Essential hypertension--therapeutic implications of epidemiological risk estimation

Epidemiological studies have repeatedly shown a relationship between blood pressure and the risk of disease and death. With rare exceptions, such studies have demonstrated a steadily increasing level of risk throughout the entire range of systolic and diastolic blood pressure with no evidence of a threshold for blood pressure-related changes in morbidity and mortality. Estimates based on community prevalence and attributable risk indicate that the majority of blood pressure-related cardiovascular complications can be attributed to the effects of only slight increases in blood pressure. Any attempt to substantially reduced blood pressure-related morbidity and mortality in the community mandates treatment of a large number of asymptomatic subjects who, on average, have only a slight increase in absolute risk. The most appealing public health approach to the epidemic of blood pressure-related complications in Western countries is the combined use of mass and high risk treatment strategies. Mass strategies could include a number of non-pharmacological interventions which aim to slightly shift the entire distribution of blood pressure, whereas high risk strategies are based on the more traditional combined drug and non-drug approach to antihypertensive therapy of subjects in the upper end of the blood pressure distribution. At present the efficacy and practicality of community-based non-pharmacological interventions remains unproven. In addition, several important questions related to antihypertensive drug administration require clarification.