Optimal blood pressure control with fewer antihypertensive medications: Achieved mostly in low‐risk hypertensive patients

Abstract

Recent studies indicate that intensive blood pressure (BP) targets can be reached with less than two medications. This cross‐sectional study, involving 4991 individuals from the Majiapu community, assessed the correlation between BP control and the burden of antihypertensive drugs. Participants on medication were categorized into controlled (BP < 140/90 mm Hg) and uncontrolled (BP ≥ 140/90 mm Hg) groups, with the former further divided into optimal (BP < 130/80 mm Hg) and good control (BP < 140/90 but >130/80 mm Hg) subgroups. Multivariate logistic regression analyzed factors affecting hypertension control across these BP categories. The study found that, 54% of participants had hypertension. Of those treated (62.5%), 55.7% achieved BP control, including 23.15% maintaining BP below 130/80 mm Hg. The average number of antihypertensive medications was 1.61 for the controlled group (with an average BP of 126.6/76 mm Hg) and 1.75 for the uncontrolled group (with an average BP of 150.6/84.0 mm Hg). Additionally, the average number of antihypertensive medications was 1.66 in the good control group and 1.55 in the optimal control group. The uncontrolled group had a higher mean systematic coronary risk estimation (SCORE) of 5.59, against 3.97 and 2.5 in the good and optimal control groups, respectively. Key factors linked to poor BP control included age over 65, male sex, obesity, and former smoking, whereas lipid‐lowering medication use was associated with better control. In conclusions, patients needing fewer antihypertensive drugs to achieve stricter targets may have a lower risk profile. Notably, only a small proportion of treated patients are low‐risk individuals who can easily achieve BP levels below 130/80 mm Hg.

1. INTRODUCTION

Hypertension is the leading cause of preventable cardio‐cerebrovascular diseases, affecting over 30% of adults (1.39 billion) worldwide. ¹ , ² making it a significant global health challenge. It is well established that achieving BP targets for treatment often necessitates using multiple antihypertensive agents. ³ , ⁴ Over the past two decades, various randomized controlled trials (RCTs) have shown that, on average, two or more antihypertensive drugs are required to manage BP effectively. However, findings from certain trials, such as the systolic blood pressure intervention (SPRINT) trial, the strategy of blood pressure intervention in the elderly hypertensive patients (STEP) trial, and the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS), have demonstrated that less than two antihypertensive agents can be sufficient for achieving stricter BP target. ⁵ , ⁶ , ⁷

This investigation aims to study the number of antihypertensive medications needed to achieve BP targets in clinical practice. The study will focus on the differences in medication usage among patients with different levels of BP control: BP < 130/80 mm Hg, BP < 140/90 mm Hg but >130/80 mm Hg, and BP > 140/90 mm Hg. Moreover, the study sought to ascertain whether these parameters could indicate a heightened risk for suboptimal BP control. To this end, a cross‐sectional analysis was conducted within the Majiapu community, examining both the control of BP and the associated burden of antihypertensive medication.

Through this research, we hope to shed light on the real‐world applicability and feasibility of intensive blood pressure (BP) control and identify which populations may benefit most from such approaches. This could potentially lead to more effective and easier‐to‐manage treatment strategies for hypertension.

2. METHOD

2.1. Study design

In this community‐based cross‐sectional study, conducted from January 2021 to October 2022 in the Majiapu community, 35 137 residents were initially surveyed as part of primary care data collection. We included 4991 residents with complete upper arm BP measurements for this analysis. Participants receiving antihypertensive treatment were categorized into controlled (BP < 140/90 mm Hg) and uncontrolled (BP ≥ 140/90 mm Hg) groups. The controlled group was further divided into an optimal control group (BP < 130/80 mm Hg) and a good control group (BP < 140/90 but >130/80 mm Hg). The study assessed BP control status, the burden of antihypertensive agents, and factors influencing different BP values. Ethics approval was obtained from the Fuwai Hospital Institutional Review Board before the start of the study, and all participants provided written informed consent.

2.2. Community characteristics

The Majiapu community is located in Beijing, the capital of China. It is characterized by a mix of residential, commercial, and industrial zones, representing a typical urban setting with a dense population and diverse socioeconomic status. Established in 1988, the population is predominantly Han Chinese. The community includes a mix of ages, with a significant proportion of elderly residents and a wide range of educational backgrounds. In our data, over 68% of the residents have attained a high school education or higher.

2.3. Data collection

Baseline characteristics such as age, sex, smoking status, and the use of hypoglycemic and antihypertensive medications were recorded. Physical and laboratory measurements included systolic blood pressure (SBP) and diastolic blood pressure (DBP), height, weight, and laboratory values. BP measurements were conducted using the Omron 1120U upper arm BP monitor. This device has been validated according to the standards set by the Association for the Advancement of Medical Instrumentation (AAMI). ⁸ Participants were advised to avoid alcohol, nicotine, caffeine, and physical activity for 30 min before the assessment. BP measurements were conducted three times at 1‐min intervals in the morning, after a 5‐min seated rest. The average of the second and third measurements was recorded as the patient's BP. Body mass index (BMI) was calculated using the standard formula. All measurements were performed by trained physicians following established protocols. Laboratory data, including low‐density lipoprotein (LDL), high‐density lipoprotein (HDL), total cholesterol (TC), and Triglycerides (TG) were also obtained during the survey.

2.4. Antihypertensive treatment protocol

In our study, antihypertensive medications were introduced using both stepwise and fixed dose combination approaches. If the target BP was not achieved, additional medications were added in a stepwise manner which aligns with current clinical guidelines. ⁹

2.5. Definition

Hypertension was defined as having an SBP ≥140 mm Hg, a DBP ≥90 mm Hg, or current use of antihypertensive medication. BP control was described as an average SBP and DBP below 140/90 mm Hg while undergoing treatment. Overweight was classified as a BMI of 24.0–27.9 kg/m², and obesity as a BMI ≥ 28.0 kg/m², according to criteria for Chinese adults. ¹⁰ The systematic coronary risk estimation (SCORE) was used to estimate the 10‐year risk of fatal cardiovascular disease, incorporating factors like age, sex, smoking status, SBP, and TC, with adjustments for Eastern Asia. Risk categories were established based on SCORE values. The SBP reading used in the SCORE calculation was obtained during the treatment period. Patients with a calculated SCORE of less than 5% were defined as low to moderate risk, those with a SCORE of 5% or more but less than 10% as high risk, and those with a SCORE of 10% or higher as very high risk. ¹¹

2.6. Statistical analysis

Continuous variables were reported as medians and interquartile ranges (IQR) or mean, and standard deviation (SD), and differences between groups were assessed using the Mann–Whitney U test and Student's t test as appropriate. Categorical variables were expressed as counts and percentages, with group differences evaluated using the chi‐square test. A univariate logistic analysis was conducted to identify factors associated with BP control, with significant variables (p < .05) included in the multivariate models. Statistical analyses were performed using SPSS version 25.0.

3. RESULTS

In this study, 4991 residents were analyzed. The average age was 65.6 years, with a mean BMI of 25.23 kg/m². The prevalence of hypertension was 54%. Among those hypertensive participants, 34.8% (939 participants) achieved BP control below 140/90 mm Hg and 14.46% (390 participants) below 130/80 mm Hg. Of the hypertensive patients, 62.5% (1685 individuals) were on antihypertensive medication, with 55.7% achieving BP control under 140/90 mm Hg and 23.15% under 130/80 mm Hg.

Patients on treatment were classified based on BP: controlled (BP < 140/90 mm Hg) and uncontrolled (BP ≥ 140/90 mm Hg). The controlled group used an average of 1.61 antihypertensive drugs (average BP 126.6 ± 9.5/76.3 ± 7.4 mm Hg). In contrast, the uncontrolled group used 1.75 drugs on average (mean BP 150.59 ± 11.6/84.02 ± 9.87 mm Hg), showing a significant difference in medication use (p < .05). SCORE assessments revealed 57.9% in the uncontrolled group as low to moderate risk, 26.7% as high risk, and 15.4% as very high risk (mean SCORE 5.59). In the controlled group, 81.2% of individuals were classified as low to moderate risk, 14.5% as high risk, and only 4.3% as very high risk with an average SCORE of 3.18. The uncontrolled group had a higher proportion of males, individuals over 65, less use of lipid‐lowering drugs, higher BMI, and a greater number of medications (p < .05) (Table 1).

TABLE 1.

Characteristics of patients in the uncontrolled group and controlled group.

Variables	Uncontrolled group (BP ≥140/90)	Controlled group (BP < 140/90)	t/x 2	p
N	746	939
Age, years, median (IQR)	71 (58, 84)	70 (59, 81)	−3.404	.001
Sex, male, n (%)	412 (55.2%)	440 (46.8%)	11.650	.001
SBP, mean (SE), mm Hg	150.6 ± 11.6	126.6 ± 9.5	−46.809	.000
DBP, mean (SE), mm Hg	84.0 ± 9.9	76.3 ± 7.4	−18.413	.000
BMI, median (IQR)	25.15 (21.05, 29.25)	24.61 (20.46, 28.76)	−3.344	.001
Smoking status, n (%)			8.861	.012
Never smoked	556 (79.9%)	722 (81.2%)
Former smokers	99 (14.0%)	131 (14.8%)
Current smokers	53 (7.5%)	36 (4.1%)
Number of agents
Average	1.75	1.61	−3.587	.000
1	318 (42.6%)	494 (52.6%)	16.802	.000
2	293 (39.3%)	311 (33.1%)
3+	135 (18.1%)	134 (14.3%)
Combined use of hypoglycemic drugs, n (%)	260 (34.9%)	284 (30.2%)	4.037	.045
Combined use of lipid‐lowering drugs, n (%)	307 (41.2%)	448 (47.7%)	7.702	.006
TC, mean (SD), mmol/L	4.76 ± 0.99	4.71 ± 1.05	−0.818	.414
HDL, median (IQR), mmol/L	1.35 (0.93, 1.77)	1.34 (0.88, 1.8)	0.954	.34
LDL, median (IQR), mmol/L	2.73 (1.6, 3.86)	2.69 (1.51, 3.87)	−1.357	.175
TG, median (IQR), mmol/L	1.42 (0.47, 2.37)	1.38 (0.53, 2.23)	−1.046	.296
Risk categories (SCORE)	5.59	3.18	102.756	.000
Low‐ to moderate‐risk persons (calculated SCORE<5%)	368 (57.9%)	672 (81.2%)
High‐risk persons (calculated SCORE ≥5% and <10%)	170 (26.7%)	120 (14.5%)
Very‐high‐risk persons (calculated SCORE ≥10%)	98 (15.4%)	36 (4.3%)

Figure 1 illustrates the logistic regression analysis for uncontrolled hypertension, indicating associations with age ≥65 years (OR: 1.727, 95% CI: [1.372–2.172]), male sex (OR: 1.387, 95% CI: [1.125–1.71]), obesity (OR: 1.406, 95% CI: [1.052–1.879]), and former smoking (OR: 1.888, 95% CI: [1.191‐2‐.991]). The use of lipid‐lowering medications (OR: 0.727, 95% CI: [0.591–0.894]) was associated with better BP control.

FIGURE 1.

Logistic regression for uncontrolled hypertension.

The optimal control group, predominantly female and more likely to use lipid‐lowering medications, had lower BMIs, TG, and LDL levels and fewer antihypertensive agents compared to the uncontrolled group (Table 2). Logistic regression showed optimal BP control was more likely in females (OR: 1.986, 95% CI: [1.425–2.767]) and associated with lower LDL levels (OR:0.751, 95% CI: [0.613–0.92]). Significant differences in sex, BMI, and TG were noted between optimal and good control groups. SCORE assessments in the good control group showed 73.1% as low to moderate risk, 17.6% as high risk, and 9.3% as very high risk, while in the optimal control group, 88.2% were low to moderate risk, 11.8% as high risk, with none in the very high‐risk category.

TABLE 2.

Characteristics of patients in the uncontrolled, good control, and optimal control groups.

Variables	BP > 140/90 mm Hg	BP (130–139/80–89)	BP < 130/80mm Hg	p
N	746	549	390
Age, years, median (IQR)	71 (58, 84)	69 (53, 85)	69 (57, 81)	.940
Sex, male, n (%)	412 (55.2%)*	278 (50.6%)*	162 (41.5%)	.000
BMI, median (IQR)	25.15 (21.05,29.25)*	25 (20.65,29.35)*	24.34 (20.48,28.2)	.000
Smoking status, n (%)				.065
Never smoked	556 (79.9%)	419 (81.2%)	303 (81.2%)
Former smokers	99 (14.0%)	76 (14.7%)	55 (14.7%)
Current smokers	53 (7.5%)	21 (4.1%)	15 (4.0%)
Combined use of hypoglycemic drugs, n (%)	260 (34.9%)	158 (28.8%)	126 (32.3%)	.069
Combined use of lipid‐lowering drugs, n (%)	307 (41.2%) *	256 (47.0%)	192 (49.2%)	.017
TC, mean (SD), mmol/L	4.76 ± 0.99	4.74 ± 1.01	4.65 ± 1.09	.415
HDL, median (IQR), mmol/L	1.35 (0.93, 1.77)	1.32 (0.91, 1.73)	1.36 (0.87, 1.85)	.209
LDL, median (IQR), mmol/L	2.73 (1.6, 3.86) *	2.77 (1.59, 3.95)	2.62 (1.42, 3.82)	.031
TG, median (IQR), mmol/L	1.42 (0.47, 2.37) *	1.45 (0.54, 2.36)*	1.30 (0.5, 2.1)	.006
Number of agents
Mean	1.75*	1.66	1.55	.000
1	318 (42.6%)	274 (49.9%)	220 (56.4%)
2	293 (39.3%)	190 (34.6%)	121 (31.0%)
3+	135 (18.1%)	85 (15.5%)	49 (12.6%)
Risk categories (SCORE)	5.59	3.97	2.50	<.001
Low‐ to moderate‐risk persons (calculated SCORE<5%)	368 (57.9%)	282 (73.1%)	390 (88.2%)
High‐risk persons (calculated SCORE ≥5% and <10%)	170 (26.7%)	68 (17.6%)	52 (11.8%)
Very‐high‐risk persons (calculated SCORE ≥10%)	98 (15.4%)	36 (9.3%)	0 (0%)

Note: Compared to the good control group, (*) indicates statistical significance between the two groups.

In the group aged below 65 years, the average BP was 133.6/84.2 mm Hg, with an average SCORE of 2.4. In contrast, for those aged 65 years and above, the average BP was 138.8/77.7 mm Hg, with an average SCORE of 4.8.

4. DISCUSSION

According to our study, hypertension control in the Majiapu community is relatively effective, with a treatment rate of 62.5%. When using 140/90 mm Hg as the benchmark, the BP control rate reached 34.8%. These rates surpass the global average reported by the WHO, which notes a treatment rate of 42% and a control rate of 21% among adults. In China, the rates are lower at 39% for treatment and 16% for control. Nevertheless, there is still a gap compared to some developed countries such as South Korea, Canada, and Iceland, where the treatment rates exceed 70% and control rates are over 50%. ¹²

In our study, the mean number of antihypertensive drugs was 1.67, achieving an average BP controlled of 137.2/79.7 mm Hg. Participants with uncontrolled hypertension (BP > 140/90 mm Hg) were prescribed a greater number of antihypertensive agents compared to those in the good control (BP 130–139/80–89 mm Hg) and optimal control (BP < 130/80 mm Hg) groups. Our findings showed a correlation between higher achieved BP values and higher SCORE risk assessments. This suggests that patients at lower cardiovascular risk levels have more readily controllable BP. Factors such as age over 65 years, male sex, obesity, and smoking history were associated with poorer BP control, while the use of lipid‐lowering drugs correlated with better control. The association between lipid‐lowering medication use and better BP control can be attributed to the overall cardiovascular health management strategies employed by patients and their healthcare providers. Patients on lipid‐lowering medications are likely to be more compliant with their treatment plans, leading to better BP control. ¹³ , ¹⁴ In our analysis, older age is associated with increased arterial stiffness and higher overall cardiovascular risk, both of which contribute to difficulties in achieving optimal BP control.

We noted differences in obesity, sex, and triglyceride levels when comparing the optimal control group to the good control group.

Although these factors have been previously established as independently associated with cardiovascular risk levels, ⁶ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ our research suggests that a composite assessment of these risks holds greater significance in BP management. Achieving moderate BP targets (less than 140/90 mm Hg) often necessitates 2–3 antihypertensive drugs. ²⁰ , ²¹ However, some studies ²² , ²³ , ²⁴ , ²⁵ discussed the effect of different antihypertensive drugs on cardiovascular outcomes in populations with low to medium cardiovascular risk, using less than two drugs to lower the average BP to around 140/90 mm Hg. Moreover, some research suggests that an increased medication burden in high‐risk populations does not invariably equate to cardiovascular benefits. ²⁶

BP of patients with lower risk is easy to be controlled. In the Majiapu community, only 23.15% of patients maintained their BP below 130/80 mm Hg despite BP control rates exceeding the global average. This is comparable to the Clustering of Cardiovascular Risk Factors and Hypertension control status among Hypertensive Patients in the Outpatient Setting (CONSIDER) study from a decade prior, which found that patients with lower cardiovascular risk had more effective BP control. Their analysis showed that 78.4% of individuals over 65 fell into high or very high‐risk categories, and 51.3% reached treatment goals (BP < 140/90 mm Hg). ²⁷ Over the past 10 years, BP control has not seen a corresponding advancement in China, with the low‐risk group remaining a small minority.

Our study has limitations, primarily its cross‐sectional design, which can produce unexpected chance phenomena due to the lack of key variables or the inability to establish causal relationships. Additionally, incomplete lipid data may lead to underestimation of overall cardiovascular risk. To address these issues, we included comprehensive variables impacting cardiovascular health, such as obesity, BP, and blood glucose levels, to provide a holistic assessment and reduce biases. Nevertheless, our results align with other studies within the Chinese population, ²⁸ suggesting that the Majiapu community's lipid profile is representative. Future longitudinal studies are needed to confirm these findings and enhance the understanding of hypertension control dynamics.

Another limitation of our study is the inability to obtain detailed information on the duration of antihypertensive treatment for participants already on medication and changes in antihypertensive treatment regimens. Although 79.4% of the participants had modifications to their treatment plans aimed at achieving target BP levels, we were only able to evaluate the treatment based on the average number of medications used during the study period. Furthermore, treatment compliance was assessed during patient follow‐up through self‐reports and by calculating the proportion of days covered (PDC) based on pharmacy refill records. However, compliance data were not recorded in our database.

Despite these limitations, our analysis accounts for whether participants were on treatment at the time of the study, providing valuable insights into the current state of BP control in our study population. Future studies should aim to collect detailed treatment duration data, specific information on treatment modifications, and comprehensive compliance data to better understand their impact on BP control and cardiovascular outcomes.

In summary, our findings suggest that while medication management is crucial, a comprehensive approach that includes identifying high‐risk groups, managing weight and lipid levels, and addressing other cardiovascular risk factors is associated with better BP control outcomes in this population. While BP in low‐risk patients is more controllable, only a small fraction achieves stricter BP targets.

5. CONCLUSIONS

Patients who achieve stricter BP targets with fewer antihypertensive medications likely represent a subset with a lower risk profile. Notably, only a small fraction of patients on medication can easily maintain their BP below 130/80 mm Hg.

AUTHOR CONTRIBUTIONS

Yuqing Zhang and Zhanyang Zhou contributed to the conception and design of the work. Yuqing Zhang, Zhanyang Zhou, Huanhuan Miao, and Shijie Yang contributed to the acquisition, analysis, and interpretation of data for the work. Zhanyang Zhou drafted the manuscript. Yuqing Zhang, Zhanyang Zhou, Huanhuan Miao, Shijie Yang, Yingjun Chen, and Zheng Yin critically revised the manuscript. All gave final approval and agreed to be accountable for all aspects of work, ensuring integrity and accuracy.

CONFLICTS OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Zhou Z, Miao H, Yang S, Yin Z, Chen Y, Zhang Y. Optimal blood pressure control with fewer antihypertensive medications: Achieved mostly in low‐risk hypertensive patients. J Clin Hypertens. 2024;26:1284–1290. 10.1111/jch.14903

DATA AVAILABILITY STATEMENT

The data underlying this article will be shared on reasonable request to the corresponding author.