Cardiovascular Disease

1. Impact of Early Hypertension
Control on CV Events in Adults
with Type 2 Diabetes
Patrick J. O’Connor MD MA MPH1, Gabriela Vazquez-Benitez Ph.D. 1,
Julie A. Schmittdiel Ph.D.2, Emily D. Parker Ph.D. 1, Nicole K. Trower BS1,
Jay R. Desai MPH1 , Karen L. Margolis MD MPH1, David J. Magid MD MPH3
1HealthPartnersResearch Foundation, Minneapolis, MN;
2Kaiser Permanente of Northern California, Oakland, CA
3Kaiser Permanente of Colorado, Denver, CO; Division of Research,

2. Duality of Interest: Dr. O’Connor
• No duality of Interest
• Funded by AHRQ HHSA 290-2005-0033-I

3. Significance
• About 70% of T2DM patients have
hypertension
• Uncontrolled BP control increases risk of both
macro and micro complications
• Timing of BP control has not been well studied
• Debate between BP < 130/80 versus < 140/90
• Time lag from control to benefit not very well
defined

4. Design, Study Sites, Data Sources
• Retrospective Cohort Study
• 3-HMO sites: KP Colorado, KP Northern
California, HealthPartners
• CVRN Hypertension Superset
• Years of Data: 2003-2009
• Used about 10 Data Tables:
demo, vitals, Dx, Rx, diagnoses, enrollment, ut
ilization, etc.

5. Study Subjects
• Age 30-74 years
• Already have T2DM, then get new-onset HT
• No CHD or CeVD at date of HT onset
• HT Onset Date= Second of 2+ consecutive
dates with elevated EBP
• Must have >1 yr follow up after hypertension
onset; AND >= 2 BP measures within 12
months of HT onset date

6. Blood Pressure Measures: Within
12 months of HT Onset Date
• Hypertension control status:
mean of all (2+) SBP/DBP measures within the first year
a. SBP < 130 AND DBP < 80
b. SBP >= 140, OR DBP >= 90
c. Else SBP 130-139 and DBP 80-89
• Hypertension recognition: was there 1+ HT
diagnosis code (401.xx) within first year
• Hypertension treatment initiation: 1+ fills for HT
medication within the first year
• Systolic BP at HT onset (mean of 2 SBP measures)

7. Covariate Definitions
• 10-Year Framingham CV risk score (FRS)
(D’Agostino 2008)
• Diabetes Microvascular severity score
• Count of common diabetes complications based
on ICD-9 codes (Young, et al @GHC, AJMC 2008)
• Risk factors (age, gender, race, BMI, smoking,
HDL, Total Cholesterol)

8. Outcome Definitions
Major CV events ascertained using inpatient
claims data from 1 year after HT onset date to
censoring date (mean of 38 months follow-up)
Major CV Events Included:
• Acute myocardial infarction (410.xx)
• Cerebrovascular event (430.xx-434.xx, 436.xx)

9. Analysis Plan
• Consistency of data across sites was assessed
• Age adjusted incident CV event rates in 38
month follow-up period by categories of BP
control, HT identification, and HT Treatment
within 12 months of HT Onset
• Incidence Rate Ratio of BP control defined as
– <130/80 vs. >= 130/80 mmHg
– 140/90 vs. >= 140/90 mmHg
Adjusting for FRS, micro complication score, and site

10. Diabetes with Incident hypertension cohort
based on study exclusion criteria

11. Table 1. Characteristics of patients with diabetes and new
onset hypertension (HT) classified by BP status in the 12-month
after HT date of onset.*
Characteristic <130/80 mmHg 130-140 /80-90 >=140/90 mmHg
mmHg
Number of Subjects 5158 7409 3098
Mean age at baseline± SD, years 51.2 10.5 51.2 10.3 53.0 10.4
Female 51.3% 42.5% 39.7%
Lipids-Framingham Risk Categories†
<10% 35.0% 29.3% 16.8%
10-19% 36.1% 37.9% 34.8%
20+% 28.9% 32.9% 38.4%
Microvascular diabetes complications at baseline††
None 74.0% 80.5% 80.2%
Mean SBP at onset ± SD, mmHg 133.1 + 8.5 135.9 + 8.5 145.3 + 10.8
Mean SBP w 1 yr HT onset ± SD, mmHg 122.2 + 5.4 131.7 + 5.5 145.9 + 8.4
A1c %
<7% 48.5% 46.6% 44.1%
7-7.9% 20.2% 21.5% 22.3%
8+% 25.5% 26.4% 30.4%
Not Available 5.7% 5.5% 3.2%

12. Table 2. Rates of hypertension recognition, hypertension treatment initiation and BP
control status within 12-months of HT onset in patients with diabetes and incident
hypertension. Incident hypertension was based on two or more consecutive BP
measures >= 130/80 mmHg.
Systolic BP Number Percent with Percent Percent with specified BP Status in the 12 month
Status at of HT Started on period after date of HT onset*
Time of HT Subjects Recognition HT
Onset (mmHg) (diagnosis Medications
Code) within Within 12 <130/80 130-140/80-90 ≥140/90 mmHg
12 months of Months of mmHg mmHg
HT onset HT onset
<130** 2,821 13.1 25.1 49.5 45.8 4.6
130-139 6,643 21.2 34.7 38.1 52.5 9.4
≥140 6,201 46.1 53.6 19.9 42.4 37.8
Overall 15,665 29.6 40.5 32.9 47.3 19.8
*Based on a median of 4 BP measures per patient in the 12-month period.
**Subjects classified as hypertensive with SBP < 130 mmHg had DBP >= 80 mmHg

13. Table 3. Age adjusted rates of Major CV Events per 1000 person years as a function of baseline
BP status, BP control status in the 12 months after hypertension (HT) onset, BP medication
initiation in the 12-months after hypertension onset, and hypertension recognition in the 12
months after hypertension onset.
Characteristics Cerebrovascular Event Acute Myocardial Total Major
Infarction Cardiovascular Event*
2.76(2.34-3.26) 3.37(2.90-3.92) 5.90(5.26-6.62)
Mean SBP at HT onset
<130 3.16(2.10-4.76) 2.05(1.24-3.40) 5.10(3.69-7.04)
130-139 2.17(1.62-2.90) 2.22(1.67-2.96) 4.27(3.47-5.25)
140+ 2.54(1.95-3.31) 4.34(3.27-5.71) 6.94(5.57-8.64)
p-value 0.33 <.0001 .004
Blood pressure status in the first
year after HT onset
<130/80 2.11(1.51-2.94) 2.76(2.06-3.71) 4.75(3.80-5.95)
130-139/80-89 2.50(1.93-3.23) 2.76(2.16-3.52) 5.02(4.19-6.02)
140+/90+ 3.01(2.17-4.19) 4.32(3.27-5.71) 6.94(5.57-8.64)
p-value 0.31 0.03 0.03
HT treatment initiation in the first
year
Yes 2.62(2.01-3.42) 3.42(2.70-4.32) 5.77(4.82-6.92)
No 2.40(1.90-3.03) 2.89(2.34-3.51) 5.07(4.32-5.96)
p-value 0.60 0.28 0.27
HT recognition in the first year
Yes 2.54(1.87-3.45) 3.26(2.48-4.28) 5.46(4.42-6.73)
No 2.46(1.98-3.05) 3.03(2.50-3.68) 5.31(4.58-6.15)
p-value 0.86 0.83 0.66
Rates were calculated using Poisson regression model with age centered at the mean of the population; p-values
correspond to type 3 likelihood ratio statistics.
*Total major cardiovascular events include myocardial infarction, hemorrhagic stroke, and thrombotic stroke.

14. Rate Ratios (95% CI ) for Cerebrovascular Event (CeVD), Acute Myocardial Infarction
(MI) and Total Major Cardiovascular Events (Any) estimated based on mean BP in the
12-month period after hypertension of: (a) above versus below 130/80 mmHg, and
(b) above versus below 140/90 mmHg

15. Conclusions—1
• BP control to < 140/90 mmHg within 12
months of HT Onset date was associated with
significantly lower rates of Total CV Events and
MI within a mean f/u period of 38 months.
• BP control to < 130/80 mmHg did not show
benefits that were as significant.
• Early BP control within 1 year of HT onset may
provide important clinical benefits to patients
in a relatively short period of time.

16. Conclusions—2
• Patients with higher baseline FRS or
microvascular complications index (more
severe DM) had a greater absolute (but not
relative) risk reduction in number of CV events
prevented by early BP control.
• However, the difference was not statistically
significant
• Larger or longer study needed to fully resolve

17. Conclusions—3
• Many patients with new onset HT returned to
normal BP levels in absence of a HT diagnosis
or HT medications.
• It may be that some of this related to lifestyle
changes, but other possibilities include:
– Accuracy and consistency of BP measures
– Need to revise diagnostic criteria for HT to require
more elevated BP readings, or higher BP readings.

18. More Information?
Please Contact:
Patrick.j.oconnor@healthpartners.com