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For many years decisions to treat or not treat hypertension with drugs were made considering the level of blood pressure alone. There was vigorous debate over whether patients should be treated at diastolic pressures of 110, 100, 90 mm Hg or some other threshold. However, epidemiological studies show that the risk of cardiovascular complications such as stroke or myocardial infarction is not determined by blood pressure alone, but is strongly influenced by other major risk factors such as age, sex, smoking habit, lipid concentrations, diabetes, target organ damage such as left ventricular hypertrophy (LVH), and established vascular disease such as angina or myocardial infarction.1 Furthermore clinical trials have shown that the absolute risk of cardiovascular disease (CVD) determines the chance of benefit from antihypertensive treatment.2 In 1995 a New Zealand guideline development group turned this knowledge into practice and recommended that treatment of hypertension should be determined by absolute cardiovascular disease risk and not blood pressure thresholds alone.3 Since then most international and national guidelines have embraced the principle of targeting antihypertensive drug treatment at absolute CVD risk, although the details and methods of estimating CVD risk differ greatly between guidelines. In the UK the British Hypertension Society and Joint British Societies (which include cardiology, lipid, hypertension, and diabetes specialist groups) have developed guidelines for the management of uncomplicated mild hypertension according to estimated absolute coronary heart disease (CHD) risk.4,5 This means that hypertension guidelines and guidelines for statins and aspirin in primary prevention cannot be implemented without a working knowledge of the estimation of absolute CHD or CVD risk. This article discusses the principle and practice of using absolute CVD or CHD risk for decisions on antihypertensive treatment.
▸ IMPORTANCE OF ABSOLUTE RISK IN HYPERTENSION
Hypertension is consistently associated with an increased risk of cardiovascular complications, including stroke, myocardial infarction, heart …