Impact of baseline prehypertension on cardiovascular events and all-cause mortality in the general population: a meta-analysis of prospective cohort studies

Long-term effects of blood pressure 130-139/80-89 mmHg on all-cause and cardiovascular mortality among Chinese adults with different glucose metabolism

BACKGROUND

This study aimed to investigate the risks of all-cause and cardiovascular mortality associated with blood pressure (BP) levels of 130-139/80-89 mmHg in Chinese adults with different glucose metabolism, during a long-term follow-up of over 20 years.

METHODS

A prospective population-based cohort of 2,132 adults in Shanghai was established in 2002 and followed for 21 years. The association between BP categories and mortality was assessed, and the risk was further analyzed using multiple Cox regression analysis by combining BP and blood glucose categories.

RESULTS

The final analysis included 2,004 participants, with 397 all-cause and 166 cardiovascular mortality. The incidence of all-cause and cardiovascular mortality per 1,000 person-years for different BP categories were as follows: BP < 130/80 mmHg (4.5 and 1.3), 130-139/80-89 mmHg (7.7 and 2.9), and ≥ 140/90 mmHg or treated groups (19.9 and 8.7), respectively. After adjusting for age, sex, and other factors, BP ≥ 140/90 mmHg was significantly associated with a higher risk of mortality across different blood glucose categories. However, using BP < 130/80 mmHg and normoglycemia as the reference, a BP of 130-139/80-89 mmHg was significantly associated with higher risks of all-cause (hazard ratio 3.30 [95% confidence interval 1.48-7.38], P < 0.01) and cardiovascular mortality (9.60 [1.93-47.7], P < 0.01) in diabetes, but not in those with normoglycemia or prediabetes.

CONCLUSIONS

BP of 130-139/80-89 mmHg may lead to a significantly higher risk of all-cause and cardiovascular mortality in Chinese adults with diabetes, but not in those with normoglycemia or prediabetes. This suggests that the targeted BP for people with diabetes should be < 130-139/80-89 mmHg.

Poor Physical Capacity Combined With High Body Fat Percentage as an Independent Risk Factor for Incident Hypertension in Chinese Suburb-Dwelling Older Adults

Background

This study examined the effects of poor physical capacity and high body fat percentage (BF%) on the incidence of hypertension in Chinese suburb-dwelling older adults.

Methods

This study was conducted on 368 Chinese suburb-dwelling participants aged ≥ 60 years without hypertension (mean age: 66.74 ± 5.59 years, 48.9% men). Poor physical capacity is defined by the Asian Working Group for Sarcopenia (AWGS) criteria as grip strength &lt; 26 kg for men and &lt; 18 kg for women or walking speed &lt;0.8 m/s. High BF% was defined as values that are greater than the upper tertile for BF% as stratified by sex. The outcome was the incidence of hypertension.

Results

Overall, 5.7% of subjects had both poor physical capacity and high BF%. After the average follow-up duration of 2 years, the incidence of hypertension was 39.7%, and those experiencing both poor physical capacity and high BF% had the highest incidence (81.0%). After multivariate adjustments, the incidence of hypertension was associated with the combination of poor physical capacity and high BF% [odds ratio (OR) = 6.43, 95% CI = 1.91–21.64] but not solely with poor physical capacity (OR = 1.11, 95% CI = 0.55–2.25) or only high BF% (OR = 1.37, 95% CI = 0.80–2.34).

Conclusion

The combination of poor physical capacity and high BF% can significantly increase the incidence of hypertension in Chinese suburb-dwelling older adults. For hypertension prevention, ideally, we should strive toward decreasing body fat mass while simultaneously improving physical capacity.

Concordance of recommendations across clinical practice guidelines for the management of hypertension in Southeast Asia with internationally reputable sources

OBJECTIVES

This study aimed to assess the rate of concordance, and to investigate sources of non-concordance of recommendations in the management of hypertension across CPGs in Southeast Asia, with internationally reputable clinical practice guidelines (CPGs).

METHODS

CPGs for the management of hypertension in Southeast Asia were retrieved from the websites of the Ministry of Health or cardiovascular specialty societies of the individual countries of Southeast Asia during November to December 2020. The recommendations for the management of hypertension specified in the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline and the 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guideline were selected to be the reference standards; the recommendations concerning the management of hypertension in the included CPGs in Southeast Asia were assessed if they were concordant with the reference recommendations generated from both the 2017 ACC/AHA guideline and the 2018 ESC/ESH guideline, using the population (P)-intervention (I)-comparison (C) combinations approach.

RESULTS

A total of 59 reference recommendations with unique and unambiguous P-I-C specifications was generated from the 2017 ACC/AHA guideline. In addition, a total of 51 reference recommendations with unique and unambiguous P-I-C specifications was generated from the 2018 ESC/ESH guideline. Considering the six included CPGs from Southeast Asia, concordance was observed for 30 reference recommendations (50.8%) out of 59 reference recommendations generated from the 2017 ACC/AHA guideline and for 31 reference recommendations (69.8%) out of 51 reference recommendations derived from the 2018 ESC/ESH guideline.

CONCLUSIONS

Hypertension represents a significant issue that places health and economic strains in Southeast Asia and demands guideline-based care, yet CPGs in Southeast Asia have a high rate of non-concordance with internationally reputable CPGs. Concordant recommendations could perhaps be considered a standard of care for hypertension management in the Southeast Asia region.

Diabetes modifies the association of prehypertension with cardiovascular disease and all-cause mortality

Prehypertension is a risk factor for cardiovascular disease (CVD) and all‐cause mortality. However, it is unclear whether prehypertension combined with diabetes associate with a higher risk for cardiovascular disease and all‐cause mortality. The purpose of this study was to explore the relationship between prehypertension and the risk of CVD and all‐cause mortality was different among individuals with or without diabetes. In the prospective community‐based Kailuan study, 67 344 participants without hypertension or a history of CVD at baseline (2006) were included. Prehypertension was defined as systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg. The outcomes were CVD and all‐cause mortality were followed up through December 31, 2017. We performed Cox proportional hazards models to evaluate the relationships between prehypertension and CVD and all‐cause mortality by diabetes status. During a median follow‐up of 11.03 years, 2981 CVD events and 4655 all‐cause mortality occurred. After adjusting age, sex, and other factors, the associations of prehypertension with risk of CVD and all‐cause mortality were significant in participants without diabetes (hazard ratio and 95% confidence interval: 1.54 [1.38–1.71] and 1.27 [1.17–1.38]), but not in participants with diabetes (1.20 [0.93–1.56] and 0.88 [0.73–1.07]). The interactions between prehypertension and diabetes for the risk of CVD and all‐cause mortality were all significant (all p < .05). Prehypertension was only associated with an increased risk for CVD and all‐cause mortality in non‐diabetes participants. Diabetes modifies the relation of prehypertension with the risk of CVD and all‐cause mortality.

Prevalence of prehypertension and its risk factors in midlife and late life: Indonesian family life survey 2014-2015

BACKGROUND

Early detection of prehypertension is important to prevent hypertension-related complications, such as cardiovascular disease, cerebrovascular disease and all-cause mortality. Data regarding the prevalence of prehypertension among mid- and late-life population in Indonesia were lacking. It is crucial to obtain the prevalence data and identify the risk factors for prehypertension in Indonesia, which may differ from that of other countries.

METHODS

The cross-sectional analysis utilized multicenter data from Indonesian Family Life Survey-5 (IFLS-5) from 13 provinces in 2014-2015. We included all subjects at mid-and late-life (aged ≥40 years old) from IFLS-5 with complete blood pressure data and excluded those with prior diagnosis of hypertension. Prehypertension was defined as high-normal blood pressure according to International Society of Hypertension (ISH) 2020 guideline (systolic 130-139 mmHg and/or diastolic 85-89 mmHg). Sociodemographic factors, chronic medical conditions, physical activity, waist circumference and nutritional status were taken into account. Statistical analyses included bivariate and multivariate analyses.

RESULTS

There were 5874 subjects included. The prevalence of prehypertension among Indonesian adults aged > 40 years old was 32.5%. Age ≥ 60 years (adjusted OR 1.68, 95% CI 1.41-2.01, p <  0.001), male sex (adjusted OR 1.65, 95% CI 1.45-1.88, p <  0.001), overweight (adjusted OR 1.44, 95% CI 1.22-1.70, p <  0.001), obesity (adjusted OR 1.77, 95% CI 1.48-2.12, p <  0.001), and raised waist circumference (adjusted OR 1.32, 95% CI 1.11-1.56, p = 0.002) were the significant risk factors associated with prehypertension. Prehypertension was inversely associated with being underweight (adjusted OR 0.74, 95% CI 0.59-0.93, p = 0.009).

CONCLUSIONS

The prevalence of prehypertension in Indonesian mid- and late-life populations is 32.5%. Age ≥ 60 years, male sex, overweight, obesity, and raised waist circumference are risk factors for prehypertension.

Prehypertension and risk for all-cause and cardiovascular mortality by diabetes status: results from the national health and nutrition examination surveys

Background

It is unclear whether prehypertension alone or combined with diabetes associate with a higher risk for cardiovascular or all-cause mortality. The purpose of this study was to explore the relationship between prehypertension and all-cause and cardiovascular mortality stratified by diabetes status.

Methods

All participants aged ≥18 years were enrolled from the 1999–2014 National Health and Nutrition Examination Surveys (NHANES). Prehypertension was defined as systolic/diastolic blood pressure (BP): 120–139/80–89 mmHg. The status of cardiovascular and all-cause mortality of participants were followed up through 31 December 2015. We performed Cox proportional hazards models and Kaplan-Meier survival curves to evaluate the relationships as mentioned above.

Results

In general, we enrolled 26,070 participants while 15,295 (58.67%) of them did not have diabetes nor prehypertension, 8,870 (34.02%) had prehypertension alone, 835 (3.20%) had diabetes alone, and 1,070 (4.11%) had both diabetes and prehypertension. Compared with participants without diabetes nor prehypertension, the multivariable adjusted hazard ratios and 95% confidence interval (CI) for all-cause mortality among participants with prehypertension alone, diabetes alone, and both diabetes and prehypertension were 1.08 (95% CI: 0.95, 1.23), 1.26 (0.98, 1.62), and 1.67 (1.38, 2.03) (P for trend <0.001), for cardiovascular mortality, the corresponding hazard ratios and 95% CI were 1.40 (95% CI: 0.92, 2.14), 2.21 (1.12, 4.38), and 2.87 (1.65, 4.99) (P for trend <0.001) respectively.

Conclusions

Our findings suggested that prehypertension associated with an increased risk for cardiovascular and all-cause mortality when compared with diabetes, but not for prehypertension alone. Early screening and intervention for BP among diabetic patients may be beneficial.

Association between blood pressure levels and cardiovascular deaths: a 20-year follow-up study in rural China

OBJECTIVES

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline recommended 130/80 mm Hg as blood pressure (BP) target goals. However, the generalisability of this recommendation to populations at large with hypertension remains controversial. We assessed the association between BP and cardiovascular diseases (CVDs) mortality using a 20-year follow-up study among Chinese populations.

DESIGN

Prospective cohort study.

PARTICIPANTS

7314 participants were followed up for a median of 20 years in Fangshan District, Beijing, China.

METHODS

The primary outcome variable was death from cardiovascular causes. The adjusted HR for CVDs mortality associated with baseline BP was calculated using Cox regression analysis.

RESULTS

We identified 350 deaths from CVDs (148 stroke, 113 coronary heart disease and 89 other CVDs) during follow-up. Hypertension (defined by systolic BP (SBP)/diastolic BP (DBP) ≥140/90 mm Hg) was significantly associated with mortality due to CVDs (HR=2.49, 95% CI=1.77 to 3.50) among people aged 35-59 years rather than people aged ≥60 years. In addition, there was no significant association between stage 1 hypertension defined by the 2017 ACC/AHA (SBP/DBP of 130-139/80-89 mm Hg) and CVDs mortality when compared with SBP/DBP of <120/80 in neither the participants aged <60 years (HR=0.90, 95% CI=0.54 to 1.50) nor participants aged ≥60 years (HR=1.47, 95% CI=0.94 to 2.29).

CONCLUSION

The study revealed hypertension of SBP/DBP≥140/90 mm Hg was an important risk factor of CVDs mortality, especially among people aged 35-59 years. However, stage 1 hypertension under the definition of 2017 ACC/AHA was not associated with an increased risk of CVDs mortality. This study indicated that whether adopting the new hypertension definition needs further consideration in rural Chinese populations.

Impacts of Pre-Diabetes or Prehypertension on Subsequent Occurrence of Cardiovascular and All-Cause Mortality among Population without Cardiovascular Diseases

BACKGROUND

Among the population without cardiovascular diseases (CVD), it is unclear whether pre-diabetes and/or prehypertension elevated the risk of all-cause and cardiovascular mortality.

METHODS

All participants without CVD at baseline were recruited from the 1999-2014 National Health and Nutrition Examination Survey (NHANES), with survival status being updated until 31 December 2015. Cox proportional hazards models and subgroup analyses were performed to estimate hazard ratios (HRs) and 95% confidence interval (CI).

RESULTS

There were 23,622 participants (11,233 [47.6%] male) with mean age of 37.2 years. Compared to participants without prehypertension or pre-diabetes, the HRs for all-cause mortality among participants with prehypertension alone, pre-diabetes alone, and combined pre-diabetes and prehypertension were 1.04 (95% CI: 0.88, 1.24), 0.96 (95% CI:0.76, 1.21), and 1.19 (95% CI:0.98, 1.46), respectively. The corresponding HRs for cardiovascular mortality were 1.51 (95% CI: 0.83, 2.77), 1.40 (95% CI: 0.64, 3.06), and 1.70 (95% CI: 0.88, 3.27), respectively. A subgroup analysis showed that participants with combined pre-diabetes and prehypertension had a higher risk of all-cause mortality among younger participants, higher BMI, white population, and people with elevated non-HDLC. Moreover, the association between combined pre-diabetes and prehypertension and cardiovascular death was only significant among people with elevated non-HDLC.

CONCLUSION

Pre-diabetes combined with prehypertension might elevate the risk of all-cause mortality among subjects, particularly for those with elevated body weight, high non-HDLC, younger participants or white population.

Pregnancy outcomes among women with American College of Cardiology- American Heart Association defined hypertension

Objective: To compare the rate of adverse pregnancy outcomes of women with hypertension defined by the ACC-AHA guidelines, women with hypertension defined by ACOG guidelines, and normotensive women.Methods: A historical cohort study of women with singleton, nonanomalous pregnancies who presented before 20 weeks for their first prenatal visit between 1 January 2014 and 31 January 2016 with (a) hypertension defined by ACC-AHA (systolic blood pressure 130 mmHg and/or diastolic blood pressure of 80 mmHg documented), (b) hypertension defined by ACOG (systolic blood pressure of 140 mmHg and/or diastolic blood pressure of 90 mmHg documented) and (c) women documented to be normotensive. Primary outcomes were preeclampsia and small for gestational age. Fisher's exact test was used to compare demographics and risk factors between the groups. Multivariable logistic regression analysis was used to predict the association of preeclampsia within the groups adjusting for additional risk factors.Results: A total of 252 women were included. Of these, 92 (36.5%) had hypertension by ACC-AHA, 34 (13.5%) by ACOG and 126 (50%) were normotensive. Sixty percent of women with the ACOG definition developed preeclampsia compared to 45.1% of women with the ACC-AHA definition and 17.1% in the control group (p < .001). The rate of preeclampsia among women with hypertension by ACC-AHA criteria was not significantly different from the rate among women with hypertension by ACOG criteria (p = .288). Differences in small for gestational age among the groups were not significant (ACOG: 20%, ACC-AHA: 11.1%, normotensive: 9.8%, p = .423).Conclusion: Women with hypertension defined by ACC-AHA have a rate of developing preeclampsia that is similar to that of women with hypertension defined by ACOG.

Relationship of the Blood Pressure Categories, as Defined by the ACC/AHA 2017 Blood Pressure Guidelines, and the Risk of Development of Cardiovascular Disease in Low-Risk Young Adults: Insights From a Retrospective Cohort of Young Adults

Background

There are limited outcome studies of hypertension among young adults, especially using the new blood pressure (BP) categories from the American College of Cardiology and the American Heart Association. We examined associations between the new BP categories and the risk of incident cardiovascular disease (CVD) in low‐risk and young adults.

Methods and Results

A cohort study was performed in 244 837 Korean adults (mean age, 39.0 years; SD, 8.9 years) who underwent a comprehensive health examination at Kangbuk Samsung Hospital from January 1, 2011, to December 31, 2016; they were followed up for incident CVD via linkage to the Health Insurance and Review Agency database until the end of 2016, with a median follow‐up of 4.3 years. BP was categorized according to the new American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines. During 924 420.7 person‐years, 1435 participants developed new‐onset CVD (incidence rate of 16.0 per 10⁴ person‐years). The multivariable‐adjusted hazard ratios (95% CIs ) for CVD comparing elevated BP, stage 1 hypertension, stage 2 hypertension, treated and strictly controlled (systolic BP/diastolic BP <130/80 mm Hg with antihypertensive use), treated and controlled (systolic BP 130–139 and diastolic BP 80 to 89 mm Hg with antihypertensive use), treated uncontrolled, and untreated hypertension to normal BP were 1.37 (1.11–1.68), 1.45 (1.26–1.68), 2.12 (1.74–2.58), 1.41 (1.12–1.78), 1.97 (1.52–2.56), 2.29 (1.56–3.37) and 1.93 (1.53–2.45), respectively.

Conclusions

In this large cohort of low‐risk and young adults, all categories of higher BP were independently associated with an increased risk of CVD compared with normal BP, underscoring the importance of BP management even in these low‐risk populations.

Supplementation with Hydroxytyrosol and Punicalagin Improves Early Atherosclerosis Markers Involved in the Asymptomatic Phase of Atherosclerosis in the Adult Population: A Randomized, Placebo-Controlled, Crossover Trial

Hydroxytyrosol (HT) and Punicalagin (PC) exert cardioprotective and anti-atherosclerotic effects. This study evaluates the effect of oral supplementation with HT and PC (SAx) on early atherosclerosis markers in middle-aged, seemingly healthy adults. A randomized, double-blinded, placebo-controlled, crossover trial was performed for 20 weeks. There were two treatment sequences (Placebo/SAx, n = 41; SAx/Placebo, n = 43) for which the intervention periods (Placebo and SAx) were 8 weeks long, followed by a 4-week wash out period. The supplement was composed of 9.9 mg of HT and 195 mg of PC, and the placebo was composed of maltodextrin. SAx increased endothelial function (Flow-mediated dilatation [FMD]: 2.36%; p < 0.001) in the endothelial dysfunction subgroup compared to the placebo (2.36 ± 3.9 vs. 0.76 ± 3.5%, p < 0.05). SAx also reduced oxLDL by -28.74 ng/mL (p < 0.05) in subjects with higher levels of oxLDL, which was an improvement compared with the placebo (-28.74 ± 40.2 vs. 25.64 ± 93.8 ng/mL, p < 0.001). The prehypertension and hypertension subgroups exhibited decreased systolic (-15.75 ± 9.9 mmHg; p < 0.001) and diastolic (-6.36 ± 8.7 mmHg; p < 0.001) blood pressure after SAx consumption. Moreover, the systolic prehypertension and hypertension subgroups presented significant differences in systolic blood pressure compared to the placebo (-15.75 ± 9.9 vs. -2.67 ± 12.0 mmHg, p < 0.05). In conclusion, the supplement exerted anti-atherosclerotic effects by improving endothelial function, blood pressure, and levels of circulating oxLDL, especially for persons in whom these parameters were altered.

Prevalence of Hypertension, Treatment, and Blood Pressure Targets in Canada Associated With the 2017 American College of Cardiology and American Heart Association Blood Pressure Guidelines

IMPORTANCE

The 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines redefined hypertension using a BP threshold of 130/80 mm Hg or greater and applied a treatment target of less than 130/80 mm Hg.

OBJECTIVE

To evaluate the potential change in the diagnosis, treatment, and control of hypertension in a Canadian cohort of patients with hypertension attending primary care practices using the ACC/AHA guidelines.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used primary care practices across Canada electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network, extracted as of June 30, 2015. Adults with at least 1 primary care encounter in the previous 2 years (July 1, 2013, to June 30, 2015) were included in the study. Those with current hypertension were identified using a validated definition consisting of diagnoses, billing codes, and/or antihypertensive medication from within the primary care electronic medical record. Data analysis was conducted from December 2017 to July 2018.

MAIN OUTCOMES AND MEASURES

Proportion of individuals with a diagnosis of hypertension, prescribed antihypertensive medication, and meeting treatment BP targets.

RESULTS

Of the 594 492 Canadian participants included in the study, 144 348 (24.2%) had hypertension (45.6% male; mean [SD] age, 65.5 [14.5] years). On applying the ACC/AHA guidelines, 252 279 individuals (42.4%) were considered hypertensive and half (51.0%; 95% CI, 50.8%-51.2%) were prescribed an antihypertensive medication. Individuals who were not previously considered to have hypertension but were reclassified as having elevated BP using the lower cutoff of 130/80 mm Hg or greater tended to be younger and were at lower cardiovascular risk. There was a shift toward more individuals requiring antihypertensive treatment, particularly in the lower-risk categories. The crude prevalence of hypertension increased from 13.3% to 32.0% in those aged 18 to 64 years, and of those aged 65 years and older, 16.6% more individuals were reclassified as having hypertension (from 55.2% to 71.8%). Only 12.3% of those who were considered at high risk were reclassified as hypertensive.

CONCLUSIONS AND RELEVANCE

Adoption of the ACC/AHA BP guidelines would result in a near doubling in the prevalence of hypertension in Canada. The changes would largely affect individuals who are younger and at low to moderate cardiovascular risk.

Management plans for populations with normal-to-hypertensive blood pressures: risks and benefits of antihypertensive drug treatment in populations previously defined as having high-normal blood pressure

Recent changes in American and European guidelines on the management of arterial hypertension have caused a considerable shift in the landscape of hypertension management. The 2017 American College of Cardiology/American Heart Association/American Society of Hypertension guideline recommends an office visit blood pressure (BP) > 130/80 mmHg as the new threshold for diagnosis of hypertension, and states that the treatment goal for all hypertensive patients should be lowered to < 130/80 mmHg. In contrast, the 2018 European guideline maintains the diagnostic threshold of hypertension at 140/90 mmHg. However, despite their differences in thresholds for diagnosis of hypertension, both guidelines are in agreement that treatment should be considered in patients with BPs in the range of 130 to 139/80 to 89 mmHg if they have high cardiovascular risk. The results from the Systolic Blood Pressure Intervention Trial (SPRINT) study and recent meta-analyses suggest that BP lowering with antihypertensive treatment may be beneficial in reducing cardiovascular event rates in subjects with high-normal BP or stage 1 hypertension according to the new American guideline. However, intensive BP lowering is associated with increased incidence of treatment-associated adverse events, and evidence suggests that BP lowering below 120/70 mmHg increases the risk of cardiovascular events. In this review, we discuss the evidence supporting antihypertensive treatment in subjects with high-normal BP and discuss the specific subgroup of subjects that might benefit from BP lowering.

Association Between Non-Dipping and Fragmented QRS Complexes in Prehypertensive Patients

Background

Fragmented QRS (fQRS) is a sign of adverse cardiovascular events in various cardiovascular diseases. It is also associated with increased blood pressure and non-dipping in hypertensive patients. However, no study has investigated the importance of fQRS in prehypertensive patients.

Objectives

The aim of our study is to investigate the relationship between fQRS and non-dipper status in prehypertensive patients.

Methods

Two hundred and sixteen eligible, newly diagnosed prehypertensive patients who underwent 24-hour ambulatory blood pressure monitoring (ABPM) for further evaluation of blood pressure between June 2015 and July 2016 were included into the study. Patients were divided into three groups according to ABPM results: normotensives, dipper prehypertensives, and non-dipper prehypertensives. Groups were compared regarding presence of fQRS on electrocardiography. Additionally, multinomial logistic regression analysis was used to determine the relationship between fQRS and blood pressure pattern in prehypertensive patients.

Results

According to ABPM recordings, 61 patients had normotensive blood pressure pattern (systolic blood pressure < 120 mmHg and diastolic blood pressure < 80 mmHg). Of the remaining 155 prehypertensive patients, 83 were dippers and 72 were non-dippers. Non-dipper prehypertensives had a significantly higher frequency of fQRS compared to normotensives (p = 0.048). Furthermore, multinomial logistic regression analysis revealed that fQRS is an independent predictor of non-dipping blood pressure pattern in prehypertensive patients (p = 0.017, OR: 4.071, 95% CI: 1.281-12.936).

Conclusions

We found that fQRS is a predictor of non-dipping in prehypertensives. As a marker of fibrosis and higher fibrotic burden within myocardium, fQRS may be useful in identifying high-risk prehypertensive patients before the development of hypertension.

Association of Blood Pressure Classification in Korean Young Adults According to the 2017 American College of Cardiology/American Heart Association Guidelines With Subsequent Cardiovascular Disease Events

IMPORTANCE

Among young adults, the association of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) High Blood Pressure Clinical Practice Guidelines with risk of cardiovascular disease (CVD) later in life is uncertain.

OBJECTIVE

To determine the association of blood pressure categories before age 40 years with risk of CVD later in life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study from the Korean National Health Insurance Service consisted of 2 488 101 adults aged 20 through 39 years with blood pressure measurements taken twice from 2002 through 2005. Starting from January 1, 2006, participants were followed up until the date of CVD diagnosis, death, or December 31, 2015.

EXPOSURES

Participants were categorized by blood pressure readings: normal (systolic, <120 mm Hg; diastolic, <80 mm Hg), elevated (sytolic, 120-129 mm Hg; diastolic, <80 mm Hg), stage 1 hypertension (systolic, 130-139 mm Hg; diastolic, 80-89 mm Hg), and stage 2 hypertension (systolic, ≥140 mm Hg; diastolic, ≥90 mm Hg).

MAIN OUTCOMES AND MEASURES

The primary outcome was CVD defined as 2 or more days of hospitalization due to CVD or death due to CVD. The secondary outcomes were coronary heart disease (CHD) and stroke.

RESULTS

The study population consisted of 2 488 101 participants (median age, 31 years [interquartile range, 27-36 years], 789 870 women [31.7%]). A total of 44 813 CVD events were observed during a median follow-up duration of 10 years. Men with baseline stage 1 hypertension compared with those with normal blood pressure had higher risk of CVD (incidence, 215 vs 164 per 100 000 person-years; difference, 51 per 100 000 person-years [95% CI, 48-55]; adjusted hazard ratio [HR], 1.25 [95% CI, 1.21-1.28]), CHD (incidence, 134 vs 103 per 100 000 person-years; difference, 31 per 100 000 person-years [95% CI, 28-33]; adjusted HR, 1.23 [95% CI, 1.19-1.27]), and stroke (incidence, 90 vs 67 per 100 000 person-years; difference, 23 per 100 000 person-years [95% CI, 21-26]; adjusted HR, 1.30 [95% CI, 1.25-1.36]). Women with baseline stage 1 hypertension compared with those with normal blood pressure had increased risk of CVD (incidence, 131 vs 91 per 100 000 person-years; difference, 40 per 100 000 person-years [95% CI, 35-45]; adjusted HR, 1.27 [95% CI, 1.21-1.34]), CHD (incidence, 56 vs 42 per 100 000 person-years; difference, 14 per 100 000 person-years [95% CI, 11-18]; adjusted HR, 1.16 [95% CI, 1.08-1.25]), and stroke (incidence, 79 vs 51 per 100 000 person-years; difference, 28 per 100 000 person-years [95% CI, 24-32]; adjusted HR [1.37, 95% CI, 1.29-1.46]). Results for state 2 hypertension were consistent.

CONCLUSIONS AND RELEVANCE

Among Korean young adults, stage 1 and stage 2 hypertension, compared with normal blood pressure, were associated with increased risk of subsequent cardiovascular disease events. Young adults with hypertension, defined by the 2017 ACC/AHA criteria, may be at increased risk of cardiovascular disease.

Time in Therapeutic Range, as a Determinant of All-Cause Mortality in Patients With Hypertension

Background

Accumulating evidence indicates that reducing systolic blood pressure (BP) to <140 mm Hg improves health outcomes; however, an optimal level has not yet been determined. Many population studies or post hoc analyses suggest a target systolic BP between 120 and 140 mm Hg with increased risk above and below that range. We tested the hypothesis that consistent control of systolic BP between 120 and 140 mm Hg—time in therapeutic range—is a strong determinant of all‐cause mortality among US veterans.

Methods and Results

A total of 689 051 individuals from 15 Veterans Administration Medical Centers were followed over a 10‐year period. Participants were classified as hypertensive, intermediate hypertensive, and normotensive according to the number of elevated BP recordings (>3, 1 or 2, and none, respectively). Time within, above, or below therapeutic range (120–140 mm Hg) was considered in quartiles and related to all‐cause mortality. The study population consisted of 54% hypertensive, 19.9% intermediate, and 26.1% normotensive participants; the corresponding mortality rates for the 3 groups were 11.5%, 8%, and 1.9%, respectively (P<0.0001 for all comparisons). Mortality rates for hypertensive participants with BP consistently within, above, or below the therapeutic range were 6.5%, 21.9%, and 33.1%, respectively (P<0.0001 for all comparisons). Mortality rates in hypertensive participants increased from 6.5% in the most consistently controlled quartile (>75%) to 8.9%, 15.6%, and 23.5% towards the less consistently controlled quartiles (50–75%, 25–50%, and <25%, respectively; P<0.0001 for all comparisons).

Conclusions

An inverse and gradual association between time in therapeutic range and all‐cause mortality was observed in this large veteran cohort. Consistency of BP control over time is a strong determinant of all‐cause mortality, and consistency of BP control should be monitored in everyday clinical practice.

Intima-Media Thickness Is Linearly and Continuously Associated With Systolic Blood Pressure in a Population-Based Cohort (STANISLAS Cohort Study)

BACKGROUND

Carotid intima-media thickness (cIMT) is a noninvasive marker of cardiovascular risk. The cIMT may be increased in patients with harmonisation, but little is known regarding the functional form of the association between blood pressure (BP) and cIMT in hypertensive and nonhypertensive persons. We aimed to define the shape of the association between BP and cIMT.

METHODS AND RESULTS

We studied cIMT and ambulatory BP monitoring data from a single-center, cross-sectional, population-based study involving 696 adult participants from the STANISLAS cohort, a familial longitudinal cohort from the Nancy region of France. Participants with a history of hypertension were more likely to have a cIMT >900 μm and had higher mean cIMT (both P<0.001). The risk of cIMT >900 μm increased linearly with higher 24-hour and daytime systolic BP in participants both with and without history of hypertension. The relationship between systolic BP and the risk of cIMT >900 μm was not dependent on hypertension status (all P for interaction >0.10). In multivariable analysis adjusted on cardiovascular risk factors, each 5-mm Hg increase in systolic BP was associated with an 8-μm increase in cIMT (β=8.249 [95% CI 2.490-14.008], P=0.005). In contrast, the association between diastolic BP and cIMT was weaker and not significant.

CONCLUSIONS

Systolic BP is linearly and continuously associated with higher cIMT in both hypertensive and nonhypertensive persons, suggesting a detrimental effect of BP on the vascular tree prior to overt hypertension. Similarly, it suggests a detrimental effect of BP at the higher end of the normal range in treated hypertensive patients.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01391442.