Quantifying cardiovascular risk in hypertension.

The facts are that blood pressure is a risk factor for cardiovascular disease and that its reduction saves lives. This has been convincingly demonstrated. The question now is how best to translate that knowledge into practice. Clearly, displacement of the whole community's pressure distribution downward would be of tremendous benefit. A change of only a few mm Hg, if feasible and without cost in health-care terms, would produce more disease prevention than any conceivable clinical strategy. Regrettably, the means to achieve this goal are not available. New tools to improve dietary and behavioral approaches to attaining these goals are desperately needed. For physicians, the immediate issue is how to apply the powerful and varied tools that dramatically lower blood pressure in individual patients. In this clinical setting, blood pressure must be seen for what it is--a reflection of relative risk, a risk factor, and only one of the multiple factors that together determine absolute risk. Blood pressure reduction is not curative (because high blood pressure is not a disease) but rather is a technique to reduce the odds of heart attack, stroke, and renal failure. Hypotensive therapy should therefore be applied when the absolute likelihood for a stroke or heart attack, is great enough to suggest a real chance for benefit by virtue of the reduction of any particular blood pressure level. Therapeutic decisions should weigh the potential for benefit as well as the burden of intervention. The worthy clinician must define those parameters, assist the patient to assess their implications, and finally implement the therapeutic choice that follows, to provide the best possible care.