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lthough blood pressure (BP) is the main variable determining cardiovascular (CV) risk in hypertensive patients, recent guidelines emphasize that management of hypertension should be related to quantification of the total CV risk. 1 This concept is based on the fact that, when concomitantly present, BP and other risk factors augment the risk and lead to a greater CV risk than the sum of the individual components. 2 Article p 1080 The most common clinical variables that should be used in stratification are risk factors, target organ damage, dia betes and established CV or renal disease. High total CV risk is a subgroup of patients with a previous diagnosis of CV disease, besides the subgroups of patients with diabetes mellitus and with severely elevated single risk factors. 1 In addition, it is widely accepted that subclinical organ damage plays a crucial role in determining the CV risk of hypertensive patients. Of these, there has been further confirmation of the adverse prognostic role of left ventricular hypertrophy (LVH), together with evidence that it is fairly common in hypertensive patients. 3 Accordingly, evaluation of cardiac complications, such as previous CV disease and the presence of LVH, is useful for detecting hypertensive subjects at increased risk of CV disease. However, whether each component cardiac complication has separate implications on the outcome of long-term CV events in hypertensive patients is not known with certainty. Ueshima et al, reporting in this issue of the Journal, 4 provide the interesting piece of information that each of 2 cardiac complications, LVH and ischemic heart disease (IHD), has a different effect on the incidence of future CV events in Japanese high-risk hypertensive patients. By using enrolled participants of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial, the authors evaluated 2,030 and 2,673 high-risk hypertensive patients with and without cardiac complications. The incidence of CV events, represented as a composite of sudden death, cerebrovascular, cardiac, renal and vascular events, was compared between patients with and without the complication of LVH and/or IHD in this post-hoc study. During 3.2 years of follow-up, the authors proved that cardiac complications as a whole are associated with the CV events rate, and further, both LVH and IHD are independent predictors for CV events. Moreover, the authors found that there are different effects on each event category of CV events between LVH and IHD. After adjustment for baseline characteristics, LVH is linked to cerebrovascular events, but not to CV death or other cardiac events, whereas IHD is associated with cardiac death, especially sudden death, and other cardiac events, but not with cerebrovascular events. Neither LVH nor IHD related to the onset of renal and vascular events. An extensive body of population studies has provided consistent evidence that LVH confers increased risk for CV events, including heart failure, myocardial infarction, sudden

Left Ventricular Hypertrophy, Ischemic Heart Disease and the Incidence of Cardiovascular Events in Japanese High-Risk Hypertensive Patients