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Tailored community intervention lowers cardiovascular risk in patients with hypertension

HOPE 4 study presented in a Hot Line Session today at ESC Congress 2019 together with WCC


Paris, France – 2 Sept 2019: An intervention tailored to communities and delivered by non-physician health workers reduced cardiovascular risk over one year in patients with new or poorly controlled hypertension in Colombia and Malaysia. The late breaking results from the HOPE 4 study are presented in a Hot Line Session today at the ESC Congress 2019 together with the World Congress of Cardiology (1) and published in the Lancet.(2)

Lead author, Dr Jon-David Schwalm of the Population Health Research Institute, McMaster University, Hamilton, Canada said: “The reduction in cardiovascular risk was 75% greater in the intervention group because we developed a comprehensive model of care that addressed multiple barriers to implementation. The intervention integrated efforts by the patient, their family or friends and their primary care physician but was led by non-physician health workers. There was a doubling in blood pressure control, reductions in low-density lipoprotein (LDL) cholesterol, and improvements in medication adherence, physical activity, and diet.”

Hypertension is the leading cause of cardiovascular disease worldwide, with the majority of the burden in low- and middle-income countries. Despite clear benefits and recommendations for the use of antihypertensive medications and statins in patients with hypertension, control of blood pressure and use of statins is very low.

Dr Schwalm said: “Previous studies with non-physician health workers led to modest effects on cardiovascular risk factors. We tested whether an intervention involving health workers, GPs, and family, with provision of evidence-based medications, can safely and substantially reduce individual cardiovascular risk.”

HOPE 4 was a community-based cluster randomised controlled trial including 1,371 patients aged 50 and older with new or poorly controlled hypertension from 30 communities in Colombia and Malaysia. (3) Sixteen communities were randomised to usual care (control group) and 14 communities were randomised to a multifaceted intervention for one year.

The intervention entailed:

  1. community screening to detect those with new or poorly controlled hypertension; 
  2. initiation and monitoring of treatments and controlling multiple risk factors by non-physician health workers using tablet-based management algorithms and counselling; 
  3. free antihypertensive and statin medications recommended by non-physician health workers under supervision  by physicians; 
  4. a treatment supporter (friend or family member) to enhance adherence to medications and lifestyle advice.

Tablets were used to collect data for the study (which was subject to quality control checks); support health worker counselling on health behaviours; and for health worker decision support at the point of care with simplified management algorithms to initiate and up-titrate antihypertensives and statins.

Treatment supporters were encouraged to attend each encounter with a health worker or physician and were present at 74% of visits. In addition, their role was to give ongoing help to improve adherence to medications and healthy behaviours between scheduled non-physician health worker visits.

The primary outcome was change in Framingham Risk Score (an estimate of the ten-year risk of cardiovascular disease) from baseline to 12 months. In the intervention arm, the Framingham Risk Score estimate was reduced by an absolute 11.2% at 12 months (relative risk reduction of 34.2%, p<0.001); which corresponds to a 75% greater reduction when compared to control (absolute risk reduction in control group = -6.4%, p<0.001).

There was an absolute 11.5 mmHg greater reduction in systolic blood pressure, and a 0.4 mmol/L larger reduction in serum LDL cholesterol in the intervention group, compared to the control group (both statistically significant). The proportion of patients with controlled hypertension was significantly higher, and more than twice as great, in the intervention group (69%) compared to the control group (31%).

There was a trend to benefit for most health behaviours in the intervention arm, resulting in significantly greater reductions in the INTERHEART Risk Score at six and 12 months. In particular, there were important improvements in physical activity and diet.

“All components of the intervention were essential to the benefits observed,” Dr Schwalm added. “Our intervention is innovative in how, by taking a systems approach, it is more than the sum of its parts. It was informed by a detailed health system assessment and barrier analysis in each country, using a combination of quantitative and qualitative research, to identify local challenges and tailor the intervention.”

Principal investigator Professor Salim Yusuf commented: “This strategy is pragmatic, effective, and scalable, and has the potential to substantially reduce cardiovascular disease globally, compared to current methods that are solely physician based. Adopting the HOPE 4 strategy to better control hypertension and reduce other risk factors could help achieve the United Nations’ target for a one-third reduction in premature cardiovascular mortality by 2030.” 


Notes to editor

Notes to editors

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Funding: This work was supported by (1) the Canadian Institutes of Health Research (CIHR), Grand Challenges Canada (GCC) as part of the Global Alliance for Chronic Disease program [CIHR grant number: 120389; GCC grant numbers: 0069-04 and 0070-04]; (2) CIHR’s Strategy for Patient Oriented Research, through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care; (3) an unrestricted grant from Boehringer Ingelheim; (4) the Department of Management of non-communicable diseases, World Health Organization; (5) the Santander Departmental Secretary of Health, Bucaramanga, Colombia; and (6) the Population Health Research Institute. This research program does not represent the official view of the GACD, WHO, or any part of the Colombian or Malaysian Federal Governments. No official support or endorsement of this article by the GACD hypertension program, WHO, or Federal Governments of participating countries is intended or should be inferred.

Disclosures: No conflicts of Interest to declare.

References and notes

(1) HOPE 4 will be discussed during:

(2) Full paper will be available during congress from

(3) Schwalm JR, McCready T, Lamelas P, et al. Rationale and design of a cluster randomized trial of a multifaceted intervention in people with hypertension: The Heart Outcomes Prevention and Evaluation 4 (HOPE-4) Study. Am Heart J. 2018;203:57–66. doi: 10.1016/j.ahj.2018.06.004.

About ESC Congress

ESC Congress is the world’s largest gathering of cardiovascular professionals contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2019 together with the World Congress of Cardiology takes place from 31 August to 4 September at the Expo Porte de Versailles in Paris, France. Explore the scientific programme.

About the European Society of Cardiology 

The European Society of Cardiology brings together health care professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

This press release accompanies both a presentation and an ESC press conference at ESC Congress 2019 together with the World Congress of Cardiology. It does not necessarily reflect the opinion of the European Society of Cardiology.