1. William B. Kannel, MD, FACC Former Director, Framingham Heart Study
Epidemiologic and Clinical Significance of Incremental Changes in Blood Pressure
William B. Kannel, MD, FACC
Professor of Medicine and Public Health Boston University School of Medicine
Former Director, Framingham Heart Study

2. Hypertension Is a Major Treatable Risk Factor for Cardiovascular Disease
Powerful independent risk factor for CHD, stroke, PAD, and heart failure
Relationship with risk is continuous and graded
Benefits of blood pressure reduction with pharmacologic treatment are incremental and continuous
CHD = Coronary heart disease.
PAD = Peripheral arterial disease.

3. Coronary Heart Disease Risk by Major Risk Factors5
Coronary Heart Disease Risk by Major Risk Factors
Framingham Study—36-yr Follow-up
Elevated Hypertension Diabetes Smoking cholesterol
Risk ratio
35-64 yr 1.9** 1.8* 2.0** 2.2** 1.5** 3.7** 1.5** 1.1
65-94 yr ** 1.6** 1.9** 1.6* 2.1**
*p < 0.01; **p < Kannel WB. Framingham Heart Study.

4. Risk for Cardiovascular Events by Diastolic Blood Pressure
Framingham Study
Patients aged 35 to 64 yr, initially free of CVD; 38-yr follow-up
Kannel WB. Framingham Heart Study.

5. Risk for Cardiovascular Events by Systolic Blood Pressure
Framingham Study
Patients aged 35 to 64 yr, initially free of CVD; 38-yr follow-up
Kannel WB. Framingham Heart Study.

6. Relative Risks of Stroke and Coronary Heart Disease†5
Relative Risks of Stroke and Coronary Heart Disease†
Stroke
CHD
7 prospective observational studies:
843 events
9 prospective observational studies:
4,856 events
4.00
4.00
2.00
2.00
1.00
1.00
Relative risk of stroke
Relative risk of CHD
0.50
0.50
0.25
0.25 76 84 91 98
105 76 84 91 98
105
Approximate mean usual DBP, mm Hg
†420,000 patients for CHD, 405,500 patients for stroke, 10-yr mean follow-up period. MacMahon et al. Lancet. 1990;335;

7. 5
Reducing Diastolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risk†
†420,000 patients for CHD, 405,500 patients for stroke, 843 strokes, 4,856 CHD events,
10-yr mean follow-up period.
MacMahon S, et al. Lancet. 1990;335:

8. Observational studies,† mm Hg Drug treatment trials,†† mm Hg
Incremental Reduction in Diastolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risk
Observational studies,† mm Hg
Drug treatment trials,†† mm Hg –2
–5 to –6
–7.5
–2†††
–5 to –6
–7.5†††
†Data from MacMahon S, et al. Lancet. 1990;335:
††Adapted from Hebert PR, et al. Arch Intern Med. 1993;153:
†††Estimated risk reduction.

9. Advantage of Additional BP Reduction: NNTT to Prevent 1 Stroke Event†
Framingham average Reduction in DBP NNTT risk/10 yr
5 - 6 mm Hg Average risk 28 38% High risk†† 15 46%
7.5 mm Hg Average risk 20 38% High risk†† %
NNTT = Number needed to treat.
†Men aged 60 to 69 yr.
††Smoker, SBP 150 mm Hg, CVD, HDL < 40 mg/dL, cholesterol > 260 mg/dL.
Kannel WB. Framingham Heart Study.

10. Reduction in Systolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risks
SHEP† Syst-Eur††
Baseline BP, mm Hg 170/77 184/85
BP reduction, mm Hg 11/3 10/4-5
†SHEP. JAMA. 1991;265: ††Staessen JA, et al. Lancet. 1997;350:

11. US Adults With Hypertension Unmet Medical Need
Percent†
Aware
Treated
Controlled††
NHANES III (Phase 2) (JNC VI). Estimated 50 million adults with hypertension in the US.
†Percent = Proportions based on persons with hypertension in the survey.
††BP < 140/90 mm Hg.

12. Physician Practices Treating Hypertension
Hypertension, particularly ISH, seldom treated to recommended goal
No increase in medication at 75% of visits despite continued BP elevation
Drugs rarely up-titrated; reluctance to include additional drugs
Therefore, more effective monotherapy drugs could facilitate attaining recommended treatment goals
ISH = Isolated systolic hypertension.
Coppola WG, et al. J Hum Hypertens. 1997;11:
Berlowitz DR, et al. N Engl J Med. 1998;339:

13. Conclusions: Importance of Incremental Blood Pressure Reduction
Hypertension is a major treatable risk factor for CVD including CHD, stroke, PAD, and heart failure
Incremental blood pressure reduction is meaningful from a public health perspective
Benefits of blood pressure reduction with pharmacologic treatment are incremental and continuous
Compelling need for clinicians to use the more effective BP-reducing drugs to achieve recommended treatment goals in individual patients