Studies support "risk-based" approach to treating people with high blood pressure

The Bottom Line

  • High blood pressure is a common condition. It is a risk factor for heart disease, but it isn’t the only one.
  • Experts believe treatment decisions should be based on individuals’ risk level, rather than on blood pressure scores alone.
  • Drugs that lower blood pressure help prevent heart attack and strokes, and offer the greatest benefit to those at higher risk.
High blood pressure, or hypertension, is a common health concern worldwide. In Canada, an estimated 7.4 million people live with this condition that can increase their risk of strokes, heart attacks and other serious diseases (1).

People are considered to have high blood pressure if they have a “systolic” score of 140 mm Hg or higher, or a “diastolic” score of 90 mm Hg or more. Currently, those numbers are what doctors look at in deciding whether a patient should be given blood pressure-lowering drugs. But there is strong opinion that a risk-based approach is better for determining who would benefit most from medication (2). High blood pressure is only one of several factors that make up a person’s risk of heart disease. Others include age, sex, diet, exercise or smoking habits and the presence of other diseases such as diabetes. Experts say a risk assessment should take all these factors into account.  

The issue has prompted considerable research. A recent meta-analysis summarized the results of 11 relevant randomized controlled trials involving close to 52,000 participants with an average age of 65 (3). Before being given blood pressure-lowering drugs they were assessed and sorted into one of four categories, based on their risk of heart disease. The number of subsequent “events” (stroke, heart attack, etc.) was compared to a “control” group – people who received no treatment.  

What the research tells us

Blood pressure-lowering drugs were effective in reducing heart disease for all risk levels, with the greatest benefit seen in those with the highest initial risk. For example, in the lowest risk category 14 fewer people out of 1,000 had a major heart problem while in the highest risk group that number jumped to 38. The clear correlation between people’s overall risk for heart disease and the effectiveness of the drugs supports a risk-based approach when treating people with high blood pressure.  

About 10 years ago the medical community faced a similar situation when it was proposed that a risk-based approach be used for prescribing cholesterol lowering medication. Today it’s standard practice in most countries and is widely believed to result in more effective and cost- efficient treatment (4).  

Those who support risk-based treatment for high blood pressure maintain it will result in similar health benefits. That could mean a person with slightly raised levels, but with no other risk factors, might be advised to make some dietary/lifestyle changes instead of being prescribed medication. Conversely someone with “normal” blood pressure, but at high overall risk, could be given the drugs as part of a heart disease prevention plan.  

Talk to your doctor about your blood pressure levels and whether you should take medication. Other strategies to help maintain heart health include getting regular exercise, managing stress and eating well. Click here to find out how salt affects your blood pressure. 

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Author Details


  1. Robitaille C, Dai S, Waters C et al. Diagnosed hypertension in Canada: incidence, prevalence and associated mortality. CMAJ. 2012; 184(1):E49-E56. 
  2. Graham I, Atar D, Borch-Johnsen K et al. European Guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2007; 2375:414. 
  3. Sundstrom J, Arima H, Woodward M et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014; 384:591-8. 
  4. Stone N, Robinson J, Lichenstein A et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation. 2014; 129:S1-45.

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