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Towards a better yardstick: the choice of treatment thresholds in hypertension
1Division of General Internal Medicine, Ottawa Civic Hospital, Ontario. fmcalister@lri.ca
Insights
Risk-based guidelines for hypertension improve cardiovascular disease (CVD) risk assessment but require careful consideration of treatment thresholds. Incorporating patient and physician preferences is key for future hypertension management strategies.
Area of Science:
- Cardiology
- Public Health
- Health Policy
Background:
- Hypertension management is shifting towards risk-based guidelines.
- Individualized treatment strategies consider multiple cardiovascular disease (CVD) risk factors beyond blood pressure.
- Mild hypertension's impact on morbidity/mortality is influenced by the overall risk factor profile.
Purpose of the Study:
- To discuss the advantages and shortcomings of risk-based hypertension guidelines.
- To highlight the critical role of treatment thresholds in guideline development.
- To propose a method for incorporating patient, physician, and public preferences into future guidelines.
Main Methods:
- Review of current risk-based hypertension guidelines.
- Analysis of the impact of treatment thresholds on population treatment rates, costs, and cost-effectiveness.
- Proposal of a novel method for preference elicitation.
Main Results:
- Risk-based guidelines offer improved risk stratification but do not eliminate the need for defined treatment thresholds.
- Treatment thresholds significantly influence healthcare resource allocation and treatment effectiveness.
- A method is proposed to integrate diverse stakeholder preferences.
Conclusions:
- While risk-based approaches enhance hypertension management, setting appropriate treatment thresholds remains a critical challenge.
- Future hypertension guidelines should actively incorporate patient, physician, and public preferences for optimal implementation.
- A balanced approach considering both risk assessment and threshold setting is essential for effective hypertension care.
Abstract:
In the past decade, enthusiasm for risk-based guidelines for the treatment of hypertensive patients, in which absolute risk profiles and individualized treatment strategies are employed, has steadily increased. This stems from the recognition that hypertension is only one of the risk factors for cardiovascular disease, and that the risk of morbidity or mortality in patients with mild hypertension depends more on their constellation of risk factors than on their actual blood pressure reading. While risk-based guidelines do offer some advantages over traditional guidelines, they also have important shortcomings that should be acknowledged. In particular, the use of risk-based guidelines does not obviate the need to set treatment thresholds. This is the key issue in any guideline because the treatment threshold determines the proportion of the population who will require treatment, the total cost of treatment, the number needed to treat to prevent one adverse event and the cost effectiveness of medical care. The advantages and shortcomings of risk-based guidelines are discussed and a method is proposed whereby the preferences of patients, practicing physicians, and the general public can be determined and incorporated into future hypertension guidelines.