Features November 2014 Issue

Treating Hypertension, Cholesterol Demands a Big-Picture Look at CVD

Research suggests that it’s best to consider your overall cardiovascular disease risks before starting treatment for individual risk factors.


Image: Thinkstock

If you’ve been diagnosed with high blood pressure or high cholesterol, you may find yourself focused on getting those numbers down into the healthy ranges. And while that’s an appropriate response, your treatment plan for hypertension or high cholesterol should take into consideration all the risk factors for cardiovascular disease (CVD). That means paying attention to your blood glucose levels, weight, physical activity level, smoking, alcohol use, and even stress.

Taking a look at the big picture of CVD risk, rather than isolated components, is the takeaway message of recent research compiled by the Blood Pressure Lowering Treatment Trialists’ Collaboration (BPLTTC). A similar study by the Cholesterol Treatment Trialists Collaboration (CTTC) also stressed the importance of basing a treatment plan on a patient’s overall CVD risk. The BPLTTC study was published in The Lancet.

Cardiologist Steven Nissen, MD, chairman of Cardiovascular Medicine at Cleveland Clinic, was among the doctors whose research was used in the study. He also agrees that no one risk factor should become your focus, especially at the expense of the others.

“We’ve been so effective at educating people about cholesterol and blood pressure, but it’s really about all the risk factors,” Dr. Nissen says. “You’ve got to focus on the sum of the parts.”

Understanding CVD
Cardiovascular disease is actually an umbrella term for several problems related to the health of your heart and the body’s network of veins and arteries—the vascular or circulatory system. Many of these problems are related to atherosclerosis, the buildup of plaque in the arteries that restricts blood flow. Blockages in certain arteries can lead to heart attacks and strokes.

But CVD can also refer to conditions such as heart failure, abnormal heart rhythms (arrhythmias) and heart valve problems.

In some cases, a heart-healthy lifestyle isn’t enough to prevent CVD. You may be born with a congenital heart defect or have a strong family history of heart disease, hypertension or high cholesterol. But many of the key risk factors for CVD are modifiable. The key is your willingness to be proactive about your cardiovascular health.

CVD prevention, treatment
For example, blood pressure control can be greatly influenced by maintaining a healthy weight, regular exercise, a low-salt diet and the use of anti-hypertensive medications if needed. The BPLTTC study emphasized, though, the need for a doctor and patient to explore the patient’s five-year risk for a major cardiovascular event before embarking on a treatment plan for blood pressure control.

A patient with borderline high blood pressure may not see the need for an aggressive treatment program. But if that same individual has recently been diagnosed with diabetes, the overall CVD risk is more serious than what simply having borderline hypertension might suggest. That patient’s medication regimen and treatment plan need to consider how the diabetes will start to affect blood pressure.

Goals vs. overall risk
Recent changes to the guidelines for blood pressure and cholesterol treatment place an emphasis on overall CVD risks. And in some cases, specific goals have been downplayed in the effort to get patients and doctors looking at the big picture.

And while Dr. Nissen agrees that all risk factors deserve attention, he also sees a place for blood pressure and cholesterol targets.

“I think goals are good for patients,” Dr. Nissen says. “It give them something specific to work toward, and then you can have a certain sense of satisfaction when you reach those goals.”

The challenge, he adds, is that not all health care providers agree on the most appropriate goals.

“Over and over again studies have shown that lower blood pressures are better,” Dr. Nissen says. “The question is always, ‘What is the threshold of blood pressure that we should treat?’ A healthy blood pressure is still under 120/80. We will continue to debate, however, what to do with people in the 120 to 140 range.”

The exception may be in the elderly, because research in recent years points to some advantages in having higher blood pressure at an advanced age.

When the risk is low
Both Dr. Nissen and the researchers with the BPLTTC agree that a big-picture, or holistic, look at your cardiovascular health and risks is especially important for individuals considered at low risk. These are people who might look at their blood pressure and cholesterol numbers and see they’re in a healthy range and ignore some of the other risk factors that may become problems down the road.

Study author Johan Sundstrom, MD, with Uppsala University of Sweden, suggests that low-risk individuals may benefit greatly from joint decision making with their doctors. “This may increase adherence to preventive treatment,” he says.

If you ever have questions about your overall CVD risk, or how your current treatment plan addresses (or fails to address) all of your risk factors, discuss your concerns with your doctor.


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