High Risk Hypertensive Patients

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Some patient groups have such high CVD risk and chance of benefit that they require antihypertensive treatment even for mild hypertension (> 140/90 mm Hg) without formal calculation of absolute risk. Patients with any form of symptomatic atherosclerotic vascular disease, including previous myocardial infarction, bypass graft surgery, angina, stroke or transient ischaemic attack, peripheral vascular disease or atherosclerotic renovascular disease need treatment of even very mild hypertension (> 140/90 mm Hg) for secondary prevention. Indeed there is mounting evidence that secondary prevention patients with "normal" blood pressure (< 140/90 mm Hg) benefit from blood pressure reduction. This is similar in principle to reducing normal or even "low" cholesterol with statins. Patients with target organ damage such as LVH, heart failure, proteinuria or renal impairment also have high CVD risk and need treatment of even very mild hypertension. Older patients (> 60 years) have high CHD risk by virtue of their age alone, and benefit from treatment of even mild hypertension (> 140/ 90mmHg). Patients with long term average blood pressure

> 160/100 mm Hg have high CVD risk because of the steep association between blood pressure and risk of stroke. The risk of developing cardiovascular complications increases dramatically with the long term average diastolic blood pressure

> 100mmHg.11 Formal risk calculation will underestimate true CVD risk for reasons discussed later, and all patients with blood pressure > 160/100 mm Hg after prolonged observation and despite lifestyle advice should be treated.

Patients with type II diabetes also have high CVD risk, but in addition gain extra benefit from antihypertensive treatment because it prevents microvascular complications (for example, nephropathy, retinopathy) as well as large vessel complications. All patients with type II diabetes and mild hypertension (> 140/90 mm Hg) should be treated regardless of their absolute CVD risk. Patients with type I diabetes and mild hypertension (> 140/90 mm Hg) generally have diabetic nephropathy and should be treated.

These high risk groups all require drug treatment for hypertension and it follows that formal risk assessment is only necessary for decisions on antihypertensive treatment in patients below age 60 with uncomplicated mild hypertension (long term average blood pressure 140-159/90-99 mm Hg). However, because of the distribution of blood pressure levels in the population, a large majority of hypertensive patients do have uncomplicated mild hypertension, and do require formal risk calculation.

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