What is the cardiovascular disease (CVD) risk for a patient with elevated blood pressure readings of 140/80 in the clinic, but normal blood pressure readings of 130/80 at home, with no available lipid profile?

Cardiovascular Risk Assessment

This patient has intermediate cardiovascular disease risk (Option B) due to white-coat hypertension with elevated home blood pressure readings that place them in the "elevated BP" category, though definitive risk stratification requires a lipid profile and formal 10-year CVD risk calculation using SCORE2 or pooled cohort equations.

Blood Pressure Classification and White-Coat Hypertension

• The clinic reading of 140/80 mmHg meets the threshold for hypertension, while the home reading of 130/80 mmHg falls into the elevated BP/high-normal range, indicating white-coat hypertension 1, 2

• The European Society of Cardiology defines elevated BP as 120-139/70-89 mmHg for office readings, with corresponding home BP thresholds of ≤130/85 mmHg 1

• White-coat hypertension carries a cardiovascular risk profile that is lower than sustained hypertension but slightly elevated compared to true normotensives 2

• Out-of-office blood pressure measurement using home monitoring is essential when screening office BP is 120-139/70-89 mmHg, as white coat hypertension carries cardiovascular risk similar to normal blood pressure 1

Why This Patient Cannot Be Definitively Low-Risk

The absence of a lipid profile is critical because it prevents complete CVD risk stratification:

• For patients aged 40-69 years with elevated BP and no established high-risk conditions, the European Society of Cardiology recommends using SCORE2 to assess 10-year CVD risk, which requires total cholesterol and HDL cholesterol values 1

• The 2024 ESC guidelines specify that treatment decisions for patients with BP 130-139/80-89 mmHg depend on whether 10-year CVD risk is ≥10%, 5-10% with risk modifiers, or <5% 3

• Total cholesterol <5 mmol/L and LDL cholesterol <3 mmol/L are recommended thresholds for general cardiovascular risk assessment 1

Why This Patient Is Not High-Risk

High-risk conditions are absent based on available information:

• The European Society of Cardiology defines high-risk conditions as established CVD, diabetes mellitus, moderate or severe CKD (eGFR <60), familial hypercholesterolemia, or hypertension-mediated organ damage—none of which are mentioned 3, 1

• The 2017 ACC/AHA guidelines classify high-risk as having clinical atherosclerotic CVD, heart failure, CKD, diabetes, or pooled cohort equation 10-year CVD risk ≥10% 3

• Without these conditions and without a lipid profile to calculate formal risk scores, high-risk classification cannot be justified 3

Why Intermediate Risk Is Most Appropriate

The home BP of 130/80 mmHg places this patient above optimal but below hypertensive thresholds:

• High-normal blood pressure (130-139/85-89 mmHg) is associated with increased cardiovascular risk compared to optimal BP, with hazard ratios of 2.5 in women and 1.6 in men 4

• The 10-year cumulative incidence of CVD in persons aged 35-64 years with high-normal BP is 4% for women and 8% for men, rising to 18% and 25% respectively in those aged 65-90 years 4

• This level of risk falls between low-risk (requiring only lifestyle modifications) and high-risk (requiring immediate pharmacological intervention) 3

Clinical Management Implications

Current recommendations based on available information:

• Lifestyle modifications are the primary intervention: weight management, dietary changes (sodium restriction, DASH diet), physical activity (150 minutes/week aerobic plus resistance training 2-3×/week), and alcohol moderation 2, 3

• Continued home blood pressure monitoring is essential to detect progression to sustained hypertension 2

• Pharmacological treatment should be deferred until a complete lipid profile is obtained and formal 10-year CVD risk is calculated 3

• If SCORE2 risk is ≥10% or 5-10% with risk modifiers, pharmacological treatment would be indicated after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 3

• If SCORE2 risk is <5% without risk modifiers, lifestyle measures alone are appropriate with yearly BP monitoring 3, 1

Critical Next Steps

To definitively classify this patient's risk:

• Obtain fasting lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides) 1

• Calculate 10-year CVD risk using SCORE2 (for European populations) or pooled cohort equations (for US populations) 3

• Screen for diabetes mellitus (HbA1c or fasting glucose) as this would immediately classify the patient as high-risk 3

• Assess for other risk modifiers: family history of premature CVD, chronic kidney disease (serum creatinine/eGFR), smoking status 3