Treating Mild Chronic Hypertension During Pregnancy: A Cost-Effectiveness Analysis

I appreciate every time a cost-effectiveness analysis is undertaken. I question, however, whether some of the conclusions reached can be appropriately extrapolated from the base article. In the April 2024 issue of Obstetrics & Gynecology, Doshi et al assert a decreased incidence of preeclampsia with and without severe features in chronic hypertension in pregnancy with a blood pressure target of lower than 140/90 compared with lower than 160/105.1 The CHAP (Chronic Hypertension and Pregnancy) trial listed as a core part of its primary composite outcome development of preeclampsia with severe features, importantly, without classifying severe hypertension alone as preeclampsia.2 The primary outcome did demonstrate a favorable risk ratio in the experimental group. A secondary outcome of preeclampsia with and without severe features was broken down into components, one of which was nonsevere preeclampsia. The treatment effect on this outcome crossed unity.2 As such, it is inappropriate to expect a decrease in the number of cases of nonsevere preeclampsia with the experimental regimen suggested in the CHAP trial, and cost efficacy must be revised. This also brings forward the more fundamental underlying issue of the definition of preeclampsia. The current definition relies on hypertension and proteinuria.3,4 It is known that the research base for superimposed preeclampsia on chronic hypertension is poor. It remains inherently problematic to define a disease state by a variable that is being actively manipulated, particularly when the disease in question (preeclampsia in general) is only partly associated with the nominal end state of the disease.