Benefit Assessment
I have been thinking a lot lately about the concept of risk and benefit. Over the last 20 to 25 years or so we have become quite adept at calculating risk for individual patients. Certainly from a cardiovascular point of view we are very good at defining high risk individuals, i.e. those at a high likelihood of having a first or subsequent adverse CV event. To date our strategy has been to treat high risk individuals aggressively, attempting to reduce CV events. In many cases this is completely appropriate.
Taking medications regularly...
Taking medications regularly and potentially for the rest of your life can be difficult. Sometimes it is a difficulty in remembering to take pills, especially when your medication schedule is complex. In other cases it has more to do with the psychological barriers associated with needing to take “drugs”. I think it is worth understanding the balance between potential benefits and potential downsides to taking medication.
Thoughts on therapeutic choices
When treating with anti-hypertensive agents several principles can help guide therapeutic choices;
Out of Office BP Monitoring
The most important component to the evaluation and treatment of hypertension is the accurate measurement of BP. Evaluation of BP in the office is limited by; small number of measurements, poor technique, the white coat effect (increase in BP in the medical environment) and the masked effect (a decrease in BP that happened in the medical environment). For these reasons there is considerable increased focus on out of office BP measurements. This includes the utilization of either home self-BP measurement or ambulatory blood pressure measurement (ABPM).
Which anti-hypertensive agent?
Patents at low cardiovascular risk and stage 1 hypertension can be initially treated with lifestyle modification solely. Those with manifestations of target organ damage and sustained BP >140/90 should have initiation of pharmacologic therapy after diagnosis of hypertension is confirmed.