Absolute cardiovascular risk stratification

Initial assessment

The stratification of absolute cardiovascular risk results from the integration of four elements: blood pressure levels, classical risk factors, subclinical hypertension-mediated organ damage (HMOD) and established cardiovascular or renal disease. The first step is to classify blood pressure as high-normal or grade 1, 2 or 3 hypertension. Elevated blood pressure values increase risk by themselves; however, it is the association with risk factors and/or organ damage that determines the severity of the overall risk profile.

Classical risk factors

These include male sex; age (≥55 years in men; ≥65 years in women); smoking; dyslipidaemia — total cholesterol ≥190 mg/dL, LDL-C >115 mg/dL, HDL-C <40 mg/dL in men or <46 mg/dL in women, and/or triglycerides >150 mg/dL; glucose abnormalities (fasting glucose 102–125 mg/dL or abnormal glucose tolerance test); obesity (BMI ≥30 kg/m²) and abdominal obesity (waist circumference ≥102 cm in men; ≥88 cm in women); and family history of premature cardiovascular disease (men <55 years; women <65 years). The accumulation of these factors progressively increases risk.

Subclinical hypertension-mediated organ damage (HMOD)

This is a marker of silent vascular damage that substantially modifies risk stratification. Typical criteria include left ventricular hypertrophy on ECG or echocardiography; carotid intima-media thickening or atherosclerotic plaques; ankle-brachial index <0.9; increased arterial stiffness (pulse wave velocity >10 m/s); eGFR 30–59 mL/min/1.73 m²; or moderate microalbuminuria. The presence of HMOD immediately reclassifies the patient into a higher risk category.

Established disease: CVD, CKD or diabetes with organ damage

The presence of clinical cardiovascular disease — myocardial infarction, stroke/TIA, angina, revascularisation, heart failure, atrial fibrillation or peripheral arterial disease — confers very high risk, regardless of the remaining parameters. The same applies to significant chronic kidney disease with eGFR <60 mL/min/1.73 m² or proteinuria >300 mg/day. In diabetes mellitus, the presence of organ damage, such as microalbuminuria, left ventricular hypertrophy or retinopathy, also implies very high risk.

Final classification and therapeutic implications

By combining blood pressure category, risk factors, HMOD and established disease, absolute risk is classified as low, moderate, high or very high. This classification guides the intensity of antihypertensive treatment, blood pressure targets and the need for additional preventive therapies, such as statins or antiplatelet therapy when indicated. It also helps determine the timing and intensity of pharmacological treatment according to global risk, enabling a personalised, prognosis-oriented approach.