Evidence Builds For Risk-based Antihypertension Guidelines

The concept of a risk-based approach to diagnosing and managing patients with hypertension is ready for more thought among U.S. physicians and policy makers. It is very logical that we could prevent more events by focusing on people who are at higher risk for cardiovascular disease events, and there is more to risk reduction than just treating to a certain blood pressure level.

This approach to managing hypertension has been in place in New Zealand for at least a decade, and was woven into the 2013 hypertension management guidelines issued by the European Society of Cardiology (Eur. Heart J. 2013;34:2159-2219). There was also some attention given to the concept in the JNC VI U.S. hypertension guidelines, but then the guidelines panels backed away from it in the next two revisions.

Mitchel L. Zoler/Frontline Medical News Dr. David C. Goff Jr.

Several lines of evidence support the risk-based approach. In addition to Dr. Karmali’s new report, there was an analysis published in August that sowed the relative risk reduction from reducing blood pressure was similar across a range of risk levels (Lancet 2014;384:591-8). And a 2011 analysis showed that if you prioritize antihypertensive treatment based on risk level rather than just on systolic pressure you could treat the same number of people but prevent far more cardiovascular disease events (Ann. Int. Med. 2011;154:627-34).

These two prior reports, Dr. Karmali’s new study, and the change in approach introduced by guidelines in New Zealand and in Europe make it the right time to give this approach serious consideration by U.S. policy makers. I think many people agree it makes sense to focus attention on people with the highest cardiovascular risk. But a significant outstanding issue is whether clinicians will be willing to withhold blood pressure lowering treatment from selected people with systolic blood pressures above 140 mm Hg.

Dr. David C. Goff Jr., dean and professor of epidemiology at the Colorado School of Public Health, Aurora, made these comments in an interview. He had no disclosures.