• Carole E Aubert, Jeremy B Sussman, Timothy P Hofer, William C Cushman, Jin-Kyung Ha, and Lillian Min.
• Center for Clinical Management Research at Veterans Affairs Ann Arbor Healthcare System and Institute for Healthcare Policy and Innovation at University of Michigan, Ann Arbor, Michigan, and Inselspital, Bern University Hospital and Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland (C.E.A.).
• Ann. Intern. Med. 2021 Dec 1; 174 (12): 1666-1673.

BackgroundThere are 2 approaches to intensifying antihypertensive treatment when target blood pressure is not reached, adding a new medication and maximizing dose. Which strategy is better is unknown.ObjectiveTo assess the frequency of intensification by adding a new medication versus maximizing dose, as well as the association of each method with intensification sustainability and follow-up systolic blood pressure (SBP).DesignLarge-scale, population-based, retrospective cohort study. Observational data were used to emulate a target trial with 2 groups, new medication and maximizing dose, who underwent intensification of their drug regimen.SettingVeterans Health Administration (2011 to 2013).PatientsVeterans aged 65 years or older with hypertension, an SBP of 130 mm Hg or higher, and at least 1 antihypertensive medication at less than the maximum dose.MeasurementsThe following 2 intensification approaches were emulated: adding a new medication, defined as a total dose increase with new medication, and maximizing dose, defined as a total dose increase without new medication. Inverse probability weighting was used to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months.ResultsAmong 178 562 patients, 45 575 (25.5%) had intensification by adding a new medication and 132 987 (74.5%) by maximizing dose. Compared with maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect, -15.2% [95% CI, -15.7% to -14.6%] at 3 months and -15.1% [CI, -15.6% to -14.5%] at 12 months) but a slightly larger reduction in mean SBP (-0.8 mm Hg [CI, -1.2 to -0.4 mm Hg] at 3 months and -1.1 mm Hg [CI, -1.6 to -0.6 mm Hg] at 12 months).LimitationObservational data; largely male population.ConclusionAdding a new antihypertensive medication was less frequent and was associated with less intensification sustainability but slightly larger reductions in SBP. Trials would provide the most definitive support for our findings.Primary Funding SourceNational Institute on Aging and Veterans Health Administration.

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