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Blood pressure management: individualized treatment based on absolute risk and the potential for benefit
1Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
Insights
Current blood pressure management often ignores cardiovascular risk, leading to unnecessary drug therapy. A personalized approach, considering individual risk factors, ensures efficient treatment for those most likely to benefit from blood pressure reduction.
Area of Science:
- Cardiology
- Epidemiology
- Public Health
Background:
- Clinical hypertension management frequently deviates from established epidemiologic evidence.
- Current practices often prescribe antihypertensive therapy based on arbitrary blood pressure thresholds, irrespective of individual cardiovascular risk.
- Conversely, individuals with blood pressure below these thresholds rarely receive interventions, even if their cardiovascular risk is elevated.
Purpose of the Study:
- To highlight the continuous, linear relationship between blood pressure and cardiovascular events (stroke, heart attack) shown in epidemiologic data.
- To advocate for a risk-stratified approach to blood pressure management, moving beyond arbitrary thresholds.
- To emphasize the potential benefits of even modest, universal blood pressure reduction.
Main Methods:
- Analysis of epidemiologic data demonstrating a continuous association between blood pressure levels and cardiovascular event incidence.
- Review of observational experience regarding the impact of blood pressure reduction strategies.
- Conceptual framework for augmenting public health strategies with individual risk assessment for pharmacologic intervention.
Main Results:
- Epidemiologic data reveal a consistent, positive, linear correlation between systolic and diastolic blood pressure and the incidence of stroke and heart attack.
- No specific blood pressure threshold reliably distinguishes individuals who will experience a cardiovascular event.
- A significant proportion of cardiovascular events occur in individuals with blood pressure levels considered 'normal'.
Conclusions:
- Universal blood pressure reduction, even by a few millimeters of mercury, may yield substantial public health benefits.
- Antihypertensive therapy should be prioritized for individuals with high cardiovascular risk, identified through risk factors or preclinical vascular disease.
- This targeted approach will optimize efficiency and effectiveness, sparing low-risk individuals from unnecessary long-term treatment and identifying high-risk 'normotensive' individuals for intervention.
Abstract:
Clinical practice often conflicts with epidemiologic evidence in the management of blood pressure. Antihypertensive therapy is generally prescribed if blood pressure exceeds some arbitrary level, thus committing many persons with minimal cardiovascular risk to long-term drug therapy. By contrast, below that level, regardless of cardiovascular risk, blood pressure reduction is rarely sought. Epidemiologic data, however, consistently show a continuous, positive, linear relationship of the height of both systolic and diastolic blood pressure with the incidence of stroke and heart attack. No threshold level distinguishes those who will have a cardiovascular event from those who will not. In fact, most heart attacks and many strokes occur among persons with "normal" blood pressures. Observational experience suggests that benefit could be obtained from universal blood pressure reduction of even a few millimeters of mercury. This public health strategy can be augmented by identifying those individuals, at every level of blood pressure, whose risk for cardiovascular disease justifies the cost of pharmacologic intervention. Antihypertensive drug therapy will be most efficient and effective if directed at those who, by virtue of their constellation of risk factors or evidence of preclinical vascular disease, are likely to have a heart attack or stroke. The resulting redirection of clinical resources will spare many hypertensive persons whose absolute risk for a cardiovascular event is small, from life-long treatment. At the same time, other persons, currently classified as normotensive, will become candidates for blood pressure reduction because their cardiovascular risk is high.
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