Page 13 - GUIAS ESC ESH 2018

ESC/ESH Guidelines 13

This metabolic risk factor clustering has a multiplicative effect on CV
32
risk. Consequently, quantification of total CV risk (i.e. the likelihood Table 6 Risk modifiers increasing cardiovascular risk
estimated by the Systemic COronary Risk Evaluation
of a person developing a CV event over a defined period) is an impor- (SCORE) system 35
tant part of the risk stratification process for patients with
hypertension.
Social deprivation, the origin of many causes of CVD
Many CV risk assessment systems are available and most project
10 year risk. Since 2003, the European Guidelines on CVD preven- Obesity (measured by BMI) and central obesity (measured by
tion have recommended use of the Systematic COronary Risk waist circumference)
Evaluation (SCORE) system because it is based on large, representa-
Physical inactivity
tive European cohort data sets (available at: http://www.escardio.org/
Guidelines-&-Education/Practice-tools/CVD-prevention-toolbox/SC Psychosocial stress, including vital exhaustion
ORE-Risk-Charts). The SCORE system estimates the 10 year risk of
Family history of premature CVD (occurring at age <55 years in
a first fatal atherosclerotic event, in relation to age, sex, smoking hab-
men and <60 years in women)
its, total cholesterol level, and SBP. The SCORE system also allows
calibration for different CV risk levels across numerous European Autoimmune and other inflammatory disorders
countries and has been externally validated. 33 A previous limitation
Major psychiatric disorders
of the SCORE system was that it applied only to patients aged 40–65
years; however, the SCORE system has recently been adapted for Treatment for infection with human immunodeficiency virus
34
patients over the age of 65 years. Detailed information on CV risk
assessment is available. 35 Atrial fibrillation
Factors influencing CV risk factors in patients with hypertension LV hypertrophy
are shown in Table 4. Hypertensive patients with documented
CKD
CVD, including asymptomatic atheromatous disease on imaging,
type 1 or type 2 diabetes, very high levels of individual risk factors Obstructive sleep apnoea syndrome
(including grade 3 hypertension), or chronic kidney disease (CKD;
stages 3 - 5), are automatically considered to be at very high (i.e.
BMI = body mass index; CKD = chronic kidney disease; CVD = cardiovascular
>_10% CVD mortality) or high (i.e. 5 - 10% CVD mortality) 10 year disease; LV = left ventricular.
CV risk (Table 5). Such patients do not need formal CV risk estima-
tion to determine their need for treatment of their hypertension
and other CV risk factors. For all other hypertensive patients, esti-
mation of 10 year CV risk using the SCORE system is recom-
Table 7 Correction factors for the Systemic
mended. Estimation should be complemented by assessment of COronary Risk Evaluation (SCORE) cardiovascular risk
hypertension-mediated organ damage (HMOD), which can also estimates in first-generation immigrants to Europe 35
increase CV risk to a higher level, even when asymptomatic (see
Table 4 and sections 3.6 and 4).
Region of origin Multiplication factor
There is also emerging evidence that an increase in serum uric acid
to levels lower than those typically associated with gout is independ- Southern Asia 1.4
ently associated with increased CV risk in both the general popula-
Sub-Saharan Africa 1.3
tion and in hypertensive patients. Measurement of serum uric acid is
recommended as part of the screening of hypertensive patients. 36 Caribbean 1.3
The SCORE system only estimates the risk of fatal CV events.
Western Asia 1.2
The risk of total CV events (fatal and non-fatal) is approximately
three times higher than the rate of fatal CV events in men and Northern Africa 0.9
four times higher in women. This multiplier is attenuated to less than
Eastern Asia 0.7
three times in older people in whom a first event is more likely to be
fatal. 37 Southern America 0.7
There are important general modifiers of CV risk (Table 6) as well
as specific CV risk modifiers for patients with hypertension. CV risk
modifiers are particularly important at the CV risk boundaries, and
.
especially for patients at moderate-risk in whom a risk modifier might .
. 3.6 Importance of hypertension-
.
convert moderate-risk to high risk and influence treatment decisions . .
.
with regard to CV risk factor management. Furthermore, CV risk . mediated organ damage in refining
.
.
estimates by the SCORE system may be modified in first-generation . cardiovascular risk assessment in
.
immigrants to Europe and CV risk scores in such patients may be . . hypertensive patients
.
adjusted by correction factors (Table 7). Further details of the impact . . . A unique and important aspect of CV risk estimation in hypertensive
of CV risk modifiers are available from the ESC 2016 CVD preven- . . . patients is the need to consider the impact of HMOD. This was previ-
tion Guidelines. 35 . . ously termed ‘target organ damage’, but HMOD more accurately
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