blood pressure reduction in context of cardiovasc risk assessment

Recent Lancet meta-analysis looking at the benefits of blood pressure lowering and relating that to overall cardiovascular risk (see htn blood pressure reduction cardiovasc risk lancet 2014 in dropbox, or Lancet 2014; 384: 591–98​). Findings:

--11 trials with 67,475 individuals, with  52K having data for overall cardiovasc risk assessment. 4167 (8%) had cardiovasc event over mean of 4 years. the data incorporated into their risk model included age, sex, BMI, syst and diast bp, antihypertensive meds, smoking, diabetes, hx of cardiovasc disease. did not have enough data about lipids. baseline 45% female, ave age 65, 15% smokers, 39% diabetic, BMI 27.8, BP 158/92.
--likelihood of cardiovasc event tracked with overall 5-yr cardiovasc risk. relative risk reduction (RRR) were and absolute risk reduction (ARR) for 1000 pts treated for hypertension for 5 years would be:
                --cardiovasc risk 6%: RRR 18% and ARR of 14 cardiovasc events/1000 pts treated
                --cardiovasc risk 12.1%: RRR 15% and ARR of 20 cardiovasc events/1000 pts treated
                --cardiovasc risk 17.7%: RRR 13% and ARR of 24 cardiovasc events/1000 pts treated
                --cardiovasc risk 26.8%: RRR 15% and ARR of 38 cardiovasc events/1000 pts
--non-significant difference in RRR according to cardiovasc risk, but ARR did have significant trend (p=.04)

so, this study reinforces the observation of the Framingham Study from a few decades ago: the attributable risk of any risk factor (including systolic blood pressure) is significantly higher if other risk factors are present (eg, the component of cardiovasc risk attributable to hypertension is markedly higher if the patient also has hyperlipidemia). probably the most important lesson of this study is that we should be looking at the whole picture, not just blood pressure in isolation. similar to what we do with lipids with the risk models. which means: in a person with lower levels of hypertension and no other risk factors, we can take a lower key approach, reinforcing lifestyle changes (weight, diet, exercise) for a longer period of time before starting meds. and vice versa.

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