Intended for healthcare professionals

Clinical Review Evidence based management of hypertension

Using cardiovascular risk profiles to individualise hypertensive treatment

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7295.1164 (Published 12 May 2001) Cite this as: BMJ 2001;322:1164

This article has a correction. Please see:

  1. Michael Pignone (pignone{at}med.unc.edu), assistant professor of medicinea,
  2. Cynthia D Mulrow, professor of medicineb
  1. a Division of General Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA,
  2. b Division of General Internal Medicine, University of Texas at San Antonio, San Antonio, TX 78249, USA
  1. 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.

    Summary points

    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.

    Table 1.

    Approximate reductions in relative risk associated with various treatments for hypertensive people with other cardiovascular risk factors but no known cardiovascular disease

    View this table:

    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.

    Table 2.

    Approximate reductions of relative risk associated with various treatments for hypertensive people with other cardiovascular risk factors and known cardiovascular disease

    View this table:
    Figure1

    Sample decision tool for a patient without cardiovascular disease

    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.

    Footnotes

    • Funding None

    • 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).

    References

    1. 1.
    2. 2.
    3. 3.
    View Abstract