Can we stratify risk to guide therapy

The relation of blood pressure to cardiovascular (CVD) disease is direct, continuous, and independent. Nevertheless, blood pressure alone is a poor predictor of CVD events. In fact, the totality of factors, including smoking, cholesterol, diabetes, target organ damage, and existing cardiovascular disease, together, permit discrimination of persons with similar blood pressure into subgroups with event expectations that might differ by more than twenty-fold. Thus, absolute CVD risk, rather than level of blood pressure, should determine the need for antihypertensive treatment. In addition, conventional treatment, even when effective, prevents only 25% of expected events. Observational study of long term treated patients provides the basis for pre-treatment stratification of CVD risk in patients who will maintain "normal" blood pressure in treatment. This stratification scheme makes it possible to modulate the intensity of therapy to match the potential for CVD prevention. Finally, specific risk factors, influenced by particular antihypertensive therapies, may guide drug selection in individual cases.