Cardiovascular risk stratification in hypertensive patients: Impact of echocardiography and carotid ultrasonography

Background Decision about the management of hypertensive patients should no t be based on the level of blood pressure alone, but also on the presence o f other risk factors, target organ damage (TOD) and cardiovascular and rena l disease. Objective To evaluate the impact of echocardiography and carotid ultrasonog raphy in a more precise stratification of absolute cardiovascular risk. Methods Never-treated essential hypertensives (n = 141; 73 men, 68 women, m ean age 46 +/- 11 years) referred for the first time to our out-patient cli nic were included in the study. They underwent the following procedures: (1 )family and personal medical history, (2) clinical blood pressure (BP) meas urement, (3) routine blood chemistry and urine analysis, (4) electrocardiog ram, (5) echocardiogram, (6) carotid ultrasonogram. Risk was stratified according to the criteria suggested by the 1999 WHO/ISH guidelines. TOD was initially evaluated by routine procedures only, and su bsequently reassessed by using data on cardiac and vascular structure obtai ned by ultrasound examinations (left ventricular hypertrophy (LVH) as left ventricular mass index (LVMI)> 134 g/m(2) in men and >110 g/m(2) in women; carotid plaque as focal thickening >1.3 mm). Results According to the first classification 20% were low-risk patients, 5 0% medium-risk, 22% high-risk and 8% very-high-risk patients. A marked chan ge in risk stratification was obtained when TOD was assessed by adding ultr asound examinations: low-risk patients 18%, medium-risk 28%, high-risk 45%, very-high-risk patients Conclusions The detection of TOD by ultrasound techniques allowed a much mo re accurate identification of high-risk patients, who represented a very la rge fraction (45%) of the patient population seen at our hypertension clini c. In particular, a large proportion of patients classified as at moderate risk by routine investigations were instead found to be at high risk when u ltrasound examinations were added. The results of this study suggest that c ardiovascular risk stratification only based on simple routine work-up can often underestimate overall risk, thus leading to a potentially inadequate therapeutic management especially of low-medium risk patients. I Hypertens 19:375-380 (C) 2001 Lippincott Williams & Wilkins.