Cardiovascular Risk Assessment in Hypertensive Patients

Hypertension is a highly prevalent and causal risk factor for cardiovascular disease (CVD). Quantitative cardiovascular (CV) risk assessment is a new paradigm for stratifying hypertensive patients into actionable groups for clinical management and prevention of CVD. The large heterogeneity in hypertensive patients makes this evaluation complex, but recent advances have made CV risk assessment more feasible. In this review, we first describe the prognostic significance of various levels and temporal patterns of blood pressure (BP). We then discuss CV risk prediction equations and the rationale of taking global risk into account in hypertensive patients. Finally, we review several adjunctive biomarkers that may refine risk assessment in certain patients. We observe that, beyond individual cross-sectional measurements, both short-term and long-term BP patterns are associated with incident CVD; that current CV risk prediction performs well, and its incorporation into hypertension management is associated with potential population benefit; and that adjunctive biomarkers of target organ damage show the most promise in sequential screening strategies that target biomarker measurement to patients in whom the results are most likely to change clinical management. Implementation of quantitative risk assessment for CVD has been facilitated by tools and direct electronic health record integrations that make risk estimates accessible for counseling and shared decision making for CVD prevention. However, it should be noted that treatment does not return an individual to the risk of someone who never develops hypertension, underscoring the need for primordial prevention in addition to continued innovation in risk assessment.