2 as physician estimation is unreliable [15]. Physicians can reliably estimate relative risk, the risk of an individual having a myocardial infarction or stroke relative to others of the same age and gender. The problem with relative risk is that by its very nature it excludes the two most important drivers of CVD risk, age and gender. There are validated algorithms speciﬁcally derived from hypertensive populations available [16] but such scores would tend to fragment absolute risk scores back into their constituent risk factor classiﬁcation rather than unify and simplify the process. Similarly there have been many validated algorithms using other than the “classic” risk factors used in the Framingham risk score (age, gender, blood pressure, serum cholesterol, smoking status, and presence of diabetes) but the beneﬁts of this increase in complexity is marginal. Absolute risk scores (ARS) derived from these algorithms have proven to have good discrimination in their source population (e.g., Framingham risk score C statistic 0.763 (males), 0.793 (females) [13]) but do have problems in sub- groups not adequately represented in the study population. For example, calculators derived from the Framingham risk score have an upper age limit because no persons over 74 years were included in the study population [17]. Obviously, from an international perspective, not only subgroups but whole populations were missing. For example, Australian aborigines, an important high adverse CVD risk ethnic minority in Australia, have resisted all attempts to be reliably and validly incorporated into Australian algorithms derived from the Framingham risk score [11, 18]. Limitations in ARS use include the following. (1) It should not be utilized in those with overt CVD. They are by deﬁnition at high risk and should be aggressively managed. (2) Those with target organ damage due to elevated blood pressure such as left ventricular hypertrophy and hypertensive retinopathy or nephropathy. Such individuals have progressed from a risk factor to a disease state. (3) Those with blood pressure ≥180/100 mm Hg. (4) Those from a non-Caucasian population unless the risk score utilized has been derived from and/or validated in this population or has been recalibrated. Once identiﬁed and the decision has been made to treat based on absolute risk score, then management reverts to that of the individual risk factor. The concept of treating absolute risk per se is supported by clinical trials such as the HOPE study [19], but the hypothesis needs to be formally tested in studies such as ongoing and planned “polypill” trials [20]. This management strategy promises simpler treatment regimens, lower direct costs, and superior clinical outcomes. Outside of the “polypill” approach it would give physicians therapeutic ﬂexibility. If adverse eﬀects prevent drug therapy of a particular risk factor then intervene on another. International Journal of Hypertension 4. Conclusions Management of persons with elevated blood pressure is best done through an absolute risk approach including the use of absolute risk scores. This promises better targeted therapy, simpler more ﬂexible management regimens, and superior clinical outcomes. References [1] N. M. Kaplan, “Systolic hypertension in the elderly program (SHEP) and swedish trial in old patients with hypertension (STOP). the promises and the potential problems,” American Journal of Hypertension, vol. 5, no. 5, part 1, pp. 331–334, 1992. [2] SHEP Cooperative Research Group, “Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension,” The Journal of the American Medical Association, vol. 265, no. 24, pp. 3255–3264, 1991. [3] S. M. Haﬀner, S. Lehto, T. Ro¨nnemaa, K. Pyo¨ra¨la¨, and M. 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[7] Guidelines Committee, “European society of hypertension- european society of cardiology guidelines for the management of arterial hypertension,” Journal of Hypertension, vol. 21, no. 6, pp. 1011–1053, 2003. [8] A. V. Chobanian, G. L. Bakris, H. R. Black et al., “The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report,” Journal of the American Medical Association, vol. 289, no. 19, pp. 2560–2572, 2003. [9] British Cardiac Society, British Hypertension Society, Diabetes UK, Heart UK, Primary Care Cardiovascular Society, and Stroke Association, “JBS 2: joint British societies’ guidelines on prevention of cardiovascular disease in clinical practice,” Heart Journal, vol. 91, supplement 5, pp. 1–52, 2005. [10] National Heart foundation of Australia (national blood pressure and vascular disease advisory committee), Guide to management of hypertension, 2008. [11] National Vascular Disease Alliance, “Guidelines for the assess- ment of absolute cardiovascular disease risk,” 2009. [12] Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice, “European guidelines on cardiovascular disease prevention in clinical practice,” European Heart Journal, vol. 24, no. 17, pp. 1601–1610, 2003. [13] R. B. D’Agostino, R. S. Vasan, M. J. Pencina et al., “General cardiovascular risk proﬁle for use in primary care: the Framingham heart study,” Circulation, vol. 117, no. 6, pp. 743– 753, 2008.