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14th February 2022
The use of anti-hypertensive drugs when combined with healthy lifestyle measures appears to be the best strategy to reduce all-cause and cause-specific mortality. This is according to a study by Chinese researchers from the Department of Epidemiology and Biostatistics, School of Public Health, Huazhong University of Science and Technology, Hubei, China.
Hypertension significantly increases the risks of heart, brain, kidney and other diseases and according to the World Health Organisation, an estimated 1.28 billion adults aged 30-79 years worldwide have hypertension, most of whom are living in low- and middle-income countries. Furthermore, a 2019 analysis calculated that a high systolic blood pressure accounted for approximately 10·8 million deaths which was 19.2% of all recorded deaths in 2019. Hypertension is managed with a range of different classes of medicines, yet non-adherence to anti-hypertensive treatment affects 10%–80% of hypertensive patients and is one of the key drivers of suboptimal BP control. With respect to lifestyle modification, there is strong evidence supporting the benefits of regular physical activity and exercise for the prevention and management of hypertension. However, whether the combination of anti-hypertensive medication and healthy lifestyle measures yields additional benefits and if adoption of healthy lifestyle measures after a diagnosis of hypertension provides a mortality benefit remains uncertain.
For the present study, the Chinese team examined the relationship between anti-hypertensive use and lifestyle measures and the effect of this on all-cause and cause-specific mortality among hypertensive patients. They used data from the Dongfeng-Tongji cohort, which prospectively followed hypertensive patients for a median of 7.3 years. The team assessed specific lifestyle factors including body mass index, smoking status, diet, physical activity and sleep duration and computed an overall lifestyle score based on these five attributes, with higher scores (ranging from 0 to 10) indicating a healthier lifestyle. In addition, participants were categorised into the following subgroups: favourable lifestyle (scores 8 – 10), intermediate (5- 7) and unfavourable (0 – 4). The use of anti-hypertensive medication was dichotomised into yes or no.
Anti-hypertensive use and subsequent mortality
A total of 14,392 participants with a mean age of 65.6 years (50.6% male) using anti-hypertensive medicines were included in the analysis. Over a median of 7.3 years, there were 2015 deaths including 761 due to cardiovascular disease and 525 from cancer. Taking individuals not using anti-hypertensives and following an unfavourable lifestyle as the reference group, individuals using anti-hypertensives and with a favourable lifestyle had the lowest risk of all-cause mortality (hazard ratio, HR = 0.32, 95% CI 0.25 – 0.42). This was also true for cardiovascular mortality (HR = 0.33) and death due to cancer (HR = 0.30).
Interestingly, when using the same reference group, individuals who were not using anti-hypertensives but adopted a favourable lifestyle, also had a lower risk of all-cause mortality (HR = 0.34), cardiovascular (HR = 0.40) and cancer mortality (HR = 0.33). In fact, there was a linear association with lifestyle score and mortality, such that regardless or anti-hypertensive medication use, each 1-point increase in lifestyle score was associated with a 17% lower risk of all-cause mortality, with similar reductions for cardiovascular and cancer deaths.
There was also a reduced mortality risk through the adoption of lifestyle measures after a diagnosis of hypertension. For example, compared to those with a consistently low lifestyle score between baseline and the first follow-up, those who instigated a change in lifestyle score from low to high also had a significantly reduced risk for all-cause (HR = 0.52), cardiovascular (HR = 0.53) mortality although the reduced risk of cancer mortality was non-significant.
The authors concluded that the combined effect of anti-hypertensive medication and adoption of a healthy lifestyle resulted in a significantly reduced risk of all and specific cause mortality.
Lu Q et al. Association of Lifestyle Factors and Antihypertensive Medication Use With Risk of All-Cause and Cause-Specific Mortality Among Adults With Hypertension in China JAMA Netw Open 2022