Why is cardiovascular risk stratification important in hypertensive patients?

Figures & data

Table I. Baseline and final data after 1-year follow-up in hypertensive patients.

	Baseline	1 year	p-value
CBP systolic, mmHg (SD)	153.88 (10,11)	148.06 (19.7)	<0.001
CBP diastolic, mmHg (SD)	90.80 (8.34)	86.46 (10.02)	<0.001
SBPM systolic, mmHg (SD)	142.5 (13.08)	136.7 (13.9)	<0.001
SBPM diastolic, mmHg (SD)	85,79 (9.144)	82.34 (9.32)	<0.05
ABPM systolic-day, mmHg (SD)	138.04 (9.71)	135.64 (11.09)	<0.05
ABPM diastolic-day, mmHg (SD)	85.80 (10.23)	84.28 (10.20)	ns
Smokers, %	20.2	20.2	ns
BMI (SD)	28.83 (4.15)	28.72 (4.22)	ns
Fasting glucose, mg/dl (SD)	89.74 (12.34)	89.57 (12.23)	ns
Cholesterol, mg/dl (SD)	215.19 (36.66)	210.63 (34.24)	<0.05
Cholesterol-LDL, mg/dl (SD)	130.65 (31.30)	127.48 (29.28)	ns
LVH by ECG, n (%)	99 (20.7)	110 (23.0)	ns
GFR <60 mil/min/1.73m2, n (%)	48 (10.0)	34 (7.0)	0.09
FO advanced damage, n (%)	49 (10.2)	27 (5.7)	<0.05
High UAER, n (%)	11 (2.4)	9 (2.0)	ns
Cardiovascular risk ESH Guidelines, n (%)			<0.001
Low, moderate	304 (63.5)	325 (67.7)
High, very high	175 (36.4)	154 (32.2)
Target organ damage, n (%)			<0.001
No	307 (64.0)	355 (74.1)
1	138 (28.8)	98 (20.4)
>1	34 (7.1)	26 (5.4)

To convert cholesterol mg/dl into mmol/l, multiply by 0.0259. To convert glucose mg/dl into mmol/l, multiply by 0.0555. To convert triglyceride mg/dl into mmol, multiply by 0.0113. CBP, clinic blood pressure; SBPM, self-blood pressure measurement; ABPM, ambulatory blood pressure measurement; BMI, body mass index; LDL, low-density lipoprotein; LVH, left ventricular hypertrophy; ECG, electrocardiogram; GFR, glomerular filtration rate; FO, fundus oculi; UAER, urinary albumin excretion rate; ESH, European Society of Hypertension.

Table II. Baseline variables according to cardiovascular risk ESH guidelines.

	Low/moderate CV risk, n =304	High/very high CV risk, n =175	p-value
Age, years, n (%), ≥55 men; ≥65 women	132 (43.4)	68 (38.8)	ns
Gender, n (%), men	168 (55.2)	87 (49.7)	ns
CBP, mmHg, n (%)			<0.005
140–159/90–99	232 (76.4)	111 (63.4)
≥160/100	72 (23.6)	64 (36.5)	Ns
Smoker, n (%)	52 (17.1)	39 (22.2)	ns
Fasting glucose >101mg/dl, n (%)	38 (12.5)	17 (9.7)	ns
Cholesterol >190 mg/dl, n (%)	224 (73.6)	100 (57.1)	<0.001
LDL-cholesterol >115 mg/dl, n (%)	172 (56.5)	73 (41.7)	<0.005
HDL-cholesterol, <40 mg/dl men/ <46 mg/dl women, n (%)	26 (8.2)	12 (6.8)	ns
Triglycerides >150 mg/dl, n (%)	63 (20.7)	33 (18.8)	ns

ESH, European Society of Hypertension; CV, cardiovascular; CBP, clinic blood pressure; CBP, clinic blood pressure; LDL, low-density lipoprotein; HDL, high-density lipoprotein.

Table III. Baseline and final variables of the cohort according to cardiovascular risk ESH guidelines stratification.

	Low/moderate CV risk, n =304	High/very high CV risk, n =175	p-value
S CBPo, mmHg, mean (SD)	152.9 (9.2)	155.6 (11.7)	<0.005
S CBPf, mmHg, mean (SD)	147.7 (22.3)	148.7 (15.4)	ns
Δ S CBP, mmHg, mean (SD)	− 5.2 (18.57)	− 6.9 (12.28)	ns
D CBPo, mmHg, mean (SD)	90.7 (7.8)	91.0 (9.3)	ns
D CBPf, mmHg, mean (SD)	86.1 (9.7)	87.1 (10.6)	ns
ΔD C BP, mmHg, mean (SD)	− 4.6 (7.44)	− 3.9 (7.94)	ns
CBPf <140/90 mmHg, n (%)	52 (16.7)	21 (12.3)	ns
CBPf >160/100 mmHg, n (%)	47 (15.6)	48 (27.6)	0.001
S SBPMo, mmHg, mean (SD)	141.8 (12.1)	143.9 (14.8)	ns
S SBPMf, mmHg, mean (SD)	135.8 (13.1)	138.3 (15.3)	ns
Δ S SBPM, mmHg, mean (SD)	− 6.0 (11.9)	− 5.6 (12.0)	ns
D SBPMo, mmHg, mean (SD)	85.9 (8.6)	85.6 (10.1)	ns
D SBPMf, mmHg, mean (SD)	82.6 (9.0)	81.9 (9.9)	ns
Δ D SBPM, mmHg, mean (SD)	− 3.3 (7.2)	− 3.7 (7.9)	ns
S ABPMo-day, mmHg, mean (SD)	137.1 (11.7)	139.7 (11.7)	ns
S ABPMf-day, mmHg, mean (SD)	134.8 (11.4)	137.1 (12.5)	ns
Δ S ABPM-day, mmHg, mean (SD)	− 2.3 (8.4)	− 2.6 (7.6)	ns
D ABPMo-day, mmHg, mean (SD)	85.4 (9.8)	86.5 (11.0)	ns
D ABPMf-day, mmHg, mean (SD)	84.1 (9.6)	84.6 (10.9)	ns
Δ D ABPM-day, mean (SD)	− 1.3 (5.1)	− 1.9 (5.0)	ns
Treatment at the last evaluation, n (%)	144 (47.3)
Lifestyle modification only		68 (38.9)	ns
Antihypertensive drugs			ns
Diuretics	34 (11.2)	21 (12.0)	ns
Beta-blockers	22 (7.2)	15 (8.6)	ns
ACEI	87 (28.6)	62 (35.4)	ns
CCB	2 (0.6)	1 (0.6)	ns
ARB	7 (2.3)	8 (4.5)	ns
Others	8 (2.6)	–	ns

ESH, European Society of Hypertension; S CBPo, baseline clinic systolic blood pressure; S CBPf, final clinic systolic blood pressure at final follow-up; ΔS CBP, variation of the clinic systolic blood pressure; D CBPo, baseline clinic diastolic blood pressure; D CBPf, clinic diastolic blood pressure at final follow-up; ΔD CBP, variation of the clinic diastolic blood pressure; S SBPMo, baseline systolic self blood pressure measurement; S SBPMf, final systolic self blood pressure measurement; Δ S SBPM, variation of the systolic self blood pressure measurement; D SBPMo, baseline diastolic self blood pressure measurement; D SBPMf, final diastolic self blood pressure measurement; Δ D SBPM, variation of the diastolic self blood pressure measurement; S ABPMo-day, baseline systolic ambulatory blood pressure day; S ABPMf-day, final systolic ambulatory blood pressure monitoring day; Δ S ABPM-day, variation of the systolic ambulatory blood pressure monitoring day; D ABPMo-day, baseline diastolic ambulatory blood pressure day; D ABPMf-day, final diastolic ambulatory blood pressure day; Δ D ABPM-day, variation of the diastolic ambulatory blood pressure day; ACEI, angiotensin-converting enzyme inhibitor; CCB, calcium channel blocker; ARB, angiotensin receptor blocker.

Table IV. Absence, regression, persistence or appearance of TOD after 1 year, according to cardiovascular risk at baseline.

	Final TOD evolution
Baseline CV risk	Persistence	Regression	Absence	Increase/appearance
Low/moderate, n (%), n =304			276 (90.8)	28 (9.2)
High/very high CV risk with TOD at baseline, n (%), n =150	68 (45.3)^b	5 (3.3)^a	70 (46.6)	7 (4.0)
High/very high CV risk without TOD at baseline, n (%), n =25			23 (92.0)	2 (8.0)

^aReduction of the number of TODs (without total absence); ^bPersistence of TOD at final follow-up. TOD, target organ damage; CV, cardiovascular.

Table V. Target organ damage evolution after 1 year, according to CV risk at baseline of hypertensive patients.

1-year TOD evolution	Low/moderate CV risk, n =304	High/very high CV risk, n =175	p-value
LVH,^a n (%)			<0.001
Favorable	276 (90.7)	102 (58.3)
Unfavorable	28 (9.2)	73 (41.7)
FO advanced damage,^b n (%)			<0.001
Favorable	301 (99.01)	150 (85.7)
Unfavorable	3 (0.99)	25 (14.3)
High UAER,^cn (%)			<0.005
Favorable	303 (99.7)	166 (94.9)
Unfavorable	1 (0.3)	9 (5.1)
GFR,^dn (%)			ns
Favorable	287 (94.4)	160 (91.4)
Unfavorable	17 (5.6)	15 (8,6)
Amount of TOD, n (%)			<0.001
Favorable	276 (90.7)	98 (56.0)
Unfavorable	28 (9.2)	77 (44.0)

Favorable evolution: regression of TOD or persistence without TOD; Unfavorable evolution: new TOD or persistence of TOD. ^aCornell voltage criteria modified; ^bHemorrhages, exudates and papiloedema; ^cHigh UAER ≥22 mg/g in men and ≥31 mg/g in women; ^dGFR ≥60 mil/min/1.73 m² or <60 mil/min/1.73 m². TOD, target organ damage; CV, cardiovascular; LVH, left ventricular hypertrophy; FO, fundus oculi; UAER, urinary albumin excretion rate; GFR, glomerular filtration rate.

Figure 1. Unfavorable evolution of target organ damage (TOD) after 1 year according to baseline cardiovascular (CV) risk. ESH, European Society of Hypertension LVH: left ventricular hypertrophy; FO: fundus oculi; UAER: urinary albumin excretion rate; GFR: glomerular filtration rate. *p <0.001 **p <0.005.

Figure 2. Absence, regression, persistence or appearance of target organ damage (TOD) after 1 year according to cardiovascular (CV) risk at baseline (%). *p <0.001.

Table VI. Odds ratio of TOD's favorable evolution, according to baseline cardiovascular risk (low/moderate risk vs high/very high risk) of hypertensive patients.

	OR^a	95% CI	p-value
LVH	5.14	3.99–6.64	<0.001
FO advanced damage	12.42	6.67–23.14	<0.001
High UAER	10.71	3.67–31.22	0.003
Amount of TOD	13.99	10.18–19.22	<0.001

^aAdjusted for variation in systolic and diastolic clinic blood pressure and for treatment with antihypertensive drugs. OR, odds ratio; CI, confidence interval; TOD, target organ damage; LVH, left ventricular hypertrophy; FO, fundus oculi; UAER, urinary albumin excretion rate.

Table VII. Multivariate analysis of cardiovascular risk change group of hypertensive patients.

Variable at baseline	OR	95% CI	p-value
Age (≥55 in women; ≤65 in men)
>55 in women; >65 in men	0.27	0.10–5.64	ns
Gender (women)
Men	0.93	0.37–2.32	ns
Smoker (no)
Yes	1.14	0.43–3.02	ns
LVH (no)
Yes	37.46	12.71–110.42	<0.001
FO advanced damage (no)
Yes	75.28	22.11–256.20	<0.001

OR, odds ratio; CI, confidence interval; LVH, left ventricular hypertrophy; FO, fundus oculi. 0 = persistence in the same risk group or worse; 1 = improvement of risk group. Adjusted for, cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, triglycerides, urinary albumin excretion rate, glomerular filtration rate, body mass index, treatment with antihypertensive drugs, clinic blood pressure at baseline and at the last evaluation.