Cardioprotection and antihypertensive therapy: The key importance of addressing the associated coronary risk factors (the Framingham experience)

Hypertension directly predisposes to all of the major atherosclerotic cardiovascular disease outcomes, including coronary artery disease, stroke, cardiac failure, and peripheral artery disease. Coronary artery disease deserves a high priority in treatment of hypertension because it is the most common and lethal sequela. However, reduction of blood pressure as the sole therapeutic goal of antihypertensive therapy is no longer appropriate. Hypertension tends to cluster with other atherogenic risk factors, including dyslipidemia, glucose intolerance, insulin resistance, obesity, and elevated uric acid. Hypertension is only one of the many risk factors for atherosclerotic cardiovascular disease and is variably hazardous, depending on the number and severity of these coexistent metabolically linked risk factors. The presence of coexistent, already overt cardiovascular disease and left ventricular hypertrophy also greatly influence the hazard and choice of therapy. The urgency for, and choice of, therapy should be based on the multivariate cardiovascular risk profile rather than relying solely on the character and severity of the blood pressure elevation. In this way at-risk hypertensive persons can be more appropriately targeted for treatment designed to improve their multivariate risk profile and to provide maximum benefit and cost effectiveness.