Effect of risk status on treatment criteria. Implications of hypertension trials.

When deciding whether to treat a patient with hypertension, clinicians must balance the benefit of treatment against its adverse effects. In the absence of an interaction, the multiplicative model of risk implies that the absolute benefit of treatment is related to the underlying risk of an adverse outcome. Thus, each additional risk factor multiplies the absolute benefit of treating hypertension. Analyses of data from subgroups in clinical trials of hypertension treatment suggest that this model is usually valid. In contrast, the adverse effects of treatment are usually unrelated to other risk factors. Thus, the cutoff point for treatment differs in different individuals: setting a single treatment threshold and goal for the entire population is not appropriate. Patients who are at high absolute risk because of prior coronary artery disease or other risk factors have a greater potential absolute benefit, and such patients deserve a low threshold and goal, such as a diastolic blood pressure of 90 mm Hg. Conversely, persons at low risk, such as white women without other risk factors, do not require such aggressive management.