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PAPERS: Francesco P Cappuccio, Pippa Oakeshott, Pasquale Strazzullo, and Sally M Kerry Application of Framingham risk estimates to ethnic minorities in United Kingdom and implications for primary prevention of heart disease in general practice: cross sectional population based study BMJ 2002; 325: 1271 [Abstract] [Full text]

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New thresholds for hypertension go beyond the evidence

Peter R Jackson, Mohsen Aarabi   (5 January 2003)

New thresholds for hypertension go beyond the evidence 5 January 2003
Peter R Jackson, Reader in Clinical Pharmacology and Therapeutics Royal Hallamshire Hospital, Sheffield S10 2JF, Mohsen Aarabi Send response to journal: Re: New thresholds for hypertension go beyond the evidence	Sir Cappuccio and colleagues raise an interesting academic point about the difference in the predicted ratio of cardiovascular disease (CVD) and coronary heart disease (CHD) in ethnic minorities. Whilst this may stimulate further epidemiological investigation we believe it adventurous to base a change in treatment policy for whole populations on the difference between two mathematical functions derived from the health of citizens from a single US town with neither African nor South Asian minorities. The CVD functions have never been adequately validated in either patient group. Tools like The Sheffield Table were devised because physicians at the front line found it difficult to use mathematical functions to estimate individual risk. They have the advantage of incorporating within 1 simple paper or software algorithm decisions about antihypertensive drugs and aspirin for patients with mild hypertension and about statins in those with hyperlipidaemia. However they only achieve this by simplifications such as assuming a constant relationship between CVD and CHD risk although this is known to vary with age, blood pressure and gender. If we are to introduce different thresholds according to ethnic group then by the same logic we must adopt different thresholds for each of these factors as well. In doing so we will lose the simplicity of the tools and re- introduce a barrier to appropriate prescribing. Implicit in adopting new thresholds is the assumption that relative risk reduction offered by all the treatments directed is constant. However aspirin has little effect on overall stroke incidence, its major benefit being in preventing CHD [1]. Even worse for haemorrhagic stroke, a subtype over-represented in one of the groups affected by the suggested threshold [2], aspirin may increase incidence and at best statins offer little benefit [3]. Comprehensive current epidemiological data on CHD and CVD is desperately required including that from ethic minorities to reassure us that our risk predictions are accurate for all. Until that is to hand we are safer sticking with the tools already in use. References 1 Barnett HJM, Taylor DW, Eliasziw M, et al, for the North American Physicians’ Health Study Research Group. Findings from the aspirin component of the ongoing physicians health study. N Engl J Med 1988; 318: 262–64. 2 Broderick JP, Brott T, Tomsick T, Huster G, Miller R. The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites. N Engl J Med 1992;326: 733-6. 3 Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo controlled trial. Lancet 2002;360:7–22. Competing interests:   PRJ has received fees for speaking on the treatment of hypertension and hyperlipidaemia. He has also been sponsored to attend a number of symposia and his department receives research funding from pharamceutical companies in relation to studies of antihypertensive and lipid lowering drugs.