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The scope of hypertension

Hypertension is the most prevalent cardiovascular disorder affecting 20–50% of the adult population in developed countries (1). Whenever we compare the prevalence of hypertension, we should be aware that this is heavily dependent on the definition of hypertension, population examined, number of blood pressure readings taken on each occasion and, finally, on the number of visits. A recent comparative analysis of hypertension prevalence and blood pressure levels in six European countries, Canada and the USA, based on the second blood pressure reading, showed a 60% higher prevalence of hypertension in Europe compared with the USA and Canada in population samples aged 35–64 years (2). There were also differences in the prevalence of hypertension among European countries, with the highest prevalence in Germany (55%), followed by Finland (49%), Spain (47%), England (42%), Sweden (38%) and Italy (38%). Prevalences in the USA and Canada were half of the rates in Germany (28% and 27%, respectively). Findings from the WHO MONItoring trends and determinants in CArdiovascular diseases (MONICA) Project showed a remarkably higher prevalence of hypertension in Eastern Europe, and virtually no difference in the rates of controlled hypertension among Eastern and Western populations (3). Hypertension is a well-established risk factor for the development of all clinical manifestations of atherosclerosis. Elevated blood pressure is a common and powerful predisposing factor for the development of coronary heart disease, stroke, peripheral arterial disease and heart failure (4). Randomized clinical trials of blood pressure lowering using different drugs have convincingly shown that the risks associated with rising blood pressure can be substantially reduced, particularly for stroke but, also, for coronary heart disease and heart failure. The impact of hypertension on the incidence of cardiovascular disease in the general population is best evaluated from the population-attributable risk. The statistics take into account both the prevalence of the risk factor (hypertension) and the strength of its impact (risk ratio) on cardiovascular disease. Because of the high prevalence of hypertension in the general population and its risk ratio, approximately 35% of atherosclerotic events are attributable to hypertension. The odds ratio or the relative risk to the individual increases with the severity of hypertension, but the attributable risk is greatest for mild hypertension because of its greater prevalence in the general population. Therefore, the burden of cardiovascular disease that arises from hypertension in the general population comes from those with relatively mild blood pressure elevation (5). About half of the cardiovascular events in the general population occur at blood pressure levels below those recommended for treatment with antihypertensive medications. This indicates a need for vigorous non-pharmacological treatment of persons with high-normal blood pressure and for initiating drug treatment in the vast majority of patients with mild hypertension based on their total cardiovascular risk. The 2003 European Society of Hypertension– European Society of Cardiology Guidelines for the