Elevated BP with borderline risk — case discussion

Presentation

Practice case (not a real patient). A 56-year-old man of South Asian background attends a GP check. Office BP, measured with a validated device by the ESC technique, is 136/86 mmHg; the second arm reads within 5 mmHg. He smokes, has no diabetes, CKD, familial hypercholesterolaemia or known cardiovascular disease, and takes no medication. Examination shows no sign of hypertension-mediated organ damage. His GP calculates a SCORE2 10-year CVD risk of 7%.^[1]

Step 1 — What is his BP category?

Discussion:

• Under ESC 2024 his office BP is elevated BP: an office systolic BP of 120–139 mmHg or diastolic BP of 70–89 mmHg.^[1]
• Under AHA/ACC 2025, an average of 136/86 mm Hg on 2 or more careful readings on 2 or more occasions would be stage 1 hypertension (SBP 130 to 139 mm Hg or DBP 80 to 89 mm Hg); a single visit does not yet meet that averaging rule.^[2]

Step 2 — Where does his risk sit under ESC 2024?

Discussion:

• He has no diabetes, CKD, familial hypercholesterolaemia or established CVD, and no HMOD is evident on examination (the baseline tests in Step 4 complete that check), so on current information he has none of the ESC increased-risk conditions (moderate or severe CKD, established CVD, HMOD, diabetes mellitus, familial hypercholesterolaemia) and SCORE2 is the recommended tool at 40–69 years (Class I, Level B).^[1]
• A SCORE2 risk of 7% is borderline (5% to below 10%).^[1]
• High-risk ethnicity (e.g. South Asian) is a shared risk modifier that should be considered to up-classify people with elevated BP and borderline 10-year risk (Class IIa, Level B).^[1]
• If the decision remained uncertain after risk scoring and modifiers, CAC score, carotid or femoral plaque on ultrasound, high-sensitivity troponin or BNP, or PWV may be considered to improve stratification in borderline risk, after shared decision-making and considering costs (Class IIb, Level B).^[1]
• In this scenario, after discussion with him, his clinician up-classifies his risk on the basis of the ethnicity modifier, so he meets the ESC 2024 Recommendation Table 17 footnote definition of sufficiently high CVD risk: a 10-year risk of 5% to ≤10% plus risk modifiers.^[1]

Step 3 — Confirming his BP

Discussion:

• ESC 2024 recommends that, in people with increased CVD risk and a screening office BP of 120–139/70–89 mmHg, BP be measured out of office with ABPM and/or HBPM or, if not logistically feasible, by repeated office measurements on more than one visit (Class I, Level B).^[1]
• The ESC text adds that, when treatment of elevated BP is being considered for individuals with high-risk CVD conditions or sufficiently high 10-year predicted CVD risk, out-of-office measurement is recommended, both to confirm BP and to assess for masked hypertension.^[1]
• He completes a 7-day home series to the ESC protocol: average 132/84 mmHg, which is in the ESC home elevated range (systolic 120–134 mmHg or diastolic 70–84 mmHg) and below the home hypertension threshold of 135/85 mmHg.^[1]

Step 4 — Baseline assessment

Discussion:

• ESC 2024 Table 8 routine tests: fasting blood glucose (and HbA1c if fasting glucose is elevated), serum lipids, blood sodium and potassium, haemoglobin and/or haematocrit, calcium and TSH, blood creatinine and eGFR with urinalysis and urinary albumin-to-creatinine ratio, and a 12-lead ECG.^[1]
• Echocardiography may be considered in elevated BP, particularly when it is likely to change management (ESC 2024, Class IIb, Level B).^[1]
• His results are normal and his ECG shows no LVH; these are illustrative scenario results.

Step 5 — Treatment decision

Discussion:

• ESC 2024 asks that BP-lowering treatment in elevated BP always be started on the basis of individual clinical judgement and shared decision-making.^[1]
• ESC 2024 Recommendation Table 17: in adults with elevated BP and sufficiently high CVD risk (10-year estimated CVD risk of 10% or more; or 10-year estimated CVD risk of 5% to ≤10% plus risk modifiers or abnormal risk tool tests; or high-risk conditions, e.g. established CVD, diabetes, moderate or severe CKD, familial hypercholesterolaemia or HMOD), after 3 months of lifestyle intervention, BP lowering with pharmacological treatment is recommended for those with confirmed BP of 130/80 mmHg or more to reduce CVD risk (Class I, Level A).^[1]
• The ESC text (not a table row) adds that in this group BP-lowering lifestyle measures should be initiated for 3 months, and that pharmacological therapy is then recommended for confirmed BP of 130/80 mmHg or more when these lifestyle changes have not worked or are not being implemented.^[1]
• At review after 3 months of lifestyle measures, a further home series is not feasible for him, so BP is confirmed by repeated office measurements on more than one visit: his standardised office BP, repeated at two visits, averages 134/84 mmHg, so he meets that threshold.^[1]
• Had he not been up-classified, he would be in the ESC low/medium-risk group for elevated BP (10-year CVD risk below 10%), for which BP lowering with lifestyle measures is recommended and can reduce CVD risk (Class I, Level B), and in which, as a person with elevated BP who does not currently meet risk thresholds for BP-lowering treatment, a repeat BP measurement and risk assessment within 1 year should be considered (Class IIa, Level C).^[1]
• If treated, ESC 2024 recommends, to reduce CVD risk, a treated systolic target of 120–129 mmHg in most adults, provided treatment is well tolerated (Class I, Level A).^[1]

Step 6 — The AHA/ACC 2025 contrast

Discussion:

• AHA/ACC 2025 would apply PREVENT, defining increased risk as a 10-year CVD risk of 7.5% or more; his PREVENT risk is not given in this scenario.^[2]
• If stage 1 hypertension is confirmed and his PREVENT risk is 7.5% or more, AHA/ACC 2025 recommends drugs at average SBP of 130 mm Hg or more (COR 1, LOE A) or DBP of 80 mm Hg or more (COR 1, LOE C-LD), to reduce the risk of CVD events and total mortality.^[2]
• If stage 1 hypertension is confirmed and his PREVENT risk is below 7.5% (he has no clinical CVD), drugs are recommended if average SBP remains 130 mm Hg or more, or DBP 80 mm Hg or more, after a 3- to 6-month trial of lifestyle intervention, to prevent target organ damage and mitigate further rise in BP (COR 1, LOE B-R).^[2]

Step 7 — Australian practice

Discussion:

• The 2023 Australian CVD risk guideline recommends CVD risk assessment in people without known CVD — all people aged 45–79 years, people with diabetes from 35 years and First Nations people from 30 years — using the Aus CVD Risk Calculator, with 5-year categories of low (below 5%), intermediate (5% to below 10%) and high (10% or more).^[6]
• It states that BP-lowering and lipid-modifying drugs should be prescribed for high risk and considered for intermediate risk, unless contraindicated or clinically inappropriate.^[6]