[Should treatment of risk factors of cardiovascular diseases be directed only by absolute risk?]

Consensus groups have recommended using the baseline absolute risk of disease over five to ten years rather than relative risk when treatment with lipid-lowering or antihypertensive drugs is considered. Targeting patients with a coronary event rate of 20% over ten years ensures that society's investment in drugs yields substantial benefits by reducing the incidence of premature disease. However, the use of absolute risk is most appropriate among the middle-aged. Because all elderly persons have a high absolute risk of disease, almost all may be eligible for drug treatment. The costs of postponing death after the age of 70 are therefore substantial. Among young persons with familial hypercholesterolemia on the other hand, the consequences of a death before middle-age are so enormous that most patients are treated with drugs even though absolute risk is very low. An additional problem with using absolute risk is that the risk of atherosclerotic disease accumulates over time. Calculation of benefit on the basis of short-term trials might underestimate long-term benefit. In the future, non-invasive measures of atherosclerosis and new markers of risk may provide valuable information on risk stratification in primary prevention.