Patients with hypertension, dyslipidaemia, diabetes mellitus, family history of premature coronary heart disease, or a combination of these risk factors, are at high risk of developing coronary heart disease or other atherosclerotic disease. Patients with diabetes mellitus are at particularly high risk. Individuals at high multifactorial risk of developing coronary heart disease, or other atherosclerotic disease, can be identified from the coronary risk prediction chart (figure).
As absolute risk of coronary heart disease (non-fatal myocardial infarction or death from coronary heart disease) increases, so lifestyle intervention should be intensified. Introducing drug treatment for raised blood pressure or lipid concentrations should be strongly determined by the absolute level of risk of developing disease(see table). An absolute risk of coronary heart disease
15% (equivalent to a cardiovascular risk of 20%) over 10 years is sufficiently high to justify drug treatment.
Exceptions to treatment based on absolute risk are:
- Hypertension (systolic blood pressure >160 mm Hg or diastolic blood pressure >100 mm Hg) or hypertension with associated target organ damage
- Familial hypercholesterolaemia or other inherited dyslipidaemia
- Diabetes mellitus with associated target organ damage.
- Drug treatment is required for all these patients to reduce the risk of coronary heart disease (and cardiovascular risk).
A staged approach to managing patients at high risk is advised. As a minimum, those with an absolute coronary heart disease risk
30% should be targeted and treated now and, as resources allow, individuals with a risk
15% should be progressively targeted. For all high risk patients, every effort should be made to achieve the lifestyle, risk factor, and therapeutic targets given in the table.
Wood DA, Durrington P, McInnes G, Poulter N, Rees A, Wray R. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998;80(suppl):S1-29.
British Hypertension Society. Guidelines for hypertension management 1999:summary. BMJ 1999;319:630-5.
Other resources available from the British Heart Foundation
- BHF Factfiles 8/99 and 9/99
- Colour wall poster of the coronary risk prediction chart
- Cardiac risk assessor program to estimate absolute risk of coronary heart disease (or cardiovascular risk) on a personal computer
- Contact the British Heart Foundation (tel: 020 7935 0185; fax: 020 7486 1273)