Using cardiovascular risk profiles to individualise hypertensive treatmentBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7295.1164 (Published 12 May 2001) Cite this as: BMJ 2001;322:1164
- a Division of General Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA,
- b Division of General Internal Medicine, University of Texas at San Antonio, San Antonio, TX 78249, USA
- Correspondence to: M Pignone
This is the fourth in a series of five articles
Individual risks must be assessed in order to for the best decision to be made as to which patients to treat and how. Assessment identifies important cardiovascular risk factors that may warrant treatment and helps to establish the absolute benefits that patients can expect from particular treatments. The benefits of treating hypertensive patients also vary, depending on each patient's competing risks of dying from other than cardiovascular causes. For example, patients with multiple serious conditions, such as end stage Alzheimer's disease, obstructive lung disease, frequent falls, gout, and urinary incontinence, have high competing risks that may minimise or negate the benefits of treating their hypertension.
Several treatment options reduce risk of cardiovascular disease and improve outcomes in patients with hypertension
Providers should consider the expected benefits and potential adverse effects of different treatment options and discuss them with patients
The use of decision tools may help decision making about options for reducing cardiovascular risk
Factors useful in helping patients prioritise their treatments
Establishing treatment priorities for patients with multiple cardiovascular risk factors and multiple conditions is difficult. Factors such as those given in the box deserve consideration. Knowing and weighing up multiple risk factors, conditions, and treatments is difficult. Explaining them to patients is daunting and time consuming. Some patients prefer to be told what to do rather than to have to take in the diverse, complicated information necessary to make their own or joint informed decisions; others prefer a great deal of information. We recommend informed decision making, with attention to the factors given in the box, when possible.
Factors helpful in prioritising patients' treatments
Type, immediacy, and magnitude of expected benefits and harms
Availability and costs of treatments
Feasibility and likelihood of compliance
Competing risks from various conditions
Expected interactions with other treatments
Patient and provider preferences and values
Patients with no known cardiovascular disease
Benefits that can be expected from treating patients with hypertension and other cardiovascular risk factors but no known cardiovascular disease include fewer deaths, longer survival times, and less fatal and non-fatal cardiovascular disease, such as myocardial infarction and stroke. Table 1 shows the approximate magnitude of such benefits in people without known cardiovascular disease. The magnitude of risk reduction for cardiovascular disease is similar for treatment with antihypertensive or lipid lowering drugs; it is slightly lower for aspirin prophylaxis. Both the type and magnitude of benefits that can be expected from lifestyle modifications, such as exercising more or quitting smoking, are less clear.
Some treatments, such as aspirin, are immediately beneficial, while others, such as lipid lowering, may take a year or more to take effect. There are no data on the effects of long term use, for over 10 years, of any of the interventions listed. Finally, some of the possibilities, such as quitting smoking, have other benefits that are not shown, including decreased risk of lung cancer and respiratory disease.
Patients with known cardiovascular disease
Patients with hypertension and known cardiovascular disease are at high risk of future cardiovascular events and warrant aggressive management of their risk factors. Several different effective treatments, which are discussed in Evidence-Based Hypertension1 and the third paper in this series,2 are available. Table 2 shows approximate risk reductions that can be expected with different treatments for patients with known cardiovascular disease.
Priorities and sequencing of treatments
We have found few data on synergy between different treatments. We usually give treatment of high risks such as extreme hypertension or extremely high lipid concentrations priority over treatment of mildly abnormal levels of these or other risk factors. We have no profound suggestions for fail safe methods for helping patients to decide the priorities and sequencing of their various treatments. Decisions about which treatments should be combined, and the order in which they should be initiated, depend on
Types of benefits that are of greatest interest to patients
Patients' individual risk profiles and accompanying conditions, and their modifiability
The magnitude of potential benefits from possible treatments
The types and frequencies of harms that may accompany particular treatments
The availability, complexity, feasibility, and costs of particular treatments
Whether patients think they are ready to adhere to particular treatments
The degree of certainty or uncertainty of assessments.
When faced with patients with multiple risk factors and conditions, we use the above principles to guide our discussions about which treatments should be tried and when. Where possible, we use balance sheets and decision aids, such as the sample shown in the figure, to guide discussions. As the data suggest that the relative risk reductions achievable with particular therapies are generally independent of underlying cardiovascular risk levels, we base projections of absolute benefits of treatments on patients' individual risk profiles. Thus, patients at higher risk stand to gain more from treatment over the next 5-10 years than patients at lower risk, and the benefits of their treatments are less likely to be offset by other harms. We try to reach agreement with patients about what constitutes sufficient risk to warrant starting or adding additional treatment.
To help prioritise treatments for patients without known cardiovascular disease, we try to estimate the amount of risk associated with each of the patient's risk factors and accompanying conditions, using tools such as those described in Evidence-Based Hypertension and in the second article in this series.3 We tie our estimate of benefit from a particular therapy to our estimate of risk from a particular factor or condition. For example, we postulate that a patient with especially abnormal levels of a risk factor, such as severe hypertension, may benefit more from having his or her hypertension treated than by taking aspirin.
We also inform patients about the types of benefits and harms that they can expect from particular treatments. For example, primary prevention trials show that aspirin and lipid lowering statins reduce risk of coronary heart disease but probably not stroke. Aspirin is much less expensive than statins, but it has more potential adverse effects, such as gastrointestinal bleeding. Some patients' choices between using aspirin or a statin may depend on cost as well as their perceived risks of adverse effects. Other patients' choices may depend more on their perceived benefits of treatments. For example, some patients may prefer to stop smoking rather than taking either aspirin or a statin, because of perceived multiple benefits of stopping smoking and fewer perceived benefits from the drug. Other patients may feel that they are not ready or able to quit smoking, but willing to take drugs.
Competing interests MP has received funding from the Pfizer Foundation for research on treatment of heart failure in low literacy patients.The book Evidence-Based Hypertension, edited by Cynthia Mulrow, can be purchased through the BMJ Bookshop (http://www.bmjbookshop.com/).
The book Evidence-Based Hypertension, edited by Cynthia D Mulrow, can be purchased through the BMJ Bookshop (http://www.bmjbookshop/. com).