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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.
CONCLUSIONS: 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.
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.
CONCLUSIONS: 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.
摘要：
目的：从鄞州的中国电子健康档案研究（CHERRY）研究中，评估在社区人群中启动抗高血压治疗对心血管疾病一级预防的不同策略的健康效益和干预效率。
方法：使用决策分析马尔可夫模型来模拟和比较不同的降压启动策略，包括：策略1，对收缩压（SBP）≥140mmHg的中国成年人开始降压治疗（2020年中国心血管疾病一级预防指南）；策略2，对SBP≥130mmHg的中国成年人开始降压治疗；策略3，对SBP≥140mmHg的中国成年人开始降压治疗，或SBP在130至140mmHg之间且具有心血管疾病的高风险（2017年美国心脏病学会/美国心脏协会预防指南，检测,评估，和成人高血压的管理）；策略4，对SBP≥160mmHg的中国成年人开始降压治疗，或SBP在140至160mmHg之间且心血管疾病的高风险（2019年英国国家健康与护理卓越研究所成人高血压指南：诊断和管理）。根据2019年世界卫生组织心血管疾病风险图表，高10年心血管风险被定义为预测风险超过10%。不同的策略用马尔可夫模型模拟了十年(周期)，参数主要来自CHERRY研究或发表的文献。经过十个周期的模拟，质量调整生命年数(QALY)，计算心血管事件和全因死亡，以评估每种策略的健康益处，计算每个心血管事件或全因死亡需要治疗的数量(NNT),以评估干预效果.对心血管疾病发病率的不确定度进行单因素敏感性分析,对干预措施风险比的不确定度进行概率敏感性分析。
结果：共纳入213987名35-79岁无心血管疾病的中国成年人。与策略1相比，策略2中可以预防的心血管事件数量增加了666（95％UI：334-975），而每次预防心血管事件的NNT增加了10（95％UI：7-20）。与策略1相反，策略3中可以预防的心血管事件数量增加了388（95％UI：194-569），预防的每次心血管事件的NNT减少了6（95％UI：4-12），表明策略3具有更好的健康益处和干预效率。与策略1相比，尽管在策略4中可以预防的心血管事件数量减少了193（95％UI：98-281），但预防的每个心血管事件的NNT减少了18（95％UI：13-37），效率更高。敏感性分析结果一致。
结论：在中国经济发达地区开始抗高血压治疗时，结合心血管风险评估的策略比单纯基于SBP阈值的策略更有效.建议采用不同SBP阈值的心血管风险评估策略，以平衡不同人群的健康益处和干预效率。
方法：使用决策分析马尔可夫模型来模拟和比较不同的降压启动策略，包括：策略1，对收缩压（SBP）≥140mmHg的中国成年人开始降压治疗（2020年中国心血管疾病一级预防指南）；策略2，对SBP≥130mmHg的中国成年人开始降压治疗；策略3，对SBP≥140mmHg的中国成年人开始降压治疗，或SBP在130至140mmHg之间且具有心血管疾病的高风险（2017年美国心脏病学会/美国心脏协会预防指南，检测,评估，和成人高血压的管理）；策略4，对SBP≥160mmHg的中国成年人开始降压治疗，或SBP在140至160mmHg之间且心血管疾病的高风险（2019年英国国家健康与护理卓越研究所成人高血压指南：诊断和管理）。根据2019年世界卫生组织心血管疾病风险图表，高10年心血管风险被定义为预测风险超过10%。不同的策略用马尔可夫模型模拟了十年(周期)，参数主要来自CHERRY研究或发表的文献。经过十个周期的模拟，质量调整生命年数(QALY)，计算心血管事件和全因死亡，以评估每种策略的健康益处，计算每个心血管事件或全因死亡需要治疗的数量(NNT),以评估干预效果.对心血管疾病发病率的不确定度进行单因素敏感性分析,对干预措施风险比的不确定度进行概率敏感性分析。
结果：共纳入213987名35-79岁无心血管疾病的中国成年人。与策略1相比，策略2中可以预防的心血管事件数量增加了666（95％UI：334-975），而每次预防心血管事件的NNT增加了10（95％UI：7-20）。与策略1相反，策略3中可以预防的心血管事件数量增加了388（95％UI：194-569），预防的每次心血管事件的NNT减少了6（95％UI：4-12），表明策略3具有更好的健康益处和干预效率。与策略1相比，尽管在策略4中可以预防的心血管事件数量减少了193（95％UI：98-281），但预防的每个心血管事件的NNT减少了18（95％UI：13-37），效率更高。敏感性分析结果一致。
结论：在中国经济发达地区开始抗高血压治疗时，结合心血管风险评估的策略比单纯基于SBP阈值的策略更有效.建议采用不同SBP阈值的心血管风险评估策略，以平衡不同人群的健康益处和干预效率。
