The Bad News About Prevalence, the Good News About Treatments -- But Pay Attention to the Details

Linda Brookes, MSc


February 14, 2005

In This Article

Treat the Patient, Not the Numbers -- Treatment Should be Based on Overall Cardiovascular Risk

The terms "hypertension" and "hypercholesterolemia" should be removed from the clinical vocabulary, and clinicians should treat patients based on estimated absolute cardiovascular risk rather than treating individual risk factors, according to Prof. Rod Jackson, PhD (University of Auckland, New Zealand), writing in the January 29 issue of The Lancet .[17] Although this approach is supported by both observational and clinical trial evidence, many clinicians still base treatment decisions mainly on blood pressure or cholesterol levels, Prof. Jackson maintains.

Prof. Jackson says that attention should be shifted from knowing a patient's blood pressure levels and cholesterol concentrations to establishing the patient's absolute cardiovascular risk and its determinants. He points out that most cardiovascular risk factors cannot be divided into present or absent categories but must be determined by the synergistic effect of all cardiovascular risk factors present. The most powerful risk predictors are age, previous symptomatic cardiovascular disease, and pathophysiologic changes such as left ventricular hypertrophy and renal impairment. Other factors include increasing blood pressure and lipids, smoking, and male gender.

A range of printed and electronic cardiovascular risk prediction scores is currently available, Prof. Jackson notes. Risk scores for specific populations should be made available for routine clinical practice, and separate management guidelines for raised blood pressure and blood cholesterol should be replaced by integrated cardiovascular risk management guidelines, he urges.

Since cardiovascular risk factors interact with each other, moderate reductions in several risk factors can be more effective than major reductions in 1 risk factor. This suggests that the most important treatment goal might be keeping patients on 1 affordable tablet that combines low doses of various drugs, such as the proposed polypill, rather than a multidrug treatment regimen that attempts to achieve the best possible target levels for a host of individual risk factors.

Individualized management of cardiovascular risk should be informed mainly by the probable size of absolute treatment benefits. Prof. Jackson states that neither doctors nor their patients are well informed about the importance of these benefits. In view of the apparent discrepancy between patients' (inflated) expectations and the actual benefits of treatment, research on patients' knowledge of treatment benefits should be a major priority, he believes.

Prof. Jackson recommends that quantitative cardiovascular risk/benefit assessment should be a routine component of quality clinical practice in middle-aged and older adults.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.