Article Text

CARDIOVASCULAR AND CORONARY RISK ESTIMATION IN HYPERTENSION MANAGEMENT
Free
  1. Erica J Wallis,
  2. Lawrence E Ramsay,
  3. Peter R Jackson
  1. Correspondence to:
    Dr Erica Wallis, Section of Clinical Pharmacology and Therapeutics, Floor L, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK;
    e.j.wallis{at}sheffield.ac.uk

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

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 …

View Full Text

Supplementary materials

  •  
    Cardiovascular and Coronary Risk Estimation in Hypertension Management
    Erica J Wallis, Lawrence E Ramsay and Peter R Jackson
     

    Publisher's Correction

    Figure 4 Summary of recommendations in the British Hypertension Society
    guidelines for targeting of antihypertensive treatment

    There is a minor error published in Figure 4. The top right box should state "< 135/85"
     

    The error is much regretted

  •  
    Cardiovascular and coronary risk estimation in hypertension management
    Erica J Wallis, Lawrence E Ramsay, and Peter R Jackson
     

    Web-only References

    [View as PDF]

    Staessen J, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhäger WH, et al for the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Randomised double-blind comparison of placebo and active treatment of older patients with
    isolated systolic hypertension. Lancet 1997;350:757-764.

    Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L, Potter JF, Poulter NR, Russell G. Guidelines for the
    management hypertension: report of the third working party of the British Hypertension Society. J Hypertens1999;13:569-592.

    Ramsay LE, Haq IU, Yeo WW, Jackson PR. Interpretation of prospective trial in hypertension: do treatment guidelines
    accurately reflect current evidence? J Hypertens 1996;14(suppl 5):S187-S194.

    Ramsay LE, Wallis EJ, Yeo WW, Jackson PR. The rationale for differing national recommendations for the treatment of
    hypertension. Am J Hypertens 1998;11:79S-88S.

    Egger M, Davey Smith G. Risks and benefits of treating mild hypertension: a misleading meta-analysis? J Hypertens 1995;13:813-815.

    Neaton JD, Grimm RH, Prineas RJ, Stamler J, Granditis GA, Elmer PJ et al for the Treatment of Mild Hypertension Study
    Group. Treatment of Mild Hypertension Study. Final results. JAMA 1993;270:713-724.

    Alderman MH, Lamport B. Labelling of hypertensives: a review of the data. Clin Epidemiol 1990;43:195-200.

    Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on
    cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med
    2000;342:145-153.

    PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105
    individuals with previous stroke or transient ischaemic attack. Lancet 2001;358:1033-1041.

    Hingorani AD, Vallance P. A simple computer program for guiding management of cardiovascular risk factors and prescribing.
    BMJ 1999;318:101-105.

    Guidelines Subcommittee. 1999 World Health Organization - International Society of Hypertension guidelines for the
    management of hypertension. J Hypertens 1999;17:151-183.

    Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The Sixth Report of the Joint
    National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413-2446.

    Haq IU, Ramsay LE, Yeo WW, Jackson PR, Wallis EJ. Is the Framingham risk function valid for Northern European
    populations? A comparison of methods for estimating absolute coronary risk in high-risk men. Heart 1998;81:40-46.

    Menotti A, Puddu PE, Lanti M. Comparison of the Framingham risk function-based coronary chart with risk function from and
    Italian population study. Eur Heart J 2000;21:365-370.

    Anand SS, Yusuf S, Vuksen V et. al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic
    groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE). Lancet 2000;356:279-84.

    Haq IU, Wallis EJ, Yeo WW, Jackson PR, Ramsay LE. The impact of ambulatory blood pressure on estimation of
    cardiovascular risk in mild hypertension. British Hypertension Society, Bristol. J Hypertens 1997;15:1540-1541.

    Johannesson M. Cost-effectiveness of hypertension treatment in Sweden. PharmacoEconomics 1995;7:242-250.

    Nicholson K, Ramsay LE, Haq IU, Wallis EJ, Ghahramani P, Jackson PR, Yeo WW. Factors affecting patients� acceptance
    of drug therapy to prevent myocardial infarction. Br J Clin Pharmacol 1999;47:575P.

    Leaman H, Jackson PR. What benefit do patients expect from adding second and third antihypertensive drugs? Br J Clin
    Pharmacol 2002;53:93-99.

    Williams A. Rationing health care by age. The case for. BMJ 1997;314:820-822.

    McNeil BJ, Pauker SG, Sox HC, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med
    1982;306:1259-1262.

Linked Articles

  • Miscellanea
    BMJ Publishing Group Ltd and British Cardiovascular Society
  • Miscellanea
    BMJ Publishing Group Ltd and British Cardiovascular Society