée F. ; Bennett, Wendy L. ; Bayliss, Elizabeth A. ; Yu, Tsung ; Leff, Bruce ; Armacost, Karen ; Glover, Carol ; Maslow, Katie ; Mintz, Suzanne ; Puhan, Milo A. / Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions : A quantitative benefit-harm assessment. In: BMJ open. 2019 ; Vol. 9, No. 8.
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abstract = "Objective Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance. Design Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey. Setting Outpatient care. Participants Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus. Interventions SBP target of 120 versus 140 mm Hg for patients without history of stroke. Primary and secondary outcome measures Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach. Results Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment. Conclusions For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.",
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Aschmann, HE, Boyd, CM, Robbins, CW, Mularski, RA, Chan, WV, Sheehan, OC, Wilson, RF, Bennett, WL, Bayliss, EA, Yu, T, Leff, B, Armacost, K, Glover, C, Maslow, K, Mintz, S & Puhan, MA 2019, 'Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions: A quantitative benefit-harm assessment', BMJ open, vol. 9, no. 8, 028438. https://doi.org/10.1136/bmjopen-2018-028438

Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions : A quantitative benefit-harm assessment. / Aschmann, Hélène E.; Boyd, Cynthia M.; Robbins, Craig W.; Mularski, Richard A.; Chan, Wiley V.; Sheehan, Orla C.; Wilson, Renée F.; Bennett, Wendy L.; Bayliss, Elizabeth A.; Yu, Tsung; Leff, Bruce; Armacost, Karen; Glover, Carol; Maslow, Katie; Mintz, Suzanne; Puhan, Milo A.

In: BMJ open, Vol. 9, No. 8, 028438, 01.08.2019.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Balance of benefits and harms of different blood pressure targets in people with multiple chronic conditions

T2 - A quantitative benefit-harm assessment

AU - Aschmann, Hélène E.

AU - Boyd, Cynthia M.

AU - Robbins, Craig W.

AU - Mularski, Richard A.

AU - Chan, Wiley V.

AU - Sheehan, Orla C.

AU - Wilson, Renée F.

AU - Bennett, Wendy L.

AU - Bayliss, Elizabeth A.

AU - Yu, Tsung

AU - Leff, Bruce

AU - Armacost, Karen

AU - Glover, Carol

AU - Maslow, Katie

AU - Mintz, Suzanne

AU - Puhan, Milo A.

PY - 2019/8/1

Y1 - 2019/8/1

N2 - Objective Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance. Design Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey. Setting Outpatient care. Participants Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus. Interventions SBP target of 120 versus 140 mm Hg for patients without history of stroke. Primary and secondary outcome measures Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach. Results Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment. Conclusions For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.

AB - Objective Recent studies suggest that a systolic blood pressure (SBP) target of 120 mm Hg is appropriate for people with hypertension, but this is debated particularly in people with multiple chronic conditions (MCC). We aimed to quantitatively determine whether benefits of a lower SBP target justify increased risks of harm in people with MCC, considering patient-valued outcomes and their relative importance. Design Highly stratified quantitative benefit-harm assessment based on various input data identified as the most valid and applicable from a systematic review of evidence and based on weights from a patient preference survey. Setting Outpatient care. Participants Hypertensive patients, grouped by age, gender, prior history of stroke, chronic heart failure, chronic kidney disease and type 2 diabetes mellitus. Interventions SBP target of 120 versus 140 mm Hg for patients without history of stroke. Primary and secondary outcome measures Probability that the benefits of a SBP target of 120 mm Hg outweigh the harms compared with 140 mm Hg over 5 years (primary) with thresholds >0.6 (120 mm Hg better), <0.4 (140 mm Hg better) and 0.4 to 0.6 (unclear), number of prevented clinical events (secondary), calculated with the Gail/National Cancer Institute approach. Results Considering individual patient preferences had a substantial impact on the benefit-harm balance. With average preferences, 120 mm Hg was the better target compared with 140 mm Hg for many subgroups of patients without prior stroke, especially in patients over 75. For women below 65 with chronic kidney disease and without diabetes and prior stroke, 140 mm Hg was better. The analyses did not include mild adverse effects, and apply only to patients who tolerate antihypertensive treatment. Conclusions For most patients, a lower SBP target was beneficial, but this depended also on individual preferences, implying individual decision-making is important. Our modelling allows for individualised treatment targets based on patient preferences, age, gender and co-morbidities.

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U2 - 10.1136/bmjopen-2018-028438

DO - 10.1136/bmjopen-2018-028438

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