7th Brazilian Guideline of Arterial Hypertension: Chapter 4 - Cardiovascular Risk Stratification

The global CV risk should be assessed in each hypertensive individual, because it aids the professionals in therapeutic decision-making and allows prognostic analysis. The identification of hypertensive individuals prone to CV complications, especially myocardial infarction (MI) and stroke, is fundamental to a more aggressive therapy. Several algorithms and risk scores based on population studies were created in past decades,1 but, considering the lack of Brazilian data for a more accurate assessment of CV risk in the Brazilian population, the use of one single risk score should be avoided to support therapeutic decisions. Multifactorial models of risk stratification can be used for a more accurate individual risk classification.


Introduction
The global CV risk should be assessed in each hypertensive individual, because it aids the professionals in therapeutic decision-making and allows prognostic analysis. The identification of hypertensive individuals prone to CV complications, especially myocardial infarction (MI) and stroke, is fundamental to a more aggressive therapy. Several algorithms and risk scores based on population studies were created in past decades, 1 but, considering the lack of Brazilian data for a more accurate assessment of CV risk in the Brazilian population, the use of one single risk score should be avoided to support therapeutic decisions. Multifactorial models of risk stratification can be used for a more accurate individual risk classification.
Informing patients about their RF can improve the efficacy of pharmacological and non-pharmacological measures to reduce global risk. In addition, estimating indicators and using aging-related terms, such as "vascular age" or "cardiometabolic age", can aid in the strategy to change the RF. 2 In clinical practice, CV risk stratification of hypertensive patients can be based on two different strategies. In the first, the assessment is aimed at determining the global risk directly related to hypertension, in which case the risk classification depends on BP levels, associated risk factors, TOD and presence of CVD or kidney disease. In the second strategy, the objective is to determine the risk of a certain individual to develop general CVD within 10 years. Although that form of assessment is not specific to hypertensive patients, since it can be applied to any individual aged 30-74 years, it is worth noting that AH is the major CVRF.

Additional cardiovascular risk stratification
Only a small minority of hypertensive patients has only one BP elevation. Aimed at making risk stratification easier, the classification system in Table 1, contemplating only low, moderate and high risk, should be used. It is worth noting that the identification of previous CVD, kidney disease or DM considerably increases the risk of future CV events, independently of BP levels. 7,8 The large majority of the hypertensive population has additional RF. Therefore, the CV risk assessment depends on information obtained from clinical history, physical examination and complementary tests, always aiming at: • Coexistence of other CVRF (Table 2); • Presence of hypertension TOD (Table 3); • Diagnosis of CVD or kidney disease already established (Table 4).
Thus, to facilitate and speed the classification process of additional CV risk in the medical visit setting, the health professional in charge should follow the flowchart described in Figure 1. It is worth noting that, in some cases, the initial classification can be modified according to the best or worst control of BP levels and RF.

Global cardiovascular risk stratification
The CV risk stratification based on three steps has been recently recommended in the V Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention 9 and the I Brazilian Guideline for Cardiovascular Prevention, 10 and it can be adopted for hypertensive patients. The steps should be performed as follows.

Identification of atherosclerotic disease or of its equivalents
The first step to estimate CV risk is the identification of clinically evident or subclinical atherosclerotic disease,

Global risk score analysis
When the individual does not meet any of the step 1 conditions, the next step is to estimate the Global Risk Score (GRS). 6 The algorithm estimates the risk of having a CV event (CAD, stroke, PAD, HF) within 10 years. The distribution of points and percentage of risk is differentiated for women (Tables 6A and 6B) and men (Tables 7A and 7B). When the GRS is lower than 5%, the patient is classified as 'low risk' Men with GRS between 5% and 20%, and women with GRS between 5% and 10% are initially considered at 'intermediate risk'. 12 (GR: I; LE: A).
Men with GRS > 20% and women with GRS > 10% are considered at 'high risk' (GR: I; LE: A).

Risk reclassification based on the presence of aggravating factors
Patients at intermediate risk with the aggravating factors listed in Table 8 are reclassified as at high risk. 9,13-15 (GR: IIa; LE: B).
The criteria used in the diagnosis of MS are shown in Table 9.
In addition, to facilitate the global CV risk determination in hypertensive patients, the flowchart in Figure 2 shows all steps necessary for the final classification.
In conclusion, so far no CV risk assessment way has been validated in Brazil. In addition, some young women tend to a risk estimate lower than the actual one, and older men are usually identified as at high risk, even with no relevant RF. Thus, the use of more than one classification allows better understanding of CV risk in hypertensive patients.  or of its equivalents, such as DM and CKD 11 (Table 5). If positive, the individual is immediately classified as at high risk, because the chance of having the first or a new CV event within 10 years is greater than 20%. (GR: I; LE: A).