The 2023 HF absolute risk guidelines provide state-of-the-art guidance on who to treat with blood pressure (BP) lowering and low density lipoprotein cholesterol (LDL-C) lowering drugs, but not how to treat. At present, BP and cholesterol control rates are poor among those treated, highlighting the need for improved prescribing of effective therapies. Our current approach depends on clinicians personalising treatment for each patient by measuring serial BP and cholesterol levels. However, fluctuations in BP and cholesterol levels are largely random because both are intrinsically variable and subject to significant measurement error. It becomes very difficult to quantify true treatment response for a given individual, meaning clinicians can be misled by random fluctuations in measurement values. This issue is further compounded by therapeutic inertia and confirmation bias: When BP and cholesterol measures are high, clinicians choose to ‘watch and wait’ or remeasure 80-90% of the time. However, when a measure is at target, patients are classified as ‘controlled’ - a form of confirmation bias.
There are two radically different approaches to this problem. On one hand, we could improve the number and quality of measurements: if clinicians have more faith in the accuracy of measures, they will be more confident in acting on them. Another approach is to prescribe treatments that have been shown to be efficacious enough to achieve desired targets based on randomized trial data. This will avoid the need for serial risk factor measures. We have recently quantified the BP and LDL-C lowering efficacy of all antihypertensives and lipid lowering drugs based on all double-blind placebo controlled randomized trials and created a clinical application tool that generates the average efficacy for any drug regimen. This project aims to test two radically different strategies: 1) a measurement intensive approach where patients and clinicians have access to gold-standard home, ambulatory BP monitors and serial lipid measurements and 2) a measurement-reduced, empirical approach to treat BP and LDL-C that relies on trial evidence to inform which regimen to prescribe.
Last updated14 October 2025