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Has antihypertensive treatment prevented vascular disease or vascular events?
1Center for Clinical Physiology and Hypertension, University of Milan, Ospedale Maggiore, Italy.
Insights
Antihypertensive therapy trials focus on preventing cardiovascular events, not underlying disease progression. New trials should assess plaque development for long-term disease prevention strategies.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Current antihypertensive therapy trials primarily assess hard cardiovascular events.
- Extrapolating event prevention to underlying disease mechanisms is limited.
Purpose of the Study:
- To differentiate between preventing cardiovascular events and preventing cardiovascular disease.
- To highlight the need for assessing long-term disease modification in antihypertensive therapy.
Main Methods:
- Review of existing therapeutic trial methodologies.
- Proposal for incorporating plaque development assessment in new randomized trials.
Main Results:
- Event-based trials effectively measure short-term outcomes.
- Long-term disease prevention requires different assessment methods, such as plaque imaging.
Conclusions:
- Antihypertensive therapy has dual goals: event prevention and disease prevention.
- Future research should explore drug mechanisms affecting disease progression, including thrombotic factors.
Abstract:
Our current knowledge of the effects of antihypertensive therapy is based on a large number of therapeutic trials based on mortal and morbid cardiovascular events. Although these events are indeed "hard" data, extrapolations from the results of trials based on events cannot be applied to possible effects on the underlying cardiovascular disease, particularly coronary artery disease, as the mechanisms responsible for the precipitation of events are often different from the mechanisms leading to disease. Once a distinction between prevention of disease and prevention of events is made, then both must be considered to be different, but essential, goals of antihypertensive therapy. The prevention of events is a short-term goal for patients who already have disease, and can be easily appreciated by traditional event-based trials; the prevention of disease, however, is a long-term goal that can be appreciated clinically only after years of treatment, but can be assessed within a shorter time frame by measuring plaque development, as in new types of randomized trials. Studies of the potential actions of antihypertensive drugs on the mechanisms precipitating events, particularly thrombotic factors, may further supplement our current knowledge in our search for the most appropriate treatment of the hypertensive patient.