Rational management of hyperlipidaemia in hypertension

Hypertension and high cholesterol are associated in the population, and have an effect on coronary (CHD) risk which is more than additive. Guidelines for detecting and managing hyperlipidaemia have not been soundly based. A rational policy should be based on the following evidence. Serum total cholesterol (TC) reduction of 1% reduces CHD risk by about 2%; the full effect of TC reduction is attained after 2 years; acceptable diets lower TC little (step-1 diet - 2% TC reduction), effective diets (step-3 diets - 13% TC reduction) are unacceptable; effective TC reduction therefore requires lipid-lowering drugs; the benefit of lipid-lowering drugs exceeds risk when CHD death risk is greater than or equal to 1.5%/year for statins, or is greater than or equal to 3.0%/year for other drug classes; the correct starting point for management is CHD death risk, not TC; knowledge of TC is not needed to estimate CHD death risk. A table to target primary prevention of CHD in hypertensive patients is presented, with the following features. It is simple; identifies those who may have CHD risk greater than or equal to 1.5%/year for TC measurement; identifies TC level for individuals associated with CHD risk greater than or equal to 1.5%/year, which may warrant treatment; and signals no TC measurement for most hypertensive patients who have CHD risk too low to warrant treatment. Targeting management at CHD risk and not TC has interesting consequences. The elderly (60-70y) rather than young are selected for treatment, and in some subjects TC of 5.5 mmol/l warrants treatment, in others TC as high as 9.0 mmol/l does not.