Comprehensive risk factor management for hypertensive patients

This editorial refers to ‘Influence of multiple risk factor control level on cardiovascular outcomes in hypertensive patients’, by Peng et al. https://doi.org/10.1093/ehjqcco/qcae056. Cardiovascular disease remains the most common cause of death worldwide.1,2 Arterial hypertension is a key pathophysiologic factor3 that may prove challenging to manage.4,5 Medications available include angiotensin-converting enzyme inhibitors, angiotensin II receptor blocker, beta-blockers, calcium-channel antagonists, and diuretics. Co-prescription of two or more antihypertensive drugs, together with appropriate non-pharmacologic measures, is often necessary to achieve control of the blood pressure. Nonetheless, achieving optimal blood pressure control remains challenging in many patients, and once non-adherence to prescribed treatment is excluded requires intensification of treatment with dose up-titration or introduction of additional antihypertensive agents. In severely resistant hypertension transcatheter renal denervation may need consideration.5,6 Yet, is our focus overly narrow when treating patients with arterial hypertension? In other words, should we focus solely on the hypertension, or more broadly and comprehensively on cardiovascular risk? In this issue of the Journal, Peng et al. make a compelling case for comprehensive management of cardiovascular risk in the management of hypertension.7 Specifically, they have investigated the impact of a broad risk reduction strategy on cardiovascular outcomes based on the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial, which included 8337 hypertensive patients aged 60 years or more (Figure 1). Briefly put, they found a significant stepwise association between risk factor control and cardiovascular risk reduction, such that each additional uncontrolled risk factor increased cardiovascular risk by 24% in relative terms, whereas optimal risk factor control led to significantly lower cardiovascular risk, irrespective of the intensity of blood pressure treatment. This work emphasizes the importance of comprehensive risk factor management in hypertensive patients and reinforces the call already championed by polypill investigators as well as by the American Heart Association's Life's Simple 7.8–10 Basics of multidimensional risk factor management in patients with arterial hypertension. The polypill concept combines multiple cardiovascular medications in a single pill, for example, statin, blood pressure lowering drugs (perhaps thiazide, beta blocker, and angiotensin converting enzyme inhibitor) aspirin and folic acid. This encourages adherence to treatment with the aim of reducing the risk of heart disease and stroke. Other important benefits include simplified treatment, cost-effectiveness, and potential for widespread prevention in at-risk populations.8,11 The American Heart Association's HA's Life's Simple 7 approach rests on explicitly promoting seven key health behaviours and metrics to improve cardiovascular health: controlling blood pressure, cholesterol, and glycaemia, maintaining an active lifestyle, improving diet, avoiding overweight and obesity, as well as smoking. In this way, the risk of heart disease and stroke risk can be substantially reduced.12 Further reductions are feasible by encouragement of healthy sleeping routines (Life's Essential 8).13 Replacement of the current hypertension control paradigm with a strategy based on cardiovascular risk management has been called for by others with the recommendation that blood pressure-lowering treatment should be directed towards those at greatest risk, not just those with the highest blood pressure levels.14 This takes the risk-based management of blood pressure a step further by making the patient's baseline risk, not simply their blood pressure, the criterion on which selection for blood pressure lowering treatment is made. This aligns with current approaches to lipid management and is now evidenced by the work of Herrett et al. who reported that a risk-based approach to assess eligibility for blood pressure-lowering treatment was superior to guideline recommended approaches based on blood pressure cut-offs.15 These concepts are now beginning to be aired in clinical guidelines16 but, as yet have shown little sign of penetrating clinical practice. The time to act is now, and there is an important need for research to identify tools to foster optimal multidimensional cardiovascular care using personalized approaches as well as population-level interventions. It is no longer adequate to target just the blood pressure in our hypertensive patients while ignoring other contributors to the risk profile such as lifestyle factors and lipids. Blood pressure reduction is important but must now be seen as part of a comprehensive treatment programme to reduce risk and improve cardiovascular outcomes. This manuscript was drafted with the assistance of artificial intelligence tools, including ChatGPT 4 (OpenAI, San Francisco, CA, USA), in keeping with established best practices (Biondi-Zoccai G, editor. ChatGPT for Medical Research. Torino: Edizioni Minerva Medica; 2024). The final content, including all conclusions and opinions, has been thoroughly revised, edited, and approved by the authors. The authors take full responsibility for the integrity and accuracy of the work and retain full credit for all intellectual contributions. Compliance with ethical standards and guidelines for the use of artificial intelligence in research has been ensured. Research leading to these results has received funding from the European Union—NextGenerationEU, through the Italian Ministry of University and Research, under PNRR—M4C2-I1.3 Project PE_00000019 ‘HEAL ITALIA’ to Giuseppe Biondi-Zoccai CUP B53C22004000006 Sapienza University of Rome. The views and opinions expressed are those of the authors only and do not necessarily reflect those of the European Union or the European Commission. Neither the European Union nor the European Commission can be held responsible for them. Conflict of interest: G. B. Z. has consulted for Aleph, Amarin, Balmed, Cardionovum, Crannmedical, Endocore Lab, Eukon, Guidotti, Innovheart, Meditrial, Menarini, Microport, Opsens Medical, Terumo, and Translumina, outside the present work. All other authors report no conflict of interest.