RECOMMENDED READING
2-19 THE HYPERTENSION DETECTION AND FOLLOW-UP PROGRAM 17 YEARS ON
The HDFP was published in 1979. This landmark study found that, overall, lowering diastolic BP by 5-6 mm Hg for 5 years reduced cardiovascular deaths by 20%, fatal stroke by 45%, and nonfatal myocardial infarction by 12%.
However, there were great differences in absolute risk in subgroups. The benefit of drug therapy for hypertension is heavily influenced by the initial absolute cardiovascular risk. Whites have less risk than blacks; young less risk than old; those with lower BPs have less risk than those with higher levels. Those with target damage have the highest risk.
In those age 30-49, step care of 600 subjects for 5 years prevented one death from stroke, one non-fatal stroke, and the development of left ventricular hypertrophy in 2. The number needed to treat in this age group is high.
The author of this article adds 9 words to the conclusion of the original report: systematic management of hypertension reduces mortality in people with high blood pressure, including these with mild hypertension who have cardiovascular risk sufficiently high to warrant (drug) treatment.
Would fully informed subjects on average choose to take treatment for 5 years for a 1 in 300 chance of preventing a cardiovascular event? We do not know and we should ask them.
JAMA January 8, 1997; 277: 167-70 "Landmark Perspective" from Royal Hallamshire Hospital, Sheffield, England
The original 1997 article is reprinted on pages 157-166.

Comment:
Again, this concerns drug therapy. Life-style therapy should be prescribed in all patients with hypertension, even the mildest. The benefit/harm-cost ratio of life-style therapy is high.
At age 40, I would be willing to take low-dose diuretic therapy even though the risk of an adverse event is low. This is because early continued treatment will likely prevent development of more severe hypertension at age 50-60, and lessen the likelihood of later target organ damage. RTJ

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