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Blood Pressure Management: Individualized Treatment Based on Absolute Risk and the Potential for Benefit

Michael H. Alderman
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From Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York. Request for Reprints: Michael H. Alderman, MD, Albert Einstein College of Medicine/Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY 10461. Acknowledgments: The author thanks Drs. Leonard Katz, Thomas Ryan, and Peter Sleight for helpful comments.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(4):329-335. doi:10.7326/0003-4819-119-4-199308150-00013
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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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Figure 1.
Relative risk for stroke and coronary heart disease by usual diastolic blood pressure.

Stroke data were compiled from 7 prospective observational studies with 843 events, and coronary heart disease data were compiled from 9 prospective, observational studies with 4856 events. The 5 categories of diastolic blood pressure (DBP) are defined by baseline diastolic blood pressure. Estimates of the usual diastolic blood pressure in each category are taken from mean diastolic blood pressure values 4 years after baseline in the Framingham Study.

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Figure 2.
Absolute and relative risk for a Cardiovascular disease event in a high- and low-risk 55-year-old man by systolic blood pressure.

High Risk: left ventricular hypertrophy, cigarette smoker, glucose intolerance, cholesterol = 8.02 mmol/L.

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Figure 3.
Cardiovascular disease events by systolic blood pressure change for high-, medium-, and low-risk men.

High risk: systolic blood pressure = 135 mm Hg, cholesterol = 8.02 mmol/L, glucose intolerance, left ventricular hypertrophy. Medium risk: systolic blood pressure = 165 mm Hg, cholesterol = 6.72 mmol/L, glucose intolerance, no left ventricular hypertrophy. Low risk: systolic blood pressure = 195 mm Hg, cholesterol = 4.78 mmol/L, no glucose intolerance, no left ventricular hypertrophy.

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Figure 4.
Ten-year probability of stroke by systolic blood pressure for four 55-year-old white men with different risk profiles.

Patient A = previously treated, history of cardiovascular disease and diabetes, smokes cigarettes, and has left ventricular hypertrophy; patient B = smokes cigarettes; patient C = no other risk factors; patient D = history of diabetes, smokes cigarettes, and has left ventricular hypertrophy; patient E = average risk.

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