Assessment of cardiovascular risk and choice of antihypertensive therapy

Indications, choices of therapy, and goals of treatment for hypertension should be closely linked to the multivariate risk of cardiovascular events and ingredients of the vascular risk profile of patients with hypertension. Hypertension commonly occurs in combination with other cardiovascular disease risk factors, and the burden of the associated risk factors greatly affects the impact of elevated blood pressure and usually requires choices of specific antihypertensive agents shown to be particularly efficacious in the context of the associated risk factors or vascular conditions present. Guidelines assign highest priority to rigorous control of the blood pressure. Risk associated with hypertension has been shown to be incremental, with the level of blood pressure extending down to what was formerly considered the high-normal blood pressure range. In this "prehypertensive" state, drug treatment is justified only if the multivariate risk is substantial or there is target-organ damage. Most individuals with the metabolic syndrome, a condition commonly associated with hypertension, and singled out as an important consideration for treatment, are usually identified by the Framingham multivariate risk formulation. They require weight control and exercise, as well as specific choices of antihypertensive agents.