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Sensitivity analysis

Implemented on the same population of potentially eligible individuals, the scenario with the lowest level of evidence according to the 2013 ESH/ESC guidelines, i.e., the opinion-based scenario, dramatically amplified the NES among the lowest risk individuals with 1472-fold more women to treat under the age 45 years, whereas the evidence-based scenario reduced to less than a half the NES among the oldest men and women compared to the 2007 guidelines (results not shown). In individuals of both sexes younger than 55 the NES was amplified by three under the opinion-based scenario, and virtually maintained by the evidence-based scenario, compared to the 2007 ESH/ESC guidelines. The LYG under the opinion-based scenario was 1,5-fold the LYG expected under the 2007 guidelines before the age 55 years; whereas in individuals aged 55 years and older the evidence-based scenario reduced this gain to one-third the LYG expected under the 2007 guidelines. The proportion of benefit, i.e. the relative life-year gain, was augmented in individuals younger than 55 years in the opinion-based scenario and reduced by more than two thirds at ages over 55 years in the evidence-based scenario, compared to the 2007 guideline version. The overall proportion of benefit from the 2007 guidelines was halved by the 2013 guidelines evidence-based scenario and increased by the opinion-based scenario (Table 2). The residual number of events was globally increased with the evidence-based scenario and decreased with the opinion-based scenario compared with the 2007 guidelines. The number needed to treat to gain a life-year over 10 years of drug treatment was greater under the 2013 guidelines disregarding the level of evidence of the scenario adopted compared to either the 2007 guidelines or the PB strategy (Table 2).

Discussion

We propose a strategy whose benefit is proportional to the specific events incidence within each category of gender and age of a population, addressing the issue of the inequity induced by the high-risk approach with a number of practical consequences. The PB strategy reduced the sex-related benefit ratios at all ages, reflecting the actual differences on CVD incidence rates between men and women. The age-related gradient of benefit was abolished under the PB strategy. Identifying the treatment target population from the incidence rates of cardiovascular death, which are easily available from vital statistics in most of countries, appears more natural and fair than the gender or generation preferences induced by the application of absolute risk thresholds arbitrarily determined. The sensitivity analysis illustrates how simulation allows measuring the impact of recommendations. We have shown how the 2013 ESH/ESC evidence-based scenario reduces treatment coverage and benefits in elderly patients in the mild hypertensive range, in contrast to decisions based on the opinion of experts, which maintain rates of residual events at levels that are similar to the 2007 guideline version.

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