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describes hypertension-induced structural and/or functional changes . . . with a markedly abnormal risk factor profile. In the latter, relative risk
in major organs (i.e. the heart, brain, retina, kidney, and vasculature) . . . is elevated even if absolute risk is low. The use of ‘CV risk age’ has
(Table 4). There are three important considerations: (i) not all fea- . . . been proposed as a useful way of communicating risk and making
tures of HMOD are included in the SCORE system (CKD and estab- . . . treatment decisions, especially for younger people at low absolute
lished vascular disease are included) and several hypertensive . . . risk but with high relative risk. 35 This works by illustrating how a
HMODs (e.g. cardiac, vascular, and retinal) have well-established . . . younger patient (e.g. a 40-year-old) with risk factors but low absolute
adverse prognostic significance (see section 5) and may, especially if . . . risk has a CV risk equivalent to a much older person (60 years) with
HMOD is pronounced, lead to a high CV risk even in the absence of . . . optimal risk factors; thus, the CV risk age of the younger patient is 60
classical CV risk factors; (ii) the presence of HMOD is common and . . . years. The CV risk age can be automatically calculated using
often goes undetected; 38 and (iii) the presence of multiple HMODs . . . HeartScore (www.heartscore.org).
in the same patient is also common, and further increases CV . . . A second consideration is that the presence of concomitant dis-
risk. 39–41 Consequently, the inclusion of HMOD assessment is . . . ease is often recorded in a binary way in CV risk assessment systems
important in patients with hypertension and helps identify high-risk . . . (e.g. diabetes, yes/no). This does not reflect the impact of the severity
or very high-risk hypertensive patients who may otherwise be mis- . . . or duration of concomitant diseases on total CV risk. For example,
42
classified as having a lower level of risk by the SCORE system. This . . . long-standing diabetes is clearly associated with high risk, whereas
is especially true for the presence of left ventricular hypertrophy . . . the risk is less certain for recent-onset diabetes. 34
(LVH), CKD with albuminuria or proteinuria, or arterial stiffening 43 . . . A third conundrum specific to hypertension is what BP value to
(see section 5). The impact of progression of the stages of . . . use in CV risk assessment in a patient who is receiving treatment for
hypertension-associated disease (from uncomplicated through to . . . hypertension. If treatment was commenced recently, it seems appro-
asymptomatic or established disease), according to different grades . . . . priate to use the pre-treatment BP value. If treatment has been
of hypertension and the presence of CV risk factors, HMOD, or . . . long-standing, using the current treated BP value will invariably
comorbidities, is illustrated in Figure 1 for middle-aged individuals. . . . . underestimate risk because it does not reflect prior longer-term

3.7 Challenges in cardiovascular risk . . . . . exposure to higher BP levels, and antihypertensive treatment does
not completely reverse the risk even when BP is well controlled. If
assessment . . . treatment has been long-standing, then the ‘treated BP value’ should
CV risk is strongly influenced by age (i.e. older people are invariably . . . . be used, with the caveat that the calculated CV risk will be lower
at high absolute CV risk). In contrast, the absolute risk of younger . . . than the patient’s actual risk. A fourth conundrum is how to impute
people, particularly younger women, is invariably low, even in those . out-of-office BP values into risk calculators that have been calibrated

BP (mmHg) grading
Hypertension Other risk factors,
disease High normal Grade 1 Grade 2 Grade 3
HMOD, or disease
staging SBP 130–139 SBP 140–159 SBP 160–179 SBP 180
DBP 85–89 DBP 90–99 DBP 100–109 or DBP 110
No other risk
Low risk Low risk Moderate risk High risk
factors
Stage 1
(uncomplicated) 1 or 2 risk factors Low risk Moderate risk Moderate to High risk
high risk
Low to Moderate to
3 risk factors High Risk High risk
Moderate risk high risk
HMOD, CKD grade
Stage 2 3, or diabetes Moderate to High to
(asymptomatic mellitus without high risk High risk High risk very high risk
disease)
organ damage
Established CVD, 2018
Stage 3 CKD grade 4, or
(established diabetes mellitus Very high risk Very high risk Very high risk Very high risk
disease) ©ESC/ESH
with organ damage

Figure 1 Classification of hypertension stages according to blood pressure levels, presence of cardiovascular risk factors, hypertension-mediated
organ damage, or comorbidities. CV risk is illustrated for a middle-aged male. The CV risk does not necessarily correspond to the actual risk
at different ages. The use of the SCORE system is recommended for formal estimation of CV risk for treatment decisions. BP = blood pressure;
CKD = chronic kidney disease; CV = cardiovascular; DBP = diastolic blood pressure; HMOD = hypertension-mediated organ damage; SBP = systolic
blood pressure; SCORE = Systematic COronary Risk Evaluation.

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