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Cardiovascular risk: who should we treat, and how much should we stratify?
  1. Anushka Patel
  1. A/Professor Anushka Patel, Cardiovascular Division, The George Institute For International Health, University of Sydney, PO Box M201, Missenden Road, NSW 2050, Australia; apatel{at}george.org.au

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Over the past decade, there has been a fundamental shift in the clinical paradigm for cardiovascular disease prevention, away from an approach based on defining and managing single risk factor abnormalities, and towards basing the need for and intensity of risk factor management on an evaluation of an individual’s future risk of experiencing a cardiovascular event. This “absolute risk” approach is rooted in an understanding of the nature of the association between key modifiable risk factors, such as blood pressure and cholesterol, and the occurrence of vascular events. In a range of diverse populations, these associations have been shown to be continuous, such that no obvious threshold value can be identified that clearly defines abnormal levels of blood pressure or cholesterol.14 Furthermore, these associations have been shown to be log-linear, suggesting that the relative benefits from a given reduction in blood pressure or cholesterol is likely to be similar, regardless of the initial level of that risk factor.14 This in turn provides a basis for expecting the absolute benefits of treatment to be greatest among those at highest initial risk of a cardiovascular event, rather than necessarily in those with the highest initial level of a particular risk factor. So, for example, one might expect that a 60-year-old smoking male with diabetes and a systolic blood pressure of 135 mm Hg will benefit more, in absolute terms, from being administered a blood-pressure-lowering drug than a 50-year-old non-smoking, non-diabetic woman with a systolic blood pressure of 160 mm Hg. These epidemiological principles have been supported by …

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