Impact of the 2017 American Heart Association and American College of Cardiology hypertension guideline in aged individuals.

OBJECTIVES: The AHA/ACC-2017 hypertension guideline recommends an age-independent target blood pressure (BP) of less than 130/80 mmHg. In an elderly cohort without established cardiovascular disease (CVD) at baseline, we determined the impact of this guideline on the prevalence of hypertension and associated CVD risk. METHODS: Nineteen thousand, one hundred and fourteen participants aged at least 65 years from the ASPirin in Reducing Events in the Elderly (ASPREE) study were grouped by baseline BP: 'pre-2017 hypertensive' (BP ≥140/90 mmHg and/or on antihypertensive drugs); 'reclassified hypertensive' (normotensive by pre-2017 guidelines; hypertensive by AHA/ACC-2017 guideline), and 'normotensive' (BP <130 and <80 mmHg). For each group, we evaluated CVD risk factors, predicted 10-year CVD risk using the Atherosclerotic Cardiovascular Disease (ASCVD) risk equation, and reported observed CVD event rates during a median 4.7-year follow-up. RESULTS: Overall, 74.4% (14 213/19 114) were 'pre-2017 hypertensive'; an additional 12.3% (2354/19 114) were 'reclassified hypertensive' by the AHA/ACC-2017 guideline. Of those 'reclassified hypertensive', the majority (94.5%) met criteria for antihypertensive treatment although 29% had no other traditional CVD risk factors other than age. Further, a relatively lower mean 10-year predicted CVD risk (18% versus 26%, P < 0.001) and lower CVD rates (8.9 versus 12.1/1000 person-years, P = 0.01) were observed in 'reclassified hypertensive' compared with 'pre-2017 hypertensive'. Compared with 'normotensive', a hazard ratio (95% confidence interval) for CVD events of 1.60 (1.26-2.02) for 'pre-2017 hypertensive' and 1.26 (0.93-1.71) for 'reclassified hypertensive' was observed. CONCLUSION: Applying current CVD risk calculators in the elderly 'reclassified hypertensive', as a result of shifting the BP threshold lower, increases eligibility for antihypertensive treatment but documented CVD rates remain lower than hypertensive patients defined by pre2017 BP thresholds.

Cost-Effectiveness of Renal Denervation Therapy for Treatment-Resistant Hypertension: A Best Case Scenario.

BACKGROUND: Renal denervation (RDN) is effective at reducing blood pressure (BP) among patients with treatment-resistant hypertension (TRH). However, recent findings regarding the effectiveness of RDN for BP reduction compared with standard treatment of care (SoC) has initiated a rigorous debate about its role in TRH management. In this study, we sought to determine the thresholds for cardiovascular risk and costs of RDN which would make RDN cost-effective. METHODS: A Markov model was constructed to simulate cardiovascular events over a lifetime among TRH subjects aged 60 years at baseline, and without prior cardiovascular disease. The effect on lowering BP was based on results observed in clinical trials of RDN undertaken to date, and the expected subsequent change to cardiovascular risk was drawn from a published meta-regression. Cost and utility data were drawn from published sources. Incremental cost-effectiveness ratios (ICER) in terms of Australian dollars (AUD) per life year and per quality-adjusted life year (QALY) gained were estimated to assess RDN cost-effectiveness relative to SoC from the Australian health care perspective, assuming a willingness-to-pay threshold of AUD 50,000. RESULTS: Over a lifetime horizon, the model predicted that at the current estimated costs of RDN (AUD 9531/€6573, 1€ = 1.45 AUD), it would be cost-effective only if it was targeted to patients whose 10-year predicted cardiovascular risk was at least 13.2% initially. The ICERs (discounted) were AUD 49,519 per life year gained and AUD 47,130 per QALY gained. CONCLUSIONS: At current costs and based on currently observed effects on BP reduction, RDN would be cost-effective among patients with TRH.