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Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study

BMJ 2015; 350 doi: (Published 05 February 2015) Cite this as: BMJ 2015;350:h158
  1. Wenxin Xu, resident physician1,
  2. Saveli I Goldberg, researcher2,
  3. Maria Shubina, biostatistician3,
  4. Alexander Turchin, director of informatics research3
  1. 1Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
  2. 2Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
  3. 3Division of Endocrinology, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115, USA
  1. Correspondence to: A Turchin aturchin{at}
  • Accepted 9 December 2014


Objectives 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.

Design Retrospective cohort study.

Setting Primary care practices in the United Kingdom, 1986-2010.

Participants 88 756 adults with hypertension from The Health Improvement Network nationwide primary care research database.

Main outcome measures 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.


  • Contributors: AT, SIG, MS, and WX made substantial contributions to the study concept and design. WX and SIG did the statistical analysis. WX drafted the manuscript. All authors were involved in interpretation of data and critical revision of the manuscript. AT is the guarantor.

  • Funding: This study was funded by the Harvard Medical School Center for Primary Care. This organization had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. All researchers acted independently of funders.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no financial support from any third party organization for the submitted work; no relationships with companies that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the Partners HealthCare System institutional review board (protocol # 2010P002806). A waiver was obtained for the requirement of written informed consent.

  • Transparency: The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Data sharing: Full dataset and statistical code are available from the corresponding author at aturchin{at} Consent was not obtained from individual participants, as the data are anonymized and the risk of identification is minimal.

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