What is the cardiovascular disease (CVD) risk for a patient with elevated clinic blood pressure readings of 140/90, but normal home readings, and normal kidney function, complete blood count (CBC), and hemoglobin A1c (HBA1c) of 4.4%?

Cardiovascular Disease Risk Assessment

This patient has low cardiovascular disease risk based on current evidence, as he does not have true hypertension but rather white coat hypertension, and his metabolic profile is excellent with no additional risk factors present. 1, 2

Blood Pressure Classification and White Coat Hypertension

The discrepancy between clinic readings (140/90 mmHg) and home readings (≤130/85 mmHg) indicates white coat hypertension, which carries a cardiovascular risk similar to normal blood pressure and should not be treated as true hypertension. 2 The 2024 ESC guidelines explicitly recommend out-of-office blood pressure measurement using ABPM or HBPM when screening office BP is 120-139/70-89 mmHg to confirm the diagnosis. 1

• Home BP readings ≤130/85 mmHg place this patient in the "elevated BP" category (120-139/70-89 mmHg), not hypertension (≥140/90 mmHg). 1
• The equivalent threshold for home blood pressure monitoring is ≥135/85 mmHg for hypertension diagnosis, which this patient does not meet. 2
• White coat hypertension should be distinguished from true hypertension as it does not warrant pharmacological treatment. 2

Risk Factor Assessment

This patient presents with an exceptionally favorable risk profile:

• HbA1c of 4.4% is well below the normal range (<5.7%), indicating no diabetes or prediabetes. 1, 3
• Normal kidney function (no chronic kidney disease). 1
• Normal CBC (no anemia or other hematologic abnormalities). 1
• No established cardiovascular disease. 1
• No medications (suggesting no other comorbidities). 1
• No mention of target organ damage (HMOD). 1

CVD Risk Stratification

According to the 2024 ESC guidelines, this patient would be classified as having low CVD risk (<10% 10-year risk) given the absence of high-risk conditions. 1

The guidelines define high-risk conditions as:

• Established CVD (absent in this patient) 1
• Diabetes mellitus (HbA1c 4.4% rules this out) 1
• Moderate or severe CKD (normal kidney function) 1
• Familial hypercholesterolemia (not mentioned, lipid profile not provided) 1
• Hypertension-mediated organ damage/HMOD (not present) 1

For patients aged 40-69 years with elevated BP and no high-risk conditions, SCORE2 should be used to assess 10-year CVD risk. 1 Without knowing this patient's age, smoking status, or lipid profile, a precise SCORE2 calculation cannot be performed, but the absence of all major risk factors strongly suggests low risk.

Clinical Implications

This patient requires lifestyle modifications only, not pharmacological treatment. 1, 2

• The 2024 ESC guidelines recommend lifestyle measures for all adults with elevated BP (120-139/70-89 mmHg) and low CVD risk. 1
• Pharmacological treatment is only indicated after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg AND the patient has high CVD risk (≥10% 10-year risk) or high-risk conditions. 1
• BP should be monitored yearly with home measurements to ensure it remains controlled. 1

Important Caveats

The missing lipid profile is a significant gap in this assessment. 1 The 2003 European guidelines recommend total cholesterol <5 mmol/L (190 mg/dL) and LDL cholesterol <3 mmol/L (115 mg/dL) for general cardiovascular risk assessment. 1 Dyslipidemia, if present, could elevate this patient's CVD risk and potentially change management recommendations. 4, 5

Proper BP measurement technique must be confirmed to avoid misclassification. 2 Common errors including incorrect cuff size, unsupported arm, full bladder, or talking during measurement can falsely elevate readings by 5-10 mmHg. 2