| COMBINATION TREATMENT OF HYPERTENSION AND DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE |
| Studies such as the Multiple Risk Factor Intervention Trial (MRFIT), an epidemiological study of 316.099 men with an average folllow-up of 12 years, have shown that even mild-to-moderate levels of both hypertension (systolic BP 132-141 mm Hg) and dyslipidemia (total cholesterol 221-244 mg/dl) can impart risk for coronary hert dsiease (CHD) that is similar or greater than due to severe elevations of either risk factor alone. Wilson et al from the Framingham Study observed that patients with moderately elevated systolic BP (140-159 mm Hg) and LDL cholesterol (100-159 mg/dl) had a similar 10-year risk of CHD as those with highly elevated systolic BP or LDL cholesterol. |
| Hypertension and dyslipidemia, two of the most prevalent risk factors for CHD frequently occur together. Almost two out of every three patietns with hypertension have dyslipidemia, and more than 2 out of every 5 patients with dyslipidemia have hypertension. The majority of these patients also have at least one other risk factor for CHD (diabetes, smoking, age). This tendency for risk factors to cluster and exert a significant impact on CHD reinforces the need to identify and concurrently treat multiple risk factors to target goals. |
Guidelines today reflect
the ongoing evolution from single risk factor to
comprehensive cardiovascular risk management and
the impact of concomitant risk factors on patients'
risk of morbidity and mortality. Guidelines from
the National Cholesterol Education Program (NCEP
ATP III) classify hypertension (defined as BP 140/90
mm Hg or presence of treatment with antihypertensive
medication) as a major risk factor to be considered
in determing a patients' overall risk for CHD and
in setting LDL goals. Similarly, the JNC-7 report
recommends assessing a patients' lipid profile when
setting appropriate blood pressure treatment goals.
These guidelines also support earlier intervention
in the management of hypertension and dyslipidemia.
JNC-7 recognises the continuous relationship between
blood pressure and cardiovascular disease. The BP
levels previously classified as normal and high
normal are now categorised by JNC-7 as prehypertension
and warrant management to prevent progression to
hypertension. Over the years, the NCEP recommended
threshold for initiation of medical management has
also been lowered, and LDL levels less than 100
mg/dl are now considered optimal. |
| Reductons in BP and cholesterol can significantly improve outcomes. A recent meta-analysis of one million subjects showed that a 2 mm Hg decrease in systolic BP translates into a 7% lower mortlity from ischaemic heart disease and 10% lower stroke mortality. For cholesterol, both MRFIT research group and Lipid Research Clincs Program report that a 1% decrease in serum cholesterol leads to a 2% reduction in coronary events. |
| Recent large outcomes trials demonstrate the need to identify and treat patients with multiple risk factors. In a 5-year, 20,536-patient trial, cholesterol lowering therapy in patients with modest elevations in LDL and at least one additional risk factor for cardiovascular disease significantly reduced coronary death, stroke and cardiac events. In another trial among 10,305 oatients, cholesterol lowering in addition to effective BP conrol among hypertensive patients with at least 3 additional risk factors and modest LDL elevations yielded significant reductions in fatal and nonfatal CHD and stroke. |
| The most recent National Health and Nutrition Examination Survey (NHANES) data show that. Of the 27 million Americans with hypertension and dyslipidemia, less than 10% are trated to both goals. This may, in part, be attributable to the practical challanges of managing several risk factors in an individual patient and patients' lack of adherence to multiple medication regimens. |
| A simple solution would be to combine an effective and safe blood pressure lowering drug with a statin, a proven LDL cholesterol reducing agent. |
| Vivek Dwivedi, Mukesh Sarna Monilek Hospital and Research Centre Jawahar Nagar, Jaipur 302004 |
Available Volumes
| EDITOR IN CHIEF |
| Dr.
Rajeev Gupta (MD PhD FACC) |
 |
| HON. EDITOR |
| Dr.
Soneil Guptha (MD FACC FESC) |
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