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The clinical heterogeneity of hypertension
1Section of Preventive Medicine and Epidemiology, Boston University School of Medicine, Massachussetts 02118.
Insights
Cardiovascular risk profiles, not just blood pressure levels, should guide hypertension treatment decisions. Multiple coexisting risk factors significantly increase cardiovascular event risk in hypertensive patients.
Area of Science:
- Cardiology
- Hypertension Management
- Preventive Medicine
Background:
- Hypertension is frequently associated with other cardiovascular risk factors.
- These coexisting factors significantly amplify the overall cardiovascular risk.
Purpose of the Study:
- To emphasize the importance of a comprehensive cardiovascular risk profile in guiding antihypertensive therapy.
- To highlight how coexisting risk factors influence treatment urgency and drug selection.
Main Methods:
- Review of existing literature on hypertension and cardiovascular risk stratification.
- Analysis of how multiple risk factors impact cardiovascular event probability.
- Consideration of the effects of antihypertensive agents on metabolic parameters.
Main Results:
- Cardiovascular risk in hypertensive patients varies more than tenfold based on coexisting factors like lipid abnormalities, obesity, ECG changes, and glucose intolerance.
- Multivariate risk formulations can estimate joint probabilities of cardiovascular outcomes.
- Certain antihypertensive drugs can negatively impact lipids, glucose, and uric acid levels.
Conclusions:
- Hypertension management should prioritize the overall cardiovascular risk profile over isolated blood pressure readings.
- Optimal antihypertensive therapy selection requires accounting for coexisting conditions and potential drug side effects.
- Viewing hypertension as part of a broader cardiovascular risk profile is crucial for effective treatment and outcome assessment.
Abstract:
More than the character of the blood pressure elevation, the cardiovascular risk profile should be the prognostic guide for antihypertensive therapeutic decision-making. Hypertension tends to occur in association with other risk factors which augment the risk and need to be considered in evaluating the hazard of hypertension, the urgency for treatment, and the choice of treatment. Elevated blood pressure is often accompanied by blood lipid abnormality, obesity, electrocardiograph (ECG) abnormality, glucose intolerance, and elevated fibrinogen and hematocrit, all of which enhance the risk of cardiovascular sequelae of hypertension. Hypertensive patients at particularly increased risk of cardiovascular events are those with an increased total/HDL-cholesterol ratio, ECG abnormality, impaired glucose tolerance, or the cigarette smoking habit. The risk of a cardiovascular event among hypertensive patients varies over more than a 10-fold range depending on the number of these coexistent risk factors. Multivariate risk formulations are available to allow a composite estimate of the joint conditional probability of a cardiovascular outcome in hypertensive patients with multiple risk factors. Since some antihypertensive agents can adversely affect blood lipids, glucose tolerance, or uric acid values, the risk profile must also be taken into account in choosing the optimal antihypertensive therapy. Also, hypertension is commonly associated with angina, myocardial infarction, left ventricular hypertrophy, stroke, or cardiac failure. These too must be taken under consideration in judging the urgency for treatment and the choice of agents. Thus, hypertension is best regarded as a component of a cardiovascular risk profile in implementing optimal therapy and in assessing its efficacy.