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Is coronary risk an accurate surrogate for cardiovascular risk for treatment decisions in mild hypertension? A
E J Wallis1, L E Ramsay, I U Haq
1Clinical Pharmacology and Therapeutics, Royal Hallamshire Hospital, Sheffield, UK.
Insights
Coronary heart disease (CHD) risk assessment accurately identifies patients with cardiovascular disease (CVD) risk, with a simple table being more sensitive for targeting mild hypertension treatment.
Area of Science:
- Cardiology
- Public Health
- Hypertension Management
Background:
- Mild hypertension requires accurate risk stratification for effective treatment.
- Current guidelines differ on the thresholds for initiating antihypertensive therapy based on coronary heart disease (CHD) and cardiovascular disease (CVD) risk.
- The British guidelines suggest using a CHD risk of 15% over 10 years to identify patients needing treatment for CVD risk of 20% over 10 years.
Purpose of the Study:
- To evaluate the relationship between CHD and CVD risk in patients with uncomplicated mild hypertension.
- To assess the accuracy of using a 15% 10-year CHD risk threshold to identify patients with a 20% 10-year CVD risk, as per British guidelines.
- To compare the performance of the Framingham risk function versus a simplified risk assessment table.
Main Methods:
- A comparison of risk assessment methods was performed using data from the 1995 Scottish Health Survey.
- The study included 624 individuals aged 35-64 years with mild systolic hypertension (SBP 140-159 mmHg).
- Key outcome measures included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detecting CVD risk.
Main Results:
- A 15% 10-year CHD risk was found to be equivalent to a 21% 10-year CVD risk.
- Using the exact Framingham risk function for a 15% 10-year CHD risk threshold demonstrated 79% sensitivity and 98% specificity for identifying a 20% 10-year CVD risk.
- The simplified risk assessment table, which slightly overestimates CHD risk, showed 88% sensitivity and 90% specificity for the same CVD risk threshold.
Conclusions:
- Coronary heart disease risk assessment provides acceptable accuracy for guiding treatment decisions in mild hypertension.
- The risk assessment table is more sensitive in identifying patients with a 20% 10-year CVD risk and may be preferable to exact calculations.
- European guidelines recommending a 20% 10-year CHD risk threshold for treatment initiation in mild hypertension appear overly conservative compared to British guidelines.
Objective:
To examine the relationship between coronary (CHD) and cardiovascular (CVD) risk in patients with uncomplicated mild hypertension and to determine the accuracy of using CHD risk > or = 15% over 10 years to identify for antihypertensive treatment those patients with CVD risk > or = 20% over 10 years as advised in recent British guidelines.
Design:
Comparison of decisions made using CHD risk > or = 15% over 10 years calculated by the Framingham risk function and estimated using a simple table with CVD risk > or = 20% over 10 years.
Setting:
British population.
Subjects:
People aged 35-64 years with uncomplicated mild systolic hypertension (SBP 140-159 mmHg, n = 624) from the 1995 Scottish Health Survey.
Main Outcome Measures:
Relationship between CHD and CVD risk. Sensitivity, specificity, positive and negative predictive values (PPV and NPV).
Results:
CHD risk 15% over 10 years was equivalent to CVD risk 21% over 10 years. Exact CHD risk > or = 15% over 10 years had sensitivity 79%, specificity 98%, PPV 94% and NPV 93% in detecting CVD risk > or = 20% over 10 years. Use of the table to estimate CHD risk > or = 15% over 10 years gave sensitivity 88%, specificity 90%, PPV 76% and NPV 95%.
Conclusion:
CHD risk appears acceptably accurate for targeting treatment in mild hypertension. The risk assessment table, which slightly overestimates CHD risk, was more sensitive in identifying patients with CVD risk > or = 20% over 10 years and may be preferable to using exact CHD risk. European guidelines which suggest targeting treatment for mild hypertension at CHD risk > or = 20% over 10 years are over-conservative compared with British guidelines.
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