The Importance and Clinical Strategies of Hypertension Risk Stratification

What is the importance of risk stratification for hypertensive patients?

As mentioned earlier, cardiovascular and cerebrovascular diseases are the result of multiple factors acting together. The more risk factors present, the greater the probability of cardiovascular and cerebrovascular events. The *Chinese Guidelines for Primary Care Management of Hypertension (2014 Revised Edition)* continues the stratification criteria of the *Chinese Guidelines for Prevention and Treatment of Hypertension (2009 Primary Care Edition)*. This involves risk stratification based on the patient's blood pressure level, existing risk factors, target organ damage, and comorbid clinical diseases. Patients are divided into three levels: low-risk, intermediate-risk, and high-risk. The main contents of low-risk, intermediate-risk, and high-risk stratification are as follows:

Low-risk: Grade 1 hypertension, with no other risk factors.

Intermediate-risk: Grade 2 hypertension; Grade 1 hypertension with 1-2 risk factors.

High-risk: Grade 3 hypertension; Grade 1 or 2 hypertension with ≥3 risk factors; hypertension (any grade) with any target organ damage.

Damage (left ventricular hypertrophy, carotid intima-media thickening or plaque, mild elevation of serum creatinine); hypertension (any level) coexisting with any clinical disease (cardiac disease, cerebrovascular disease, kidney disease, peripheral vascular disease, diabetes, etc.).

With risk stratification, a basic assessment of the severity of a patient's condition can be made. Because the risk levels differ, the likelihood of developing cardiovascular or cerebrovascular events within 10 years also differs.

High-risk patients have a higher probability of developing cardiovascular or cerebrovascular events within 10 years (20%–30%) and should receive more aggressive treatment and stronger interventions. Conversely, low-risk patients have a lower probability of developing cardiovascular or cerebrovascular events within 10 years. Before initiating drug therapy, non-pharmacological treatment should be the primary approach, with observation for several weeks to months, and a decision on whether to begin drug therapy should be made based on the situation. Assessing the likelihood of cardiovascular events over a 10-year period and identifying possible treatment strategies based on risk stratification.

How is risk stratification performed?

When performing risk stratification, the degree of blood pressure is undoubtedly the most important reference factor. If blood pressure is simply high, reaching stage 2 hypertension (160–179/100–109 mmHg), even without other risk factors, the risk stratification reaches intermediate risk. Blood pressure at stage 3 (>180/120 mmHg) is considered high risk or above.

Other important factors include whether there is corresponding damage to vital organs (i.e., target organs, such as the heart, brain, kidneys, retina, and peripheral blood vessels) and whether the patient has diabetes. Patients who have previously experienced cardiovascular or cerebrovascular diseases (as described in Tables 1-3, such as myocardial infarction, a confirmed diagnosis of coronary heart disease, heart failure, coronary artery bypass grafting or stent surgery, or related stroke, cerebrovascular disease, severe kidney disease, or peripheral vascular disease) are considered extremely high-risk individuals with a very high probability of developing cardiovascular or cerebrovascular events in the future. They require aggressive and effective comprehensive treatment.

For patients with hypertension, or those with one or more risk factors, it is crucial to actively investigate for other risk factors. Studies have found that risk factors often cluster in the same individual, their effects interacting and mutually reinforcing each other. Failure to intervene early can significantly accelerate the progression of cardiovascular and cerebrovascular diseases.

Of course, ordinary patients should undergo relevant examinations at medical institutions. A specialist physician will assess and stratify the risk based on damage to vital organs (target organs) and the examination results.

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