Cuspidi Cesare, Meani Stefano, Salerno Maurizio, Severgnini Barbara, Fusi Veronica, Valerio Cristiana, Catini Eleonora, Magrini Fabio, Zanchetti Alberto
Istituto di Medicina Cardiovascolare, Centro di Fisiologia Clinica e Ipertensione, Universitá degli Studi di Milano, Ospedale Maggiore Policlinico, IRccs, Milano, Italy.
Blood Press. 2004;13(3):144-51. doi: 10.1080/08037050410033169.
The 2003 European Society of Hypertension/European Society of Cardiology (ESH-ESC) guidelines have recently proposed a new risk stratification scheme for estimating absolute risk for cardiovascular disease. At variance from the previous 1999 World Health Organization-International Society of Hypertension (WHO/ISH) guidelines, the new criteria include some additional risk factors such as obesity, abnormal high-density (HDL) or low-density lipoprotein (LDL) cholesterol levels and define a slight increase in creatinine and microalbuminuria as signs of target organ damage (TOD).
The aim of the study was to assess overall cardiovascular risk in uncomplicated hypertensives according to the 2003 ESH-ESC guidelines comparing this approach with the stratification scheme of the 1999 WHO/ISH guidelines.
Four hundred and twenty-five never-treated grade 1 and 2 essential hypertensive patients, referred for the first time to our outpatient clinic without diabetes mellitus, were included in the study. They underwent the following procedures: (i) repeated clinical blood pressure measurements; (ii) routine blood chemistry and urine analysis; (iii) electrocardiogram; (iv) 24-h urine collection for microalbuminuria; (v) echocardiogram; and (vi) carotid ultrasonogram. Risk was assessed according to both stratification schemes suggested by the 2003 ESH-ESC and 1999 WHO/ISH guidelines.
According to the 2003 ESH-ESC guidelines, 15.5% of the 425 patients were considered at low added risk, 47.8% at medium added risk and 36.7% at high added risk; 146 patients (34.3%) were classified in the high-risk stratum because of at least one manifestation of TOD and 5.6% having three or more risk factors. The accuracy in detecting TOD of the combined approach with ultrasound procedures and microalbuminuria was approximately 10-fold higher than that provided by routine investigation. As a result of the 1999 WHO/ISH stratification scheme, 34.5% were low-risk, 34.4% medium-risk and 31.1% high-risk patients.
Our findings show that: (i) more than one-third of uncomplicated grade 1 and 2 hypertensives seen in a outpatient hypertension hospital clinic have a high added risk according to the ESH-ESC scheme; (ii) classification of the patients in the high stratum is mainly influenced by the presence of TOD; (iii) the routine diagnostic work-up is a highly insensitive approach for the detection of TOD; (iv) the 2003 ESH-ESC guidelines stratify a higher proportion of hypertensive patients in the medium and high-risk groups than do the 1999 WHO/ISH guidelines.
2003年欧洲高血压学会/欧洲心脏病学会（ESH-ESC）指南最近提出了一种新的风险分层方案，用于评估心血管疾病的绝对风险。与先前1999年世界卫生组织-国际高血压学会（WHO/ISH）指南不同，新的标准纳入了一些额外的风险因素，如肥胖、异常的高密度脂蛋白（HDL）或低密度脂蛋白（LDL）胆固醇水平，并将肌酐和微量白蛋白尿的轻微升高定义为靶器官损害（TOD）的迹象。
本研究的目的是根据2003年ESH-ESC指南评估未合并并发症的高血压患者的总体心血管风险，并将这种方法与1999年WHO/ISH指南的分层方案进行比较。
425例从未接受过治疗的1级和2级原发性高血压患者首次被转诊至我们的门诊，且无糖尿病，纳入本研究。他们接受了以下检查：（i）重复测量临床血压；（ii）常规血液化学和尿液分析；（iii）心电图；（iv）收集24小时尿液检测微量白蛋白尿；（v）超声心动图；（vi）颈动脉超声检查。根据2003年ESH-ESC和1999年WHO/ISH指南建议的两种分层方案评估风险。
根据2003年ESH-ESC指南，425例患者中15.5%被认为是低附加风险，47.8%为中等附加风险，36.7%为高附加风险；146例患者（34.3%）因至少一种TOD表现而被归类为高危组，5.6%有三种或更多风险因素。超声检查和微量白蛋白尿联合检测TOD的准确性比常规检查高约10倍。根据1999年WHO/ISH分层方案，低风险患者占34.5%，中等风险患者占34.4%，高风险患者占31.1%。
我们的研究结果表明：（i）根据ESH-ESC方案，在门诊高血压医院诊所就诊的未合并并发症的1级和2级高血压患者中，超过三分之一具有高附加风险；（ii）患者在高危组的分类主要受TOD存在情况的影响；（iii）常规诊断检查对TOD的检测是一种高度不敏感的方法；（iv）与1999年WHO/ISH指南相比，200年ESH-ESC指南将更高比例的高血压患者分层为中高危组。
