Potency of vascular risk factors as the basis for antihypertensive therapy

Hypertension is a powerful predisposing risk factor for cario vascular disease at all ages and in both sexes. Epidemiological assessment indicates the largest risk ratios for stroke and congestive heart failure (CHF), but coronary heart disease (CHD) is the most common and most lethal sequela of hypertension. Examination of the risk of cardiovascular sequelae in the hypertensive population indicates that this is not uniform and varies over a 10-fold range, depending on the associated risk factors. Systolic pressure merits greater consideration than the diastole pressure because isolated systolic hypertension is a powerful cardiovascular risk at all ages. Furthermore, recent trials have indicated the benefit of therapy for systolicbased hypertension in the elderly, even using a diuretic, for coronary disease as well as stroke. Persons with hypertension have a high prevalence of associated cardiovascular risk factors, including elevated cholesterol, reduced HDL-C, diabetes, left ventricular hypertrophy (LVH), and obesity. About 9% under the age of 65 years have an associated overt cardiovascular disease; above age 65 about 30% are so afflicted. Each of these risk factors can double the risk associated with hypertension. Because they are so common, a large fraction of the disease sequelae of hypertension is attributable to these associated risk factors. The high risk of coronary disease in hypertensive patients is concentrated in those with a high total/HDL-cholesterol ratio, impaired glucose tolerance, high fibrinogen, ECG abnormalities, and cigarette smokers. Stroke risk in hypertensive persons is concentrated in those with cardiovascular disease, diabetes, atrial fibrillation, LVH and cigarette smoking. As for CHD and cardiovascular disease in general, stroke risk varies over a 10-fold range, depending on the associated clustering of risk factors. Consideration of these cardiovascular risk factors is required to evaluate properly the needfor treatment, to select the best treatment and to set goals and determine the efficacy of treatment. Optimal therapy of hypertension should improve the composite risk profile as well as blood pressure. Long-standing hypertension is commonly associated with angina, a myocardial infarction, cardiac failure, renal insufficiency, peripheral artery disease, retinopathy, stroke and left ventricular hypertrophy. Choice of therapy for hypertension accompanied by these conditions must be selected so as to benefit the associated conditions as well as the hypertension. Silent or unrecognized myocardial infarctions must be sought out since almost half of all MIs in hypertensive women and 35% of MIs in hypertensive men are clinically silent. ECG and anatomical evidence of LVH each independently triple the risk of hypertension and must be considered ominous harbingers of cardiovascular catastrophes. Thus, therapy for hypertension must take into account associated risk factors, concomitant disease, age, race and side effect profile. Therapy must also give more attention to step-down of drugs, hygienic measures such as weight control, salt and alcohol restriction, less fat in the diet and potassium and magnesium supplementation. Hypertension must be dealt with as an ingredient of a cardiovascular risk profile requiring multivariate risk reduction.