Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention.

Abstract

Elevated blood pressure (BP) is a causal risk factor for cardiovascular disease (CVD). Epidemiological analyses have established the graded and continuous association between higher BP and CVD. Moreover, randomized clinical trials among individuals with hypertension have demonstrated, in aggregate, a reduction in CVD events by 20%, coronary heart disease (CHD) by 17%, stroke by 27%, and heart failure by 28% for every 10 mm Hg systolic BP (SBP) lowering with medical therapy.1 Therefore, prevention, detection, treatment, and control of elevated BP, and its clinical correlate hypertension, is an important public health priority and a primary target for CVD prevention. Although national health surveys have demonstrated improvements in hypertension awareness and treatment, strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment, using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables, has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines, however, have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity. In this review, we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines. Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a …