GUIDELINES FOR ANTIHYPERTENSIVE THERAPY - PROBLEMS WITH A STRATEGY BASED ON ABSOLUTE CARDIOVASCULAR RISK

It has been suggested that selection for antihypertensive therapy shou ld be based on absolute risk of a cardiovascular disease (CVD) event a nd that treatment should be offered only if the 10-year risk exceeds 2 0%. Although interesting and challenging, this strategy would have the effect of greatly emphasizing treatment of the elderly and downplayin g treatment of the middle-aged. It is argued in this paper that the us e of one and the same time-frame for all age groups is illogical; some inverse age-related adjustment is needed. In addition, it is suggeste d that selection for active treatment would be better based not on the total absolute risk of CVD but rather on the marginal hypertensive ri sk (i.e, that part of the total risk which can be attributed to raised blood pressure). Problems in the use of antihypertensive drugs in peo ple with 'high normal' blood pressure in order to compensate for risk factors such as obesity, hyperlipidaemia and smoking are discussed. Th e effect of antihypertensive treatment administered in large-scale tri als to the most hypertensive control subjects has been (and continues to be) largely ignored; it should be taken into account in all calcula tions in this field. A policy based on absolute risk is certainly wort h examining but it should not be considered self-evidently correct and needs testing in all its aspects before it is adopted on a large scal e.