An Overview of the Expanded Definition and Classification of Hypertension Part 3/5

The+Interrelationship+of+High+Blood+Pressure+and+Other+Cardiovascular+Risk+Factors%0D%0A%0D%0AAnother+key+principle+endorsed+by+the+HWG+is+that+of+the+interrelationship+between+elevated+BP+and+other+CV+risk+factors.+Even+in+patients+with+frank+elevations+in+BP%2C+risk+stratification+based+on+BP+levels+alone+often+underestimates+CV+risk.+This+is+because+above-optimal+BP+levels+rarely+occur+in+isolation%2C+and+patients+seen+in+clinical+practice+frequently+have+multiple+CVD+markers+or+risk+factors+%28eg%2C+overweight%2C+insulin+resistance%2C+dyslipidemia%29+that+point+to+greater+overall+risk.%5B1%2C9-13%5D+What+is+particularly+significant%2C+from+the+perspective+of+defining+hypertension+beyond+BP+thresholds%2C+is+that+many+of+these+disease+processes+are+intimately+interrelated+and+interact+via+common+pathobiologic+processes+involving+oxidative+stress+and+endothelial+dysfunction+%28Figure%29.%5B14%5D+Moreover%2C+the+presence+of+risk+factors+and+disease+markers+defines+the+earliest+stage+in+this+CVD+continuum%2C+well+before+overt+CVD+and+target-organ+damage+can+be+measured+in+the+clinic.%5B14%5D+From+this+perspective%2C+above-optimal+BP+%28a+risk+factor%29+is+not+necessarily+synonymous+with+hypertension+%28a+disease+representative+of+progressive+CVD+and+tissue+injury%29.%5B6%5D+%0D%0A%0D%0AAnother+consequence+of+the+CV+and+renal+pathophysiologic+continuum+is+that+the+complex+interplay+of+risk+factors+and+disease+markers+frequently+may+manifest+as+a+dramatically+higher+CV+risk+than+would+be+expected%2C+based+on+thresholds+for+each+individual+risk+factor+alone.+This+is+highlighted+by+the+particularly+deleterious+condition+known+as+the+cardiometabolic+syndrome%2C+in+which+individual+risk+factors+combine+to+increase+CV+risk+synergistically%2C+rather+than+additively.%5B12%2C15%5D+Ultimately%2C+a+more+clinically+meaningful+assessment+of+CV+risk+can+be+obtained+by+global+assessment+of+a+patient%27s+risk%2C+rather+than+focusing+solely+on+whether+a+patient+has+crossed+a+particular+BP+threshold.%0D%0A%0D%0ATaken+together%2C+this+evidence+suggests+that+it+may+be+more+useful+to+view+BP+as+1%2C+but+not+the+only%2C+biomarker+for+the+disease+hypertension%2C+and+to+view+above-optimal+levels+of+BP+in+an+individual+patient+as+those+that%2C+when+sustained%2C+cause+damage+to+the+vasculature.%5B6%5D+This+forms+the+basis+of+the+revised+definition+of+hypertension%2C+as+shown+in+Table+1.%0D%0A%0D%0A%3Cb%3ETable+1.+Revised+Definition+of+Hypertension+From+Hypertension+Writing+Group+2009%3C%2Fb%3E%0D%0A%E2%80%A2+Hypertension+is+a+progressive+CV+syndrome+arising+from+complex+and+interrelated+etiologies%0D%0A%E2%80%A2+Early+markers+of+the+syndrome+are+often+present+before+BP+elevation+is+sustained%3B+therefore%2C+hypertension+cannot+be+classified+solely+by+discreet+BP+thresholds%0D%0A%E2%80%A2+Progression+is+strongly+associated+with+functional+and+structural+cardiac+and+vascular+abnormalities+that+damage+the+heart%2C+kidneys%2C+brain%2C+vasculature%2C+and+other+organs%2C+and+lead+to+premature+morbidity+and+death%0D%0A%E2%80%A2+Reduction+of+elevated+BP+generally+confers+a+reduction+in+the+risk+for+CV+events.+Note+that+HWG+separates+elevated+BP+%28one+manifestation+of+the+disease%29+from+hypertension+%28the+disease%29%0D%0A%0D%0ABP+%3D+blood+pressure%3B+CV+%3D+cardiovascular%0D%0AFrom+Giles+T%2C+et+al.%5B6%5D+%0D%0A%0D%0ABecause+hypertension+is+defined+by+as+%22a+progressive+cardiovascular+syndrome%2C%22+it+is+clinically+helpful+to+categorize%2C+or+stage%2C+patients+%28Table+2%29%2C+with+each+stage+characterized+by+the+cumulative+presence+or+absence+of+markers+of+hypertensive+CVD+and+evidence+of+target-organ+damage.+This+provides+a+snapshot+of+the+extent+to+which+the+disease+has+advanced+at+a+particular+time.%5B6%5D%0D%0A%0D%0A%3Cb%3ETable+2.+Revised+Definition+and+Classification+of+Hypertension+From+Hypertension+Writing+Group+2009%3C%2Fb%3E+++++++++++++++++++++++++%0D%0A%3Ctable+border%3D%221%22+cellpadding%3D%223%22+cellspacing%3D%221%22%3E%3Ctbody%3E%0D%0A%3Ctr+valign%3D%22top%22%3E+++++++++++++++++++++++++++++++++++++%3Ctd%3E%3Cb%3EClassification%3C%2Fb%3E+++++++++++++++++++++++++++++++++++++%0D%0A%3C%2Ftd%3E++++++++++++++++++++++++++++++++++++++%3Ctd%3E%3Cb%3ENormal%3C%2Fb%3E+++++++++++++++++++++++++++++++++++++%0D%0A%3C%2Ftd%3E++++++++++++++++++++++++++++++++++++++%3Ctd%3E%3Cb%3EStage+1+Hypertension%3C%2Fb%3E+++++++++++++++++++++++++++++++++++++%0D%0A%3C%2Ftd%3E++++++++++++++++++++++++++++++++++++++%3Ctd%3E%3Cb%3EStage+2+Hypertension%3C%2Fb%3E+++++++++++++++++++++++++++++++++++++%0D%0A%3C%2Ftd%3E++++++++++++++++++++++++++++++++++++++%3Ctd%3E%3Cb%3EStage+3+Hypertension%3C%2Fb%3E+++++++++++++++++++++++++++++++++++++%0D%0A%3C%2Ftd%3E++++++++++++++++++++++++++++++++++%3C%2Ftr%3E%0D%0A%3Ctr+valign%3D%22top%22%3E+++++++++++++++++++++++++++++++++++++%3Ctd%3EDescriptive+category%0D%0A%3C%2Ftd%3E++++++++++++++++++++++++++++++++++++++%3Ctd+align%3D%22center%22%3ENormal+BP+or+rare+BP+elevations%0D%0AAND%0D%0Ano+identifiable+CVD%0D%0A%3C%2Ftd%3E+++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