ASCVD Risk Criteria for Initiating Antihypertensive Medication
For adults with persistent clinic blood pressure ≥130/80 mm Hg, initiate antihypertensive medication when the 10-year ASCVD risk is ≥10% using the ACC/AHA Pooled Cohort Equations, or when blood pressure reaches ≥140/90 mm Hg regardless of ASCVD risk. 1
Risk Assessment Framework
Calculate 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations (available at http://tools.acc.org/ASCVD-Risk-Estimator/), which estimates the probability of a first CHD death, non-fatal MI, or fatal/non-fatal stroke. 1, 2
The calculator requires the following inputs: 2
- Age (40-79 years for primary prevention)
- Sex
- Race
- Total cholesterol and HDL cholesterol
- Systolic blood pressure
- Diabetes status
- Current smoking status
- Current use of antihypertensive medications
Treatment Thresholds Based on BP and ASCVD Risk
Stage 1 Hypertension (BP 130-139/80-89 mm Hg)
Initiate pharmacological therapy when 10-year ASCVD risk is ≥10% (Class I recommendation, Level A evidence for SBP). 1 This represents a lower number needed to treat because absolute CVD risk reduction is greater at higher baseline risk levels. 1
For patients with 10-year ASCVD risk <10%, use lifestyle modifications only and reassess in 3-6 months. 1 Pharmacological therapy is not recommended until BP reaches ≥140/90 mm Hg in this lower-risk group (Class I recommendation, Level C-LD evidence). 1
Stage 2 Hypertension (BP ≥140/90 mm Hg)
Initiate pharmacological therapy immediately regardless of ASCVD risk (Class I recommendation). 1, 3 Consider starting with two antihypertensive agents from different classes, particularly when BP is ≥160/100 mm Hg. 1
Automatic High-Risk Categories
Certain conditions automatically place patients in the high-risk category (≥10% equivalent), warranting medication at BP ≥130/80 mm Hg: 1, 4
- Clinical cardiovascular disease (prior MI, acute coronary syndrome, stroke, TIA, coronary revascularization, peripheral arterial disease, aortic aneurysm) 1
- Diabetes mellitus 1, 4
- Chronic kidney disease (stage 3 or higher) 1, 4
- Age ≥65 years 4
These patients do not require formal ASCVD risk calculation—they should receive antihypertensive medication at BP ≥130/80 mm Hg for secondary prevention or primary prevention with established high-risk conditions. 1
Evidence Supporting Risk-Based Treatment
The relative risk reduction from BP-lowering medications is fairly constant across different baseline CVD risk levels (approximately 20-30% reduction in CVD events per 10 mm Hg SBP reduction). 1, 2, 3 However, the absolute CVD risk reduction is substantially greater in higher-risk individuals, meaning fewer patients need to be treated to prevent one cardiovascular event. 1
For example, treating 100 patients with 10-year ASCVD risk ≥10% prevents significantly more events than treating 100 patients with risk <10%, even though the relative risk reduction is similar. 1
Comparison with European Guidelines
The European Society of Cardiology/European Society of Hypertension uses different criteria, recommending immediate drug therapy at BP ≥140/90 mm Hg only for high/very-high-risk patients, with a 3-month trial of lifestyle modification for lower-risk patients. 1 The ACC/AHA approach is more aggressive, particularly for Stage 1 hypertension with elevated ASCVD risk. 1
Common Pitfalls to Avoid
Do not delay medication in patients with Stage 1 hypertension and ASCVD risk ≥10%—this represents a missed opportunity for meaningful cardiovascular risk reduction. 1, 2, 4 The evidence shows substantial benefit from treating this population. 1
Do not forget that patients with diabetes or CKD are automatically high-risk and should receive medication at BP ≥130/80 mm Hg without needing to calculate ASCVD risk. 1, 4
Address LDL cholesterol concurrently—treating BP alone while leaving LDL elevated addresses only one component of cardiovascular risk. 2 Patients with 10-year ASCVD risk ≥10% should also receive moderate-to-high intensity statin therapy. 2, 5
Recognize that age is the strongest contributor to calculated ASCVD risk—older adults may have elevated risk scores based primarily on age, even without traditional modifiable risk factors, but they still experience substantial event rates and benefit from treatment. 6, 7
Treatment Target
The target BP is <130/80 mm Hg for most adults under 65 years and <130 mm Hg systolic for adults ≥65 years (if tolerated). 2, 4, 3 This target applies regardless of the threshold used to initiate therapy. 1