Trial Design Can't Detect Heterogeneity in Hypertension Treatments

Clinically important heterogeneity in intensive BP treatment remains undetectable in conventional trial designs but can be detected in sequential randomization trial designs.
Clinically important heterogeneity in intensive BP treatment remains undetectable in conventional trial designs but can be detected in sequential randomization trial designs.

(HealthDay News) — Conventional clinical trials are unable to detect clinically important heterogeneity in intensive blood pressure (BP) treatment effects, according to a modeling study published online in the Annals of Internal Medicine.

Sanjay Basu, MD, PhD, from Stanford University in Palo Alto, Calif., and colleagues performed a theoretical modeling study in a population of US adults to identify whether large, clinically important differences in benefit and harm can be hidden among patients (heterogeneous treatment effects [HTEs]) in BP trials. The authors used data from 2 trials comparing standard with intensive BP treatment and from the National Health and Nutrition Examination Survey 2013 to 2014.

The researchers found that in base-case analysis, clinically important HTEs could explain the differences in outcomes between 2 trials of intensive BP treatment, with decreasing benefit with each additional agent (adding a second agent reduces cardiovascular disease risk, but adding a fourth agent had no benefit) and increasing harm at low BP. In sensitivity analyses, despite large samples, conventional treat-to-target trial designs had poor power to detect HTEs (<5%), and produced biased estimates. Despite small samples, a trial with sequential randomization to more intensive therapy achieved greater than 80% power and unbiased HTE estimates.

"Clinically important heterogeneity in intensive BP treatment effects remains undetectable in conventional trial designs but can be detected in sequential randomization trial designs," the authors write.

Reference

  1. Basu S, Sussman JB, Hayward RA. Detecting Heterogeneous Treatment Effects to Guide Personalized Blood Pressure Treatment: A Modeling Study of Randomized Clinical Trials. Ann Intern Med. 3 January 2017. doi: 10.7326/M16-1756.

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