ASCVD Risk Assessment in a 55-Year-Old Man with Stage 1 Hypertension
This patient falls into the intermediate ASCVD risk category (≥7.5% to <20% 10-year risk), making the answer C: Intermediate Risk.
Risk Stratification Approach
The ACC/AHA guidelines mandate using the Pooled Cohort Equations (PCE) to calculate 10-year ASCVD risk for adults aged 40-75 years 1. This calculation requires specific inputs: age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, treatment status for hypertension, diabetes status, and smoking status 1, 2.
Why This Patient Cannot Be Definitively Categorized
The critical limitation here is the absence of a lipid profile 1. Without total cholesterol and HDL cholesterol values, the PCE cannot be calculated with precision 1. However, we can make reasonable clinical inferences:
Factors Suggesting Intermediate Risk:
- Age 55 years: This is a significant risk driver in the PCE, particularly for men 1
- Stage 1 hypertension confirmed: Clinic BP 140/90 mmHg meets criteria for stage 1 hypertension (130-139/80-89 mmHg), though home readings are lower 1
- Male sex: Men have inherently higher baseline ASCVD risk than women at equivalent ages 1, 2
- No diabetes: HbA1c 4.4% excludes diabetes (which would automatically place him at ≥10% risk) 1, 2
- Normal renal function: Excludes chronic kidney disease as a high-risk condition 1, 2
Clinical Context from Guidelines:
The ACC/AHA specifically addresses stage 1 hypertension management, stating that patients should be categorized as <10% or ≥10% 10-year ASCVD risk for therapeutic decisions 1. For a 55-year-old man with treated blood pressure of 130/80 mmHg and reasonable cholesterol values (total cholesterol 210 mg/dL, HDL 50 mg/dL), the 10-year risk would be approximately 6.0% according to the MESA calculator example provided 1. With untreated BP of 140/90 mmHg, this risk would be higher, likely pushing into the 7.5-10% range.
Most Likely Risk Category: Intermediate
Based on age, sex, and hypertension status alone, this patient most likely falls into intermediate risk (≥7.5% to <20%) 1. A 55-year-old man with stage 1 hypertension typically has a 10-year ASCVD risk between 7.5-15%, depending on lipid values 1, 2. He is unlikely to be low risk (<5%) given his age and hypertension, and unlikely to be high risk (≥20%) without additional major risk factors like diabetes, established CVD, or severe dyslipidemia 1, 2.
Clinical Implications
For intermediate-risk patients, the ACC/AHA recommends considering risk-enhancing factors to guide preventive interventions 1. These include:
- Family history of premature ASCVD 1
- Metabolic syndrome components 1
- Chronic inflammatory conditions 1
- Elevated biomarkers (hsCRP, Lp(a), apoB) if measured 1
If uncertainty persists after obtaining the lipid profile, coronary artery calcium (CAC) scoring is reasonable for intermediate-risk patients to guide statin therapy decisions 1. A CAC score of 0 would reclassify risk downward (1.5-3.0% 10-year risk), while CAC ≥100 would support statin initiation 1.
Important Caveats
The white coat effect evident in this patient (clinic BP 140/90 vs. home BP ≤130/85) should be considered 1. Home BP monitoring is more predictive of cardiovascular outcomes than clinic measurements 1. If home readings consistently remain ≤130/85 mmHg, his true hypertension status may be borderline, potentially lowering his calculated ASCVD risk 1.
The answer is C: Intermediate Risk, though obtaining a lipid profile is essential for precise risk calculation and treatment decisions 1.