Hypertension, Genes, and Environment
Challenges for Prevention and Risk Prediction
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Article, see p 653
Despite substantial progress in treatment and control, hypertension still accounts for 10% of the population attributable risk for all-cause mortality in most societies.1 In addition to better pharmacological control, a preventive population approach is needed because the lifetime incidence of hypertension is 90%, and the years spent with a high normal blood pressure (BP) also have vascular consequences. Unfortunately, the challenge of primary prevention has not even been seriously addressed, at least in the United States.2 Therefore, much research on BP is an attempt to move forward from the traditional, and some might say antiquated, approach of repeated measurements of a patient’s BP, estimation of average risk based on data from published studies, followed by life-long therapy with daily medications. Enthusiasts of the precision medicine paradigm argue that prediction of risk based on genetic susceptibility, coupled with individualized choices of therapy, will add great efficiency to the management of high BP.
To address that question, in this issue of Circulation, Pazoki and colleagues3 compared the relative impact of lifestyle factors on BP versus a suite of 314 risk alleles in a cohort of 277 000 persons in the UK Biobank. The main finding was a systolic BP difference of 3.5 mm Hg in the high- versus low-risk tertiles of risk, which was equivalent for both lifestyle factors and genetic risk. As expected, clinical events tracked the BP gradient. The broad overlap of BPs across the risk strata will mean that perhaps half of patients could be misclassified and therefore both measures have little predictive …