Preventing cardiovascular disease in hypertension: effects of lowering blood pressure and cholesterol

Background: In guidelines for the primary prevention of cardiovascular disease, systolic blood pressure (SBP) or diastolic blood pressure (DBP) is treated with medication at lower levels of risk than those at which statin treatment is recommended for cholesterol lowering. Aim: To compare the potential benefits of antihypertensive medication and statin therapy in hypertensive patients, and examine whether this policy is rational. Design: Retrospective cross-sectional survey. Methods: We studied 146 men and 150 women aged 56 (54-58) (mean (95% CI)) years and 60 (58-62) years, respectively, who had commenced drug therapy for hypertension within 10 years in five general practices in Greater Manchester. Coronary heart disease (CHD) and stroke risk were calculated, and the potential benefit of blood pressure lowering treatment and statin therapy estimated using the results of published meta-analyses of clinical trials. Results: Blood pressure before treatment was initiated was 176 (173-179)/102 (100-104) mmHg in men and 176 (172-179)/98 (96-100) mmHg in women. Serum cholesterol was 5.7 (5.5-5.9) mmol/l and high density lipoprotein (HDL) cholesterol 1.3 (1.2-1.4) mmol/l in men. The corresponding values in women were 6.3 (6.1-6.5) mmol/l and 1.5 (1.4-1.6) mmol/l. Of the men, 44% (36-52%) smoked and 23% (17-31%) had diabetes mellitus, whereas 27% (20-35%) of the women smoked and 26% (19-34%) had diabetes. These risk factors gave the combined group of men and women a CHD risk of 19.7% (12.0-28.0%) (median (IQR)) and a stroke risk of 8.8% (3.8-13.9%) over the next 10 years. All patients were prescribed antihypertensive medication and 15% subsequently received statin treatment. The 10-year CHD risk would be expected to decrease to 16.5% (10.1-23.5%) on anti-hypertensive therapy. Had statin treatment been given instead, it would have been reduced to 13.2% (8.05-18.7%). For stroke, the 10-year risk on antihypertensive therapy was calculated as 5.5% (2.4-8.6%) and on statin 6.2% (2.7-9.9%). This meant that combined CHD and stroke risk would be reduced from 29.4% (17.5-41.5%) to 22.4% (17.5-41.5%) on antihypertensive therapy and to 20.1% (11.9-28.2%) on statins. The difference between statin and antihypertensive therapy was statistically significant (p<0.0001). Discussion: Because the object of drug treatment in mild-moderate hypertension is to reduce cardiovascular disease risk and not simply to decrease blood pressure, current recommendations and practice should be revised so that more patients can benefit from evidence-based therapy favouring a more holistic approach, including cholesterol-lowering therapy.