Cardiovascular risk stratification according to the 2003 ESH‐ESC guidelines in uncomplicated patients with essential hypertension: comparison with the 1999 WHO/ISH guidelines criteria

Abstract

Background: The 2003 European Society of Hypertension/European Society of Cardiology (ESH‐ESC) guidelines have recently proposed a new risk stratification scheme for estimating absolute risk for cardiovascular disease. At variance from the previous 1999 World Health Organization–International Society of Hypertension (WHO/ISH) guidelines, the new criteria include some additional risk factors such as obesity, abnormal high‐density (HDL) or low‐density lipoprotein (LDL) cholesterol levels and define a slight increase in creatinine and microalbuminuria as signs of target organ damage (TOD). Objective: The aim of the study was to assess overall cardiovascular risk in uncomplicated hypertensives according to the 2003 ESH‐ESC guidelines comparing this approach with the stratification scheme of the 1999 WHO/ISH guidelines. Methods: Four hundred and twenty‐five never‐treated grade 1 and 2 essential hypertensive patients, referred for the first time to our outpatient clinic without diabetes mellitus, were included in the study. They underwent the following procedures: (i) repeated clinical blood pressure measurements; (ii) routine blood chemistry and urine analysis; (iii) electrocardiogram; (iv) 24‐h urine collection for microalbuminuria; (v) echocardiogram; and (vi) carotid ultrasonogram. Risk was assessed according to both stratification schemes suggested by the 2003 ESH‐ESC and 1999 WHO/ISH guidelines. Results: According to the 2003 ESH‐ESC guidelines, 15.5% of the 425 patients were considered at low added risk, 47.8% at medium added risk and 36.7% at high added risk; 146 patients (34.3%) were classified in the high‐risk stratum because of at least one manifestation of TOD and 5.6% having three or more risk factors. The accuracy in detecting TOD of the combined approach with ultrasound procedures and microalbuminuria was approximately 10‐fold higher than that provided by routine investigation. As a result of the 1999 WHO/ISH stratification scheme, 34.5% were low‐risk, 34.4% medium‐risk and 31.1% high‐risk patients. Conclusions: Our findings show that: (i) more than one‐third of uncomplicated grade 1 and 2 hypertensives seen in a outpatient hypertension hospital clinic have a high added risk according to the ESH‐ESC scheme; (ii) classification of the patients in the high stratum is mainly influenced by the presence of TOD; (iii) the routine diagnostic work‐up is a highly insensitive approach for the detection of TOD; (iv) the 2003 ESH‐ESC guidelines stratify a higher proportion of hypertensive patients in the medium and high‐risk groups than do the 1999 WHO/ISH guidelines.