title: Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study.
abstract: OBJECTIVE
  To investigate the optimal systolic blood pressure goal above which new antihypertensive medications should be added or doses of existing medications increased ("systolic intensification threshold") and to determine the relation between delays in medication intensification and follow-up and the risk of cardiovascular events or death.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Primary care practices in the United Kingdom, 1986-2010.
  
  
  METHODS
  88 756 adults with hypertension from The Health Improvement Network nationwide primary care research database.
  
  
  METHODS
  Rates of acute cardiovascular events or death from any cause for patients with different hypertension treatment strategies (defined by systolic intensification threshold, time to intensification, and time to follow-up over the course of a 10 year treatment strategy assessment period) after adjustment for age, sex, smoking status, socioeconomic deprivation, history of diabetes, cardiovascular disease or chronic kidney disease, Charlson comorbidity index, body mass index, medication possession ratio, and baseline blood pressure.
  
  
  RESULTS
  During a median follow-up of 37.4 months after the treatment strategy assessment period, 9985 (11.3%) participants had an acute cardiovascular event or died. No difference in risk of the outcome was seen between systolic intensification thresholds of 130-150 mm Hg, whereas systolic intensification thresholds greater than 150 mm Hg were associated with progressively greater risk (hazard ratio 1.21, 95% confidence interval 1.13 to 1.30; P<0.001 for intensification threshold of 160 mm Hg). Outcome risk increased progressively from the lowest (0-1.4 months) to the highest fifth of time to medication intensification (hazard ratio 1.12, 1.05 to 1.20; P=0.009 for intensification between 1.4 and 4.7 months after detection of elevated blood pressure). The highest fifth of time to follow-up (>2.7 months) was also associated with increased outcome risk (hazard ratio 1.18, 1.11 to 1.25; P<0.001).
  
  
  CONCLUSIONS
  Systolic intensification thresholds higher than 150 mm Hg, delays of greater than 1.4 months before medication intensification after systolic blood pressure elevation, and delays of greater than 2.7 months before blood pressure follow-up after antihypertensive medication intensification were associated with increased risk of an acute cardiovascular event or death. These findings support the importance of timely medical management and follow-up in the treatment of patients with hypertension.
authors: Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA.
authors: Wenxin
authors: W
authors: Xu
authors: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA.
authors: Saveli I
authors: SI
authors: Goldberg
authors: Division of Endocrinology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA.
authors: Maria
authors: M
authors: Shubina
authors: Division of Endocrinology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA aturchin@partners.org.
authors: Alexander
authors: A
authors: Turchin
mesh_terms: D000328:Adult; D000959:Antihypertensive Agents / Q000008:administration & dosage*; D001794:Blood Pressure / Q000502:physiology*; D001795:Blood Pressure Determination / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013599:Systole; D013997:Time Factors; D061665:Time-to-Treatment; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D000959:Antihypertensive Agents
references: N Engl J Med. 2010 Apr 29;362(17):1575-85
references: 20228401
references: Hypertension. 2006 Mar;47(3):345-51
references: 16432045
references: JAMA. 2014 Feb 5;311(5):474-6
references: 24352710
references: Eur Heart J. 2013 Jul;34(28):2159-219
references: 23771844
references: Hypertension. 2003 Dec;42(6):1206-52
references: 14656957
references: Natl Health Stat Report. 2010 Nov 3;(27):1-32
references: 21089986
references: Stat Med. 2009 Apr 15;28(8):1315-7
references: 19288532
references: Pharmacoepidemiol Drug Saf. 2007 Apr;16(4):393-401
references: 17066486
references: Stat Med. 2007 Mar 15;26(6):1343-59
references: 16955538
references: Lancet. 2004 Jun 19;363(9426):2022-31
references: 15207952
references: Lancet. 2012 Dec 15;380(9859):2224-60
references: 23245609
references: Br Med J (Clin Res Ed). 1985 Jul 13;291(6488):97-104
references: 2861880
references: Cochrane Database Syst Rev. 2012;8:CD006742
references: 22895954
references: PLoS One. 2013;8(1):e53744
references: 23349738
references: J Clin Hypertens (Greenwich). 2005 Jun;7(6):327-32
references: 16088295
references: J Fam Pract. 1989 Jun;28(6):667-72
references: 2723595
references: BMC Fam Pract. 2010;11:1
references: 20051110
references: N Engl J Med. 1998 Dec 31;339(27):1957-63
references: 9869666
references: Eur Heart J. 2011 Jun;32(12):1500-8
references: 21345850
references: Ann Intern Med. 2009 May 5;150(9):604-12
references: 19414839
references: Arch Intern Med. 2011 Sep 26;171(17):1542-50
references: 21949161
references: J Hypertens. 2005 Dec;23(12):2157-72
references: 16269957
references: Hypertension. 2010 Jul;56(1):68-74
references: 20497991
references: Pharmacoepidemiol Drug Saf. 2009 Feb;18(2):120-31
references: 19109801
references: J Hypertens. 2004 Apr;22(4):847-57
references: 15126928
references: BMJ. 1991 Mar 30;302(6779):766-8
references: 2021768
references: J Hypertens. 2011 Jan;29(1):4-16
references: 20881867
references: Circulation. 2008 Feb 5;117(5):623-8
references: 18212279
references: JAMA. 2010 May 26;303(20):2043-50
references: 20501926
references: J Chronic Dis. 1987;40 Suppl 2:139S-161S
references: 3667861
references: Pharmacoepidemiol Drug Saf. 2005 Jul;14(7):443-51
references: 15898131
references: Hypertension. 1999 Dec;34(6):1181-5
references: 10601115
references: Contemp Pharm Pract. 1982 Summer;5(3):150-5
references: 10256918
references: Ann Intern Med. 2014 Apr 1;160(7):499-503
references: 24424788
references: J Clin Hypertens (Greenwich). 2000 Mar;2(2):134-137
references: 11416637
references: JAMA. 2003 Aug 20;290(7):891-7
references: 12928465
references: JAMA. 2014 Feb 5;311(5):507-20
references: 24352797
references: Ann Intern Med. 2002 Mar 19;136(6):438-48
references: 11900496
references: N Engl J Med. 1982 Oct 14;307(16):976-80
references: 7110301
references: J Investig Med. 2003 Nov;51(6):373-85
references: 14686641