Physicians' Academy for Cardiovascular Education

Global CV risk distribution associated with hypertension: high risk, low control

Literature - Wong ND et al, Am J Hypertens. 2012 Feb 9

Global Cardiovascular Risk Associated With Hypertension and Extent of Treatment and Control According to Risk Group.

Wong ND, Dede J, Chow VH, Wong KS, Franklin SS

Am J Hypertens. 2012 Feb 9. doi: 10.1038/ajh.2012.2.

Hypertension leads to increased CV risk; however treatment choice and goals are usually based on blood pressure than on individual risk [1-3]. Treatment and control of hypertension can vary according to level of CVD risk and clinical outcomes might be improved by risk assessment. This has not been studied adequately yet. Framingham risk scores (FRS) are widely used to assess CVD risk [4].

In this study, the distribution of global CVD risk in subjects with hypertension was evaluated. Framingham risk scores were compared with the guidelines for risk stratification from the European Society of Hypertension (ESH) and gaps were identified on treatment and control of hypertension among different risk groups.

The National Health and Nutrition Examination Survey (NHANES) 2005-2006 was used [5]to identify 1,509 subjects with hypertension aged ≥ 30 years in various risk groups.

Main results

In this study, 55% of US persons with hypertension were at high 10-year risk of CVD by FRS criteria or had pre-existing CVD, and an additional 39% of low and 51% of intermediate FRS groups were at high risk of CVD by ESH criteria, with 80% overall at high risk providing a compelling indication for antihypertensive therapy. Hypertension treatment was only modestly related to global risk; treatment rates were lowest among lower risk men and Hispanics and highest in those with pre-existing CVD. Control rates were best among lower risk individuals but worst among higher risk persons. While the FRS is influenced primarily by age, many younger persons at a calculated low or intermediate risk actually have cardiometabolic risk factors (identified by the ESH approach) that would place them at higher longer-term risk.

Distribution of global risk of cardiovascular disease (CVD)

in US adults aged 30 and over with hypertension (HTN) according to Framingham, European Society of Hypertension (ESH) criteria and combined approaches. *Combined approach indicates proportion of subjects at low risk by both Framingham and ESH criteria, intermediate risk by either, and high risk by either criteria (including those with pre-existing cardiovascular disease). FRS, Framingham risk score.


CVD risk largely varies in persons with hypertension; control rates are lowest in high risk persons.
Future guidelines should consider risk stratification combining shorter and longer-term risk assessment to best identify persons at highest CVD risk


1. Franklin SS, Wong ND. Cardiovascular risk evaluation: an inexact science. J Hypertens 2002; 20:2127–2130.
2. Chobanian AV, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560–2572.
3. Ikeda A, Iso H, et al. Blood pressure and the risk of stroke, cardiovascular disease, and all-cause mortality among Japanese: the JPHC Study. Am J Hypertens 2009; 22:273–280.
4. D’Agostino RB Sr, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008; 117:743–753.
5. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. National Health and Nutrition examination Survey Laboratory/Medical Technologists Procedures Manual Hyattsville, MD: US Department of Health and Human Services, Center for Disease Control and Prevention: 2003–2004.


Background Hypertension (HTN) confers increased cardiovascular disease (CVD) risk; however, the variation in risk and how treatment and control rates may differ according to extent of risk needs clarification. We examined CVD risk distribution and treatment and control patterns according to risk group.

Methods We estimated 10-year Framingham global risk in 1,509 US persons aged ≥30 years from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 with HTN and the proportion of subjects in low (<10%), intermediate (10-20%), and high (>20%) risk groups, or with pre-existing CVD, or who otherwise had high cardiometabolic risk according to European Society of Hypertension (ESH) criteria (diabetes (DM), metabolic syndrome (MetS), stage 3 HTN, or 3 additional CVD risk factors). We also examined HTN treatment and control rates by risk group.

Results From Framingham risk assessment, 24% of subjects were low risk, 21% intermediate risk, 23% high risk, and 32% had CVD. An additional 39% of low and 51% of intermediate risk subjects were at high or very high risk based on European criteria, for a total of 80% classified high risk or with CVD by either criterion. Treatment rates across Framingham risk groups ranged from 58 to 75%. HTN control rates were over 80% for lower risk persons, but under 50% for higher risk subjects.

Conclusions There is a wide variation in CVD risk in persons with HTN with control rates still suboptimal in higher risk subjects. Future guidelines should consider risk stratification combining shorter and longer-term risk assessment to best identify those who have the greatest CVD risk

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