Treatment of High Blood Pressure and Gain in Event-Free Life Expectancy

OBJECTIVE: Consideration of absolute risk has been recommended for making decisions concerning preventive treatment in hypertension. We performed simulations to estimate the benefit of antihypertensive therapy over a life-time. METHODOLOGY: The rate of nonfatal and fatal events of untreated hypertensives in the US population were estimated using data from Individual Data ANalysis of Antihypertensive drug intervention trials (INDANA; a meta-analysis on individual data in hypertension) and specific cause of death from national statistics. Disease-free survival curves until all patients have died were built using the “life-table” method. The treatment effect estimated from INDANA was applied to this curve to obtain the disease-free survival curve of the life-long treated population. Gains in event-free life expectancy (GLE) were estimated from survival curves. A sensitivity analysis was performed to assess the impact of possible death misclassifications. RESULTS: For a 40-year-old man, the gain in life expectancy without stroke and major cardiovascular events were 27 and 32 months, respectively, and were more substantial than those without coronary disease (19 months). The GLE decreased slowly with increasing age at the beginning of treatment, whereas short-term absolute risk reductions increase sharply with age. CONCLUSIONS: Policies based on the selection of patients to treat according to absolute benefit do not maximize the GLE compared with strategies that treat low-risk patients.