The Health Outcomes Prevention and Evaluation 4 (HOPE 4) project: A successful community-based intervention to lower cardiovascular risk in people with hypertension

Cardiovascular disease is the most common cause of death in the world, and hypertension is the most common risk factor for cardiovascular disease. Despite proven benefits of antihypertensive treatment, hypertension control is poor in most countries, particularly low-income and middle-income countries [1]. Therefore, there are good reasons to pay attention to randomised controlled trials suggesting that improvements in hypertension control can be achieved. The Health Outcomes Prevention and Evaluation 4 (HOPE 4) project was started in 2013 and the results show that major reductions in cardiovascular risk can be achieved in people with hypertension with a relatively simple community-based intervention [2].

HOPE 4 was an open, cluster-randomised control trial that enrolled 1371 persons with poorly controlled or newly diagnosed hypertension living in 30 townships in Columbia and Malaysia. Sixteen of these communities with 727 persons were randomised to usual care, and 14 communities with 644 persons were randomised to intervention. The intervention was a model of care involving two new aspects: first, a counselling by non-physician health workers under supervision of primary care physicians using a simplified treatment algorithm, and second, a support from one family member or friend. In addition, effective and free antihypertensive medications and statins were provided, along with additional efforts to improve adherence and maintain a healthy life style. The control population received relevant written information and were recommended to see their local health care providers as usual. At 12 months follow-up, the intervention populations had reduced their Framingham Risk Score for 10-year cardiovascular disease by –4.78% (95% CI –7.11 to –2.44, p < .0001) more than the control population. There was a 11.45 mmHg (95% CI –14.94 to –7.97) greater reduction in systolic blood pressure, and a 0.41 mmol/L (95% CI –0.60 to –0.23) greater reduction in LDL cholesterol in the intervention group (both p < .0001). Change in blood pressure control status to <140 mmHg was achieved by 69% in the intervention group compared to 30% in the control group (p < .0001). The investigators found no safety concerns.

The Health Outcomes Prevention and Evaluation 4 (HOPE 4) project thus showed that a model of care led by non-physician health workers, supervised by primary care physicians, but also involving family members of the study participants and free medication, substantially improved cardiovascular risk and blood pressure control in the community. The strategy was seen as effective, pragmatic, and with the potential to substantially reduce the burden of cardiovascular disease compared with current strategies that are typically physician based. The medications provided to lower cholesterol were generic atorvastatin 20 mg or rosuvastatin 10 mg, and the blood pressure medications were also generic and given as single pill two component combinations at half or full doses. Components were the guidelines recommended first line medications, namely angiotensin converting enzyme inhibitor or angiotensin receptor blocker, thiazide diuretic or calcium channel blocker [3].

The HOPE 4 findings suggest that reduction in cardiovascular risk may be achieved with simple and inexpensive means. The approach of involving counselling by non-physician health workers and educating family members to support people with high cardiovascular risk should be supported. Inexpensive generic medication may be provided and drug persistence secured through this supportive network.

Sverre E. Kjeldsen
Department of Cardiology, University of Oslo,
Ullevaal Hospital, Oslo, Norway
[email protected]
Krzysztof Narkiewicz
Department of Hypertension and Diabetology,
Medical University of Gdansk, Poland

Michel Burnier
Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Suzanne Oparil
Vascular Biology and Hypertension Programme, Department of Medicine, University of Alabama at Birmingham, AL, USA

Disclosure statement

No potential conflict of interest was reported by the authors.