Is the same cholesterol's Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator used to assess stage one hypertension?

ASCVD Risk Calculator and Stage 1 Hypertension Assessment

The ASCVD risk calculator is used as part of the risk assessment for stage 1 hypertension, but it is not the sole determinant for measuring or classifying hypertension itself. According to the 2017 ACC/AHA Blood Pressure guidelines, the ASCVD risk calculator (Pooled Cohort Equation) is specifically used to determine which patients with stage 1 hypertension should receive antihypertensive medication 1.

How Stage 1 Hypertension is Defined and Assessed

• Stage 1 hypertension is defined as systolic blood pressure 130-139 mmHg or diastolic blood pressure 80-89 mmHg 1
• The diagnosis is based on blood pressure measurements, not on ASCVD risk calculations 1
• Blood pressure should be measured at every routine clinical visit, with elevated readings confirmed using multiple measurements on separate days 1

Role of ASCVD Risk Calculator in Hypertension Management

• The ASCVD risk calculator (Pooled Cohort Equation or PCE) is used to determine which patients with stage 1 hypertension should receive antihypertensive medication 1
• High-risk stage 1 hypertension requiring medication is defined by the presence of any of the following:
  • PCE-estimated 10-year ASCVD risk ≥10% 1
  • Diabetes mellitus 1
  • Estimated GFR <60 mL/min per 1.73 m² 1
  • Age ≥65 years with systolic BP ≥130 mmHg 1
• In the absence of these risk factors, individuals with stage 1 hypertension are classified as low-risk and typically not recommended for antihypertensive medication 1

Limitations and Recent Developments

• The 2023 PREVENT equations estimate significantly lower ASCVD risk compared to the PCE, which could impact treatment decisions for stage 1 hypertension 2
• For patients with familial hypercholesterolemia, cardiovascular risk calculators developed for the general population (including PCE) should not be used 1
• Coronary artery calcium (CAC) scoring may provide additional risk stratification beyond the ASCVD risk calculator for patients with stage 1 hypertension 3

Biomarkers and Risk Assessment

• Approximately one-third of adults with stage 1 hypertension who are not recommended for medication based on traditional criteria have elevated cardiac biomarkers (hs-cTnT or NT-proBNP) 1
• These individuals with elevated biomarkers have more than 10% risk of ASCVD or heart failure over 10 years, suggesting they might benefit from treatment despite not meeting traditional criteria 1
• Biomarker-based risk assessment may help identify high-risk individuals who would benefit from BP-lowering therapy but are currently not recommended for treatment 1

Clinical Implications

• Stage 1 hypertension is associated with a 35% higher 10-year cardiovascular disease risk and 36% higher lifetime risk compared to normal blood pressure 4
• Progression from stage 1 to stage 2 hypertension increases 10-year risk by 156% and lifetime risk by 129%, highlighting the importance of early intervention 4
• For individuals with diabetes and hypertension at higher cardiovascular risk (ASCVD risk ≥15%), a blood pressure target of <130/80 mmHg is recommended 1
• For those with diabetes and hypertension at lower cardiovascular risk (ASCVD risk <15%), a target of <140/90 mmHg is recommended 1

In summary, while the ASCVD risk calculator is an important tool in determining treatment strategies for stage 1 hypertension, it is not used to measure or classify hypertension itself, which is defined by blood pressure measurements.