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Patient with elevated BPa office SBP 120–139 mmHg or

DBP 70–89 mmHg

Y

Established CVD, moderate/severe CKD,

HMOD, DM, or FH

(Class I)

N

Calculate SCORE2 or SCORE2-OP

(Class I) Patient with T2DM (only)

and <60 years old

10-year predicted CVD risk

Any of the following: Gestational diabetes Gestational hypertension Pre-eclampsia Pre-term delivery One or more still births Recurrent miscarriage

N

Consider shared risk modifiers

(Class IIa)

Any of the following: High-risk ethnicity Family history of premature onset ASCVD Socio-economic deprivation Auto-immune diseases Severe mental illness HIV

N

If still uncertain, shared decision-making informed by risk tools

(Class IIb)

Any of the following meeting abnormal criteria: CAC score Carotid or femoral plaque High-sensitivity cardiac troponin NT-proBNP Pulse wave velocity

Lifestyle measures

to reduce BP

(Class I) Reassess risk/BP one year later

(Class IIa) N Lifestyle measures

to reduce BP

(Class I) After 3 months of lifestyle measures, pharmacological treatment for patients with

≥130/80 mmHg

(Class I)

Y N

Y

Y

Calculate SCORE2- Diabetes

(Class IIa)

Y

<5% 5% – <10% ≥10%

Consider sex-specific risk modifiers

(Class IIa)

aExercise caution when considering treating persons with elevated BP and;

Moderate-to-severe frailty Symptomatic orthostatic hypotension Age ≥85 years

Figure 9 Summary of cardiovascular disease risk-stratification approach for blood pressure treatment in adults with elevated blood pressure. ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CAC, coronary artery calcium; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; DM, diabetes mellitus; FH, familial hypercholesterolaemia; HMOD, hypertension-mediated organ damage; NT-proBNP, N-terminal pro-brain natriuretic peptide; SBP, systolic blood pressure; SCORE2, Systematic COronary Risk Evaluation 2; SCORE2-OP, Systematic COronary Risk Evaluation 2–Older Persons. Downloaded from academic.oup.com/eurheartj/article/45/38/3912/7741010 by guest on 07 October 2026