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Can we stratify risk to guide therapy
1Albert Einstein College of Medicine, Dept. of Epidemiology & Social Medicine, Bronx, NY 10461, USA.
Insights
Absolute cardiovascular disease (CVD) risk, not just blood pressure, should guide antihypertensive treatment decisions. Stratifying patients by CVD risk optimizes therapy intensity for better event prevention.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Pharmacology
Background:
- Blood pressure is directly related to cardiovascular disease (CVD) risk.
- Blood pressure alone is an insufficient predictor of CVD events.
- Multiple risk factors significantly alter CVD event expectations even with similar blood pressure levels.
Purpose of the Study:
- To emphasize the importance of absolute CVD risk over blood pressure levels in guiding antihypertensive treatment.
- To highlight the limitations of conventional antihypertensive therapy in preventing expected events.
- To introduce a risk stratification scheme for modulating therapy intensity.
Main Methods:
- Analysis of observational data from long-term treated patients.
- Development of a pre-treatment CVD risk stratification scheme.
- Consideration of specific risk factors influencing drug selection.
Main Results:
- Absolute CVD risk, incorporating factors like smoking, cholesterol, diabetes, and existing CVD, provides superior discrimination of event risk compared to blood pressure alone.
- Conventional treatments prevent only a fraction of expected CVD events.
- Risk stratification allows for tailored antihypertensive therapy intensity to maximize CVD prevention.
Conclusions:
- Antihypertensive treatment decisions should be based on absolute CVD risk stratification, not solely on blood pressure readings.
- Risk stratification enables personalized modulation of therapy intensity for improved CVD prevention.
- Individual risk factors can guide the selection of specific antihypertensive medications.
Abstract:
The relation of blood pressure to cardiovascular (CVD) disease is direct, continuous, and independent. Nevertheless, blood pressure alone is a poor predictor of CVD events. In fact, the totality of factors, including smoking, cholesterol, diabetes, target organ damage, and existing cardiovascular disease, together, permit discrimination of persons with similar blood pressure into subgroups with event expectations that might differ by more than twenty-fold. Thus, absolute CVD risk, rather than level of blood pressure, should determine the need for antihypertensive treatment. In addition, conventional treatment, even when effective, prevents only 25% of expected events. Observational study of long term treated patients provides the basis for pre-treatment stratification of CVD risk in patients who will maintain "normal" blood pressure in treatment. This stratification scheme makes it possible to modulate the intensity of therapy to match the potential for CVD prevention. Finally, specific risk factors, influenced by particular antihypertensive therapies, may guide drug selection in individual cases.