SAGE-Hindawi Access to Research International Journal of Hypertension Volume 2011, Article ID 595791, 3 pages doi:10.4061/2011/595791 Review Article Management of High Blood Pressure in Those without Overt Cardiovascular Disease Utilising Absolute Risk Scores Mark R. Nelson Discipline of General Practice, Menzies Research Institute, Private Bag 23, Hobart, TAS 7001, Australia Correspondence should be addressed to Mark R. Nelson, Mark.Nelson@utas.edu.au Received 22 January 2011; Accepted 31 March 2011 Academic Editor: Samy I. McFarlane Copyright © 2011 Mark R. Nelson. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Increasing blood pressure has a continuum of adverse risk for cardiovascular events. Traditionally this single measure was used to determine who to treat and how vigorously. However, estimating absolute risk rather than measurement of a single risk factor such as blood pressure is a superior method to identify who is most at risk of having an adverse cardiovascular event such as stroke or myocardial infarction, and therefore who would most likely beneﬁt from therapeutic intervention. Cardiovascular disease (CVD) risk calculators must be used to estimate absolute risk in those without overt CVD as physician estimation is unreliable. Incorporation into usual practice and limitations of the strategy are discussed. 1. Introduction Physicians treat diseases. For this reason when increasing blood pressure was recognized as a risk factor for coronary artery disease and stroke, it was dichotomized into a disease state “hypertension” and a nondisease state “normotension” by creating an arbitrary cut point. This cut point has gen- erally become lower over time as evidence of beneﬁt in treating blood pressure levels lower than the contemporary accepted cut points accumulated. Recognition of other risk factors such as dyslipidemia, higher risk groups such as the aged [1, 2], and those with comorbid conditions such as diabetes [3] has led to diﬀerential treatment thresholds and target blood pressures resulting in confusing or conﬂicting guideline recommendations, depending on which peak body produced them. Is there a simpler way to identify those most likely to have a major adverse cardiovascular event who do not have overt disease, and therefore who needs rigorous therapeutic intervention for their blood pressure and other CVD risk factors? 2. Absolute Cardiovascular Risk Increasing blood pressure has a log-linear relationship with adverse risk for cardiovascular events [4]. Using this ﬁgure alone in clinical decision making risks overtreatment (“med- icalization” where medication adverse events likely to exceed beneﬁt, and adverse cost-eﬀectiveness) and undertreatment (failure to act where medication beneﬁt is likely to exceed adverse events and be cost eﬀective). Estimating absolute risk, the risk of having an adverse cardiovascular event over a speciﬁed period of time (usually 5 or 10 years), is a superior method to measurement of blood pressure alone to identify who is most at risk of having a cardiovascular event and therefore who would most likely beneﬁt from intervention [5, 6]. It does this because the ﬁgure derived is more holistic, incorporating other CVD risk factors that explain almost all risk including blood pressure, and directly estimates why we treat blood pressure in any population without CVD, to prevent its onset and complications. Guidelines are increasingly recognizing the beneﬁt of utilizing absolute risk scores rather than blood pressure measurements alone [7– 12]. 3. Cardiovascular Disease Risk Calculators CVD risk calculators are based on algorithms derived from observational prospective cohort studies such as the Fram- ingham study [13, 14]. CVD risk calculators must be used to estimate absolute risk in those without prior CVD events