The AHA Guidelines and Scientifi c Statements Handbook
Framingham Heart Study:
1010 - YYCHDRikiM dWearCHD RiskinMen andWomen
Men Women
8090100Men Women
80901004050607040506070% Risk % Risk010203001020300
30-39 40-49 50-59 60-69 70-790
30-39 40-49 50-59 60-69 70-79<6% 6-10% 10-20% >20%
CHD = coronary heart disease.Fig. 11.6 Data from the Framingham Heart Study experience. Much of the middle-aged population has a low to intermediate risk for hard
CHD events (myocardial infarction or CHD death). Even up to age 80 years, more than three-quarters of women experience a 10-year risk of
CHD that falls below 10%. The risks are higher for men, and by age 70 the majority of men are at high risk (>10% per 10 years) for CHD.
Nearly all men in the 70–79 year age group are at high risk. Original fi gure courtesy Peter W. F. Wilson, MD, Framingham Heart Study
(unpublished data). Modifi ed, with permission, from Pasternak et al. [26].
therapy is effective in reducing stroke risk, but evi-
dence for a reduction in coronary events is less
certain (Class IIa; Level of Evidence C).
The choice of drugs remains controversial. There
is a general consensus that the amount of BP reduc-
tion, rather than the choice of antihypertensive
drug, is the major determinant of reduction of car-
diovascular risk; however, there is suffi cient evi-
dence in the comparative clinical trials to support
the use of an ACE inhibitor (or ARB), CCB, or thia-
zide diuretic as fi rst-line therapy, supplemented by
a second drug if BP control is not achieved by
monotherapy. Most patients will require two or
more drugs to reach goal, and when the BP is
20/10 mm Hg above goal, two drugs should usually
be used from the outset either as separate prescrip-
tions or in fi xed-dose combinations. β-Blockers
should not be used as fi rst-line therapy in uncom-
plicated hypertension since outcomes are not as
good as those with ACE inhibitors, ARBs or CCBs
[25]. However, β-blockers are indicated in patients
with coronary artery disease for both symptom relief
and blood pressure control, and the β-blockers
carvedilol, metoprolol and bisoprolol have improved
outcomes in patients with heart failure. In the
asymptomatic post-MI patient, a β-blocker is a
more appropriate choice for secondary prevention
for at least 6 months after the infarction and is the
drug of fi rst choice if the patient has angina pectoris.
(Class I; Level of Evidence A). The European guide-
lines differ [9] from those of the AHA in that β-
blockers are included in the list of fi rst-line drugs for
any patient except those with metabolic syndrome
or at high-risk for incident diabetes. The older
JNC 7 guidelines recommend thiazide diuretics
as the initial agent for patients who do not have