Risk predictors, risk indicators, and benefit factors in hypertension.

Hypertension, cigarette smoking, and hypercholesterolemia are the most important treatable factors that predispose patients to coronary heart disease. Numerous epidemiologic studies have investigated the importance of single risk factors and the extent of their interaction. These studies have demonstrated that the incidence of coronary heart disease is greatly augmented if more than one risk factor is present. The recent British Medical Research Council mild hypertension trial demonstrated that blood pressure reduction was highly effective in preventing stroke, although there were important differences between smokers and nonsmokers with regard to the efficacy of individual drugs. In this trial, there was no overall reduction in coronary heart disease morbidity or mortality. Other trials such as the Veterans Administration Cooperative Study on Antihypertensive Agents, the United States Public Health Service Hospital Cooperative Study, the Australian Therapeutic Trial in mild hypertension, and the European Working Party Trial on High Blood Pressure in the Elderly have failed to demonstrate significant reduction in coronary heart disease mortality. The Pooling Project and other epidemiologic studies have identified other factors that are associated with increased coronary heart disease; these include glucose intolerance, hypertriglyceridemia, hyperuricemia, obesity, lack of exercise, and, more arguably, type A personality. Methods of controlling these factors should involve both patient education programs promoting change in life-style, such as those proposed by the American Heart Association, and pharmacologic interventions. The British Medical Research Council trial and other such trials have shown the importance of interactions between antihypertensive therapy and individual risk factors, not all of which are readily predictable and some of which may be adverse. Coronary heart disease is now the leading cause of death in many countries and is the major unsolved problem in the treatment of hypertension. A successful attack on this problem would necessarily involve application of a number of measures and the tailoring of such measures to the needs of individual patients.