Research in context
Evidence before this study
We searched PubMed on Nov 26, 2022, using the search terms “nonphysician healthcare providers[Text Word]” OR “nurse[MeSH Terms]” OR “pharmacist[MeSH Terms]” OR “community health worker[MeSH Terms]” AND “antihypertensive treatment[MeSH Terms]” OR “blood pressure intervention[MeSH Terms]” AND “cardiovascular disease[MeSH Terms]” OR “myocardial infarction[MeSH Terms]” OR “stroke[MeSH Terms]” OR “heart failure[MeSH Terms]” AND “randomized controlled trial[Filter]”. We searched for randomised controlled trials on non-physician health-care provider-led blood pressure interventions on cardiovascular disease published between Jan 1, 1965 and Nov 26, 2022, with no language or date restrictions, and found no relevant publications. In addition, we searched for publications reporting results from randomised controlled trials on intensive blood pressure interventions (ie, systolic blood pressure target <130 mm Hg) on cardiovascular disease. The following search terms were used: “intensive blood pressure intervention[MeSH Terms]” OR “systolic blood pressure target <120 mm Hg[Text Word]” OR “systolic blood pressure target <130 mm Hg[Text Word]” AND “cardiovascular disease[MeSH Terms]” OR “myocardial infarction[MeSH Terms]” OR “stroke[MeSH Terms]” OR “heart failure[MeSH Terms]” AND “randomized controlled trial[Filter]”. We identified four randomised controlled trials that compared intensive blood pressure interventions with standard intervention. These trials were conducted in patients with lacunar stroke (the SPS3 trial) or type 2 diabetes (the ACCORD trial), those at high risk for cardiovascular disease (the SPRINT trial), or older patients aged 60–80 years (the STEP trial). Overall, among the four trials, there was a 20% reduction in the hazard of major cardiovascular disease (pooled hazard ratio [HR] 0·80; 95% CI 0·73–0·88; p<0·0001). There were no randomised controlled trials of intensive blood pressure interventions conducted in the general population with hypertension.
Added value of this study
To our knowledge, the China Rural Hypertension Control Project (CRHCP) is the first randomised controlled trial to test the effectiveness of a non-physician health-care provider-led hypertension control on cardiovascular disease outcomes. It is also the first randomised controlled trial to test the effect of an intensive blood pressure intervention on cardiovascular disease and mortality in the general population with hypertension. Non-physician health-care providers initiated and titrated antihypertensive medications based on a simple treatment protocol and were supervised by primary care physicians. They also delivered discounted and free medications to patients and conducted health coaching on lifestyle modification, home blood pressure measurement, and medicine adherence. In the intervention group, systolic blood pressure decreased from 157·0 mm Hg at baseline to 126·1 mm Hg at 36 months and diastolic blood pressure from 87·9 mm Hg to 73·1 mm Hg. The net group difference in blood pressure reduction was –23·1 mm Hg for systolic and –9·9 mm Hg for diastolic between two groups. The primary composite outcome of myocardial infarction, stroke, heart failure, or cardiovascular disease death was significantly reduced by 33% in the intervention group compared with the usual care group. The secondary outcomes also declined significantly in the intervention: there was a 23% reduction in myocardial infarction, 34% reduction in stroke, a 42% reduction in hospitalised heart failure, a 30% reduction in cardiovascular disease death, and a 15% reduction in all-cause death. The effect of blood pressure reduction on cardiovascular disease and all-cause mortality was consistent between older and middle-aged individuals, and between those at high risk and not at high risk for cardiovascular disease.
Implications of all the available evidence
Previous randomised controlled trials have reported that non-physician health-care provider-led interventions were effective in reducing blood pressure and improving hypertension control in low-resource populations. This study has added new evidence that a non-physician community health-care provider-led blood pressure intervention reduced cardiovascular disease and all-cause death. Furthermore, this study has provided novel evidence that an intensive blood pressure intervention reduced cardiovascular disease and all-cause mortality in the general population with hypertension. Evidence from this trial and previous trials in high-risk and older populations support a lower blood pressure target (ie, systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) for all patients with hypertension to further reduce cardiovascular disease and all-cause mortality. Moreover, this non-physician community health-care provider-led strategy, which has proven to be feasible and effective, could be scaled up in rural China and other low-resource settings to reduce blood pressure-related cardiovascular disease and all-cause death.