Guidelines for antihypertensive therapy: Problems with a strategy based on absolute cardiovascular risk

It has been suggested that selection for antihypertensive therapy should be based on absolute risk of a cardiovascular disease (CVD) event and that treatment should be offered only if the 10-year risk exceeds 20%. Although interesting and challenging, this strategy would have the effect of greatly emphasizing treatment of the elderly and downplaying treatment of the middle-aged. It is argued in this paper that the use of one and the same time-frame for all age groups is illogical; some inverse age-related adjustment is needed. In addition, it is suggested that selection for active treatment would be better based not on the total absolute risk of CVD but rather on the marginal hypertensive risk (i.e, that part of the total risk which can be attributed to raised blood pressure). Problems in the use of antihypertensive drugs in people with 'high normal' blood pressure in order to compensate for risk factors such as obesity, hyperlipidaemia and smoking are discussed. The effect of antihypertensive treatment administered in large-scale trials to the most hypertensive control subjects has been (and continues to be) largely ignored; it should be taken into account in all calculations in this field. A policy based on absolute risk is certainly worth examining but it should not be considered self-evidently correct and needs testing in all its aspects before it is adopted on a large scale.