Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

Abstract

AbstractBackgroundThe 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines newly classified 31 million US adults as having stage 1 hypertension. The ACC/AHA guidelines recommend behavioral change without pharmacology for the low-risk portion of this group. However, the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achievable by evidence-based dietary improvements, sustained weight loss, adequate physical activity, and alcohol moderation remain unquantified. We estimated the effect of systolic BP (SBP) control and behavioral changes on 10-year CVD outcomes and costs.MethodsWe used the CVD Policy Model to simulate CVD events, mortality, and healthcare costs among US adults aged 35-64. We simulated interventions on a target population, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: defined as untreated SBP 130-139 mmHg and diastolic BP <90 mmHg; no history of CVD, diabetes, or chronic kidney disease; and low 10-year risk of CVD. We used published meta-analyses and trials to estimate the effects of behavior modification on SBP. We assessed the extent to which intermittent healthcare utilization or partial uptake of nonpharmacologic therapy would decrease CVD events prevented.ResultsControlling SBP to <130 mmHg among the estimated 8.8 million U.S. adults (51% women) in the target population could prevent 26,100 CVD events, avoid 2,900 deaths, and save $1.6 billion in healthcare costs over 10 years. The Dietary Approaches to Stop Hypertension (DASH) diet could prevent 16,000 CVD events among men and 12,000 among women over a decade. Other nonpharmacologic interventions could avert between 3,700 and 19,500 CVD events. However, only 5.5 million (61%) of the target population regularly utilized healthcare where recommended clinician counseling could occur.ConclusionsAs only two-thirds of U.S. adults with Stage 1 hypertension regularly receive medical care, substantial benefits to cardiovascular health and associated costs may only stem from policies that promote widespread adoption and sustained adherence of nonpharmacologic therapy. Future work should quantify the population-level costs, benefits, and efficacy of improving the food system and local infrastructure on health behavior change.Clinical PerspectiveWhat is new?Guidelines recommend modifying health behaviors to achieve blood pressure control in individuals with stage 1 hypertension, but the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achieved remain unquantified.Using a public policy simulation model of CVD, we projected that controlling stage 1 systolic hypertension with nonpharmacologic therapy among an initially low-risk population of nearly 9 million young- and middle-aged adults would avert approximately 26,000 CVD events, 3000 deaths, and $1.6 billion in healthcare costs over 10 years.The Dietary Approaches to Stop Hypertension (DASH) diet could provide the greatest population benefit.What are the clinical implications?Evidence-based health behaviors, such as adopting the unprocessed foods-centric Dietary Approaches to Stop Hypertension (DASH) diet, could provide long-term dividends to improved cardiovascular health.However, one-third of initially low-risk adults with stage 1 hypertension did not regularly use healthcare. There additionally are documented challenges to sustaining these lifestyle changes. Systemic deprivation of health-promoting resources in the social and built environment can pose insurmountable economic barriers for marginalized patients, perpetuating cardiovascular disparities.The recommended medical provider counseling on behavioral modification must be paired with community interventions, infrastructure improvements, and nutrition-promoting food system policies to promote adherence.