Differences in prevalence of hypertension subtypes according to the 2018 Korean Society of Hypertension and 2017 American College of Cardiology/American Heart Association guidelines: The Korean National Health and Nutrition Examination Survey, 2007-2017 (KNHANES IV-VII)

The Effect of Sleep Duration on Hypertension Risk in an Adult Asian Population: A Systematic Review and Meta-Analysis

Sleep duration has been proposed as a potential and important modifiable risk factor, yet its precise relationship with hypertension among Asian adults remains unclear. This meta-analysis aims to elucidate the impact of short sleep duration on hypertension risk within the adult Asian population. A systematic search of databases, including PubMed, Scopus, and ScienceDirect, was conducted to identify relevant studies published up to January 4, 2024. Eligible studies comprised observational cohort studies and cross-sectional studies that compared short sleep duration to normal sleep duration in relation to hypertension risk among Asian adults. The definitions for short and normal sleep durations were derived from the respective studies. The random effects model was utilized to pool effect estimates, and all statistical analyses were conducted using Review Manager 5.4 software (RevMan) (Cochrane Collaboration, Oxford, UK). Results from a systematic search obtained seven studies assessing sleep duration and hypertension risk in Asian populations. Based on a meta-analysis of six studies, short sleep duration is associated with a higher hypertension risk when compared to normal sleep duration (OR: 1.36; 95% CI: 1.13-1.64; p: 0.0010; I2: 75%). Subgroup analysis based on sex showed that the association is evident across males (OR: 1.12; 95% CI: 1.01-1.25; p: 0.03; I2: 64%) and females (OR: 1.22; 95% CI: 1.10-1.35; p: 0.0003; I2: 82%). In conclusion, based on the analyzed studies, short sleep duration is associated with a higher mild risk of hypertension, irrespective of sex. Thus, short sleep duration can be a modifiable risk factor that can be prevented to reduce the risk of hypertension. By incorporating sleep hygiene practices and promoting healthy sleep habits, significant improvement in cardiovascular health can be made, especially in hypertension risk at a population level. Further studies on the effect of sleep duration in different age populations should be conducted to confirm the impact of short sleep duration.

Cumulative Diastolic Blood Pressure Burden in Normal Systolic Blood Pressure and Cardiovascular Disease

BACKGROUND

The clinical significance of isolated diastolic hypertension defined by the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines remains inconsistent. We examined whether long-term diastolic burden predicts the first major adverse cardiovascular event in participants with sustained and untreated normal systolic BP.

METHODS

The Mass General Brigham Biobank is a New England health care-based cohort recruited between 2010 and 2021. A total of 15 979 participants aged 18 to 64 years and without prior cardiovascular disease, antihypertensives, or high systolic BP were studied. The cumulative diastolic burden was determined as the area under the curve for diastolic BP (DBP) ≥80 mm Hg over 5 years before enrollment. Major adverse cardiovascular event was defined as a composite of first incident ischemic heart disease, stroke, heart failure, or all-cause death.

RESULTS

Of the 15 979 participants, mean (SD) age at enrollment was 47.6 (14.3) years, 11 950 (74.8%) were women, and the mean (SD) systolic BP and DBP were 118.0 (12.9) and 72.2 (9.3) mm Hg, respectively. Over a median (interquartile range) follow-up of 3.5 (1.8-5.4) years, 2467 (15.4%) major adverse cardiovascular events occurred. Using Cox proportional hazards regression, each SD increase in cumulative DBP was independently associated with a hazard ratio (95% CI) of 1.06 (1.02-1.10) without effect modification by sex (P=0.65), age (P=0.46), or race/ethnicity (P=0.24). In addition to traditional risk factors, cumulative DBP modestly improved the discrimination C index (95% CI) from 0.74 (0.72-0.75) to 0.75 (0.74-0.76; likelihood ratio test, P=0.037).

CONCLUSIONS

Among individuals with normal systolic BP, cumulative DBP may augment cardiovascular disease risk stratification beyond a single DBP measure and traditional risk factors.

The heterogeneity of metabolic syndrome presentation and challenges this causes in its pharmacological management: a narrative review focusing on principal risk modifiers

INTRODUCTION

Metabolic syndrome (MetS), i.e. the cluster of cardiometabolic risk factors comprising visceral obesity, impaired glucose metabolism, arterial hypertension and atherogenic dyslipidemia, is prevalent globally and exacts a heavy toll on health care expenditures.

AREAS COVERED

The pathophenotypes of individual traits of the MetS in adults are discussed first, with strong emphasis on nonalcoholic fatty liver disease (NAFLD) and sex differences. Next, I discuss recent studies on phenotypic and outcome heterogeneity of the MetS, highlighting the role of NAFLD, sex, reproductive status, and depressive disorders. In the second half of the article, the therapeutic implications of the variable MetS types and features are analyzed, focusing on the most recent developments, and guidelines.

EXPERT OPINION

I have identified physiological, pathological, social and medical sources of phenotypical heterogeneity in the MetS and its constitutive traits. Improved understanding of these variables may be utilized in the setting of future precision medicine approaches in the field of metabolic disorders and target organ damage.

Hypertension Subtypes, Mortality Risk, and Differential Effects Between Two Hypertension Guidelines

Aim:

To examine which hypertension subtypes are primarily responsible for the difference in the hypertension prevalence and treatment recommendations, and to assess their mortality risk if 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline were adopted among Chinese adults.

Methods

We used the nationally representative data of China Health and Retirement Longitudinal Study (CHARLS) to estimate the differences in the prevalence of isolated systolic hypertension (ISH), systolic diastolic hypertension (SDH) and isolated diastolic hypertension (IDH) between the 2017 ACC/AHA and the 2018 China Hypertension League (CHL) guidelines. We further assessed their mortality risk using follow-up data from the China Health and Nutrition Survey (CHNS) by the Cox model.

Results

The increase from the 2017 ACC/AHA guideline on hypertension prevalence was mostly from SDH (8.64% by CHL to 25.59% by ACC/AHA), followed by IDH (2.42 to 6.93%). However, the difference was minuscule in the proportion of people recommended for antihypertensive treatment among people with IDH (2.42 to 3.34%) or ISH (12.00 to 12.73%). Among 22,184 participants with a median follow-up of 6.14 years from CHNS, attenuated but significant associations were observed between all-cause mortality and SDH (hazard ratio 1.56; 95% CI: 1.36,1.79) and ISH (1.29; 1.03,1.61) by ACC/AHA but null association for IDH (1.15; 0.98,1.35).

Conclusion

Adoption of the 2017 ACC/AHA may be applicable to improve the unacceptable hypertension control rate among Chinese adults but with cautions for the drug therapy among millions of subjects with IDH.

Prevalence, awareness, treatment, and control of hypertension based on ACC/AHA versus JNC7 guidelines in the PERSIAN cohort study

In this cross-sectional population-based study, we used the baseline data of the Prospective Epidemiologic Research Studies in IrAN cohort study collected in Iran from 2014 to 2020. The main outcomes were the prevalence of hypertension and proportion of awareness, treatment, and control based on the 2017 ACC/AHA guideline compared to the seventh report of the Joint National Committee (JNC7). Of the total of 163,770 participants, aged 35-70 years, 55.2% were female. The sex-age standardized prevalence of hypertension was 22.3% (95% CI 20.6, 24.1) based on the JNC7 guideline and 36.5% (31.1, 41.8) based on the ACC/AHA guideline. A total of 24,312 participants [14.1% (10.1, 18.1)] were newly diagnosed based on the ACC/AHA guideline. Compared to adults diagnosed with hypertension based on the JNC7 guideline, the newly diagnosed participants were mainly young literate males who had low levels of risk factors and were free from conventional comorbidities of hypertension. About 30.7% (25.9, 35.4) of them (4.3% of the entire population) were eligible for pharmacologic intervention based on the ACC/AHA guideline. Implementation of the new guideline may impose additional burden on health systems. However, early detection and management of elevated blood pressure may reduce the ultimate burden of hypertension in Iran.

Isolated Diastolic Hypertension and Risk of Cardiovascular Events: A Systematic Review and Meta-Analysis of Cohort Studies With 489,814 Participants

Background: The association between isolated diastolic hypertension (IDH) and cardiovascular events has been inconsistently reported. This meta-analysis of cohort studies was designed to investigate the effect of the 2018 European Society of Cardiology (ESC) definition of IDH on the risk of composite cardiovascular events, cardiovascular mortality, all-cause mortality, and all strokes including ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to July 6, 2021. Cohort studies that investigated the association between IDH and cardiovascular events risk, compared to normotension, were included. Pooled hazard ratios (HRs) and 95% CIs were calculated using a random-effects models and heterogeneity was evaluated using Q-test and I ² statistic. The robustness of the associations was identified using sensitivity analysis. The methodological quality of the studies was assessed using the Newcastle-Ottawa scale. Publication bias was assessed using funnel plot, trim-and-fill method, Begg's test, and Egger's test. Results: A total of 15 cohort studies (13 articles) including 489,814 participants were included in this meta-analysis. The follow-up period ranged from 4.3 to 29 years. IDH was significantly associated with an increased risk of composite cardiovascular events (HR 1.28, 95% CI: 1.07-1.52, p = 0.006), cardiovascular mortality (HR 1.45, 95% CI: 1.07-1.95, p = 0.015), all strokes (HR 1.44, 95% CI: 1.04-2.01, p = 0.03), and HS (HR 1.64, 95% CI: 1.18-2.29, p = 0.164), but not associated with all-cause mortality (HR 1.20, 95% CI: 0.97-1.47, p = 0.087) and IS (HR 1.56, 95% CI: 0.87-2.81, p = 0.137). Subgroup analysis further indicated that IDH in the younger patients (mean age ≤ 55 years) and from Asia were significantly associated with an increased risk of composite cardiovascular events, while the elderly patients (mean age ≥ 55 years), Americans, and Europeans were not significantly associated with an increased risk of composite cardiovascular events. Conclusion: This meta-analysis provides evidence that IDH defined using the 2018 ESC criterion is significantly associated with an increased risk of composite cardiovascular events, cardiovascular mortality, all strokes and HS, but not significantly associated with all-cause death and IS. These findings also emphasize the importance for patients with IDH to have their blood pressure within normal, especially in the young adults and Asians. Trial Registration: PROSPERO, Identifier: CRD42021254108.

Is Isolated Diastolic Hypertension an Important Phenotype?

PURPOSE OF REVIEW

Isolated diastolic hypertension (IDH) is a frequent hypertension phenotype. We review IDH pathophysiology, risk stratification, and therapeutic decisions.

RECENT FINDINGS

Recent guidelines lowering blood pressure cutoff levels have increased IDH prevalence and likely decreased associated cardiovascular risk. Long-term cardiovascular risk and pharmacological intervention in IDH are controversial. Narrow pulse pressure and other physiological and epidemiological characteristics are shared with a systodiastolic hypertension (SDH) subgroup. We propose that IDH be incorporated into a broader category, predominantly diastolic hypertension (PDH), defined by pulse pressure ≤ 45 mmHg and includes IDH and SDH with a narrow pulse pressure. IDH-PDH is associated with cardiovascular risk in the long term, especially in young patients. Standardization of the IDH definition and population may contribute to future research to understand genetics, pathophysiology, and eventually therapy in this important subgroup of hypertensive patients.

Long-term trends and regional variations of hypertension incidence in China: a prospective cohort study from the China Health and Nutrition Survey, 1991-2015

OBJECTIVE

The aim is to explore the trends of hypertension incidence and regional variations in China from 1991 to 2015.

DESIGN

A dynamic prospective cohort study.

SETTING

China Health and Nutrition Survey 1991-2015.

PARTICIPANTS

12 952 Chinese adults aged 18+ years.

PRIMARY OUTCOME MEASURES

Incident hypertension from 1993 to 2015.

RESULTS

Age-standardised hypertension incidence increased from 40.8 per 1000 person-years (95% CI 38.3 to 43.4) between 1993 and 1997 to 48.6 (95% CI 46.1 to 51.0) between 2011 and 2015. The increasing trends were further supported by results from subsequent extended Cox proportional hazard model. In addition, results from the modelling analysis showed that individuals in eastern, central and northeastern China had greater risks of hypertension occurrence in comparison with their counterparts in western China.

CONCLUSION

Hypertension incidence increased during the study period. The growth called for more attention on the health education and health promotion of individuals with great risks.

Prevalence of high blood pressure under 2017 ACC/AHA guidelines: a systematic review and meta-analysis

To understand the prevalence of high blood pressure among the general adult population under the new diagnostic criteria. PubMed and Embase databases were systematically searched. Two investigators independently performed data extraction and quality assessment, and the disagreements were resolved by consensus with a third investigator. The random-effects model was performed to pool the prevalence of high blood pressure among the population. Subgroup and meta-regression analyses were performed to explore the source of heterogeneity. The study protocol has been registered with PROSPERO, number CRD42019147330. In total, 52 articles included in the meta-analysis with a total of 54 studies. An obvious increase in the prevalence of high blood pressure was identified by the application of new diagnostic criteria. The pooled prevalence of high blood pressure among the population was 53.01% (95% confidence interval 51.13-54.88%). Subgroup analysis showed that the WHO region, national, and age could significantly influence the prevalence of hypertension (P < 0.01). Meta-regression analyses revealed that study quality and sex ratio (male, %) did not contribute to the heterogeneity of the results (P > 0.05). The sensitivity analysis showed that the results were stable. With the use of new diagnostic criteria, the prevalence of high blood pressure has shown an upward trend, especially in Europe countries. Prevention and control measures should focus more on improving cardiovascular and cerebrovascular status in Europe countries. Standard electronic blood pressure monitors were recommended for use in future studies, and at least two more readings should be taken during a visit.

The clinical significance of isolated diastolic hypertension

The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by others. It is also more common in the young subjects who are at low CV risk and quite rare in the older subjects, who are at increased CV risk. Treatment of IDH in the older subjects could increase the CV complications due to a J-curve effect and, in addition, could increase the incidence of stroke from further lowering the normal systolic blood pressure (SBP). Very low SBP and DBP cannot be sustained by the cerebral blood flow autoregulation and could lead to cerebral ischemia. In order to get a better perspective of the current status of the treatment of IDH, a review of the English language literature of the available studies was conducted and 12 papers with pertinent information were retrieved. The analysis of results from these studies suggests that IDH is associated with adverse CV events in younger persons and it should be treated. In contrast, the prevalence of IDH is low in older subjects and is not associated with adverse CV events in the majority of cases. Thus, its further lowering should be avoided to prevent further decrease in normal SBP and prevent the onset of adverse CV events. However, the decision to treat IDH in older subjects should be individualized.

The contribution of the systolic and diastolic components for the diagnosis of arterial hypertension under the 2017 ACC/AHA Guideline and metabolic heterogeneity among individuals with Stage 1 hypertension

Little is known about the impact of the 2017 ACC/AHA hypertension guideline on the distribution pattern of hypertension modalities (isolated systolic hypertension [ISH], isolated diastolic hypertension [IDH], and systolic-diastolic hypertension [SDH]). This cross-sectional study had the following objectives: to compare the prevalence of hypertension, ISH, IDH, and SDH, according to the definitions of the JNC 7 or the 2017 guideline; to determine the relative contribution of the systolic and the diastolic components for the diagnosis of hypertension; and to compare the metabolic profile of ISH, IDH, or SDH among new hypertensive individuals by the 2017 guideline. The authors retrospectively evaluated 33 594 patients (42 ± 10 years, 67% male) who underwent a routine health evaluation. Hypertensive patients not using antihypertensive medication were classified into ISH, IDH, or SDH using guideline-defined thresholds. The prevalence of hypertension increased from 21.1% by the JNC 7 definition to 54.7% using the 2017 criteria (2.6-fold increase). More profound increases were seen in the prevalence of IDH (8.7-fold) and SDH (3.3-fold), whereas the prevalence of ISH reduced from 1.1% (JNC 7) to 0.5% (2017 definition). Among patients with Stage 1 hypertension by the 2017 document, 85% had IDH and fewer metabolic abnormalities compared to those with SDH or ISH. The authors concluded that the 2017 guideline inflates the role of the diastolic component and diminishes the contribution of the systolic component for the diagnosis of hypertension. Individuals with Stage 1 hypertension by the 2017 guideline are metabolically heterogeneous and may have different long-term prognoses.

Cardiovascular Risk of Isolated Systolic or Diastolic Hypertension in Young Adults

BACKGROUND

Little is known regarding health outcomes associated with isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), or systolic and diastolic hypertension (SDH) among young adults with stage 1 hypertension, defined using the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline.

METHODS

From a nationwide health screening database, we included 6 424 090 participants, aged 20 to 39 years, who were not taking antihypertensive medication at the baseline examination in 2003 to 2007. Participants were categorized as having normal BP (untreated systolic BP [SBP] <120/diastolic BP [DBP] <80 mm Hg; n=2 665 310); elevated BP (SBP 120-129/DBP <80 mm Hg; n=705 344); stage 1 IDH (SBP <130/DBP 80-89 mm Hg; n=1 271 505); stage 1 ISH (SBP 130-139/DBP <80 mm Hg; n=255 588); stage 1 SDH (SBP 130-139/DBP 80-89 mm Hg; n=711 503); and stage 2 hypertension (SBP ≥140, DBP ≥90 mm Hg; n=814 840). The primary outcome was composite cardiovascular disease (CVD) events, including myocardial infarction, stroke, heart failure, and CVD-related death.

RESULTS

The median age of the participants was 30 years and 60.9% were male. Over a median follow-up of 13.2 years, 44 070 new CVD events occurred. With normal BP as the reference, multivariable-adjusted hazard ratios (95% CIs) for CVD events were 1.14 (1.09-1.18) for elevated BP, 1.32 (1.28-1.36) for stage 1 IDH, 1.36 (1.29-1.43) for stage 1 ISH, 1.67 (1.61-1.72) for stage 1 SDH, and 2.40 (2.33-2.47) for stage 2 hypertension.

CONCLUSIONS

Among young adults, stage 1 ISH, IDH, and SDH were all associated with higher CVD risks than normal BP. The CVD risks of stage 1 ISH and IDH were similar to each other but lower than the risk of stage 1 SDH. Categorizing young adults with stage 1 hypertension further into stage 1 ISH, IDH, and SDH may improve risk stratification for identifying high-risk individuals.

Comparison and Implication of the Contemporary Blood Pressure Guidelines on Korean Population

Background and Objectives

This study compared the potential impacts of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) and the 2018 Korean Society of Hypertension (KSH) guidelines on prevalence of hypertension, recommended antihypertensive treatment, and achievement of target blood pressure (BP) in Korean population.

Methods

We analyzed the 2007–2017 Korea National Health and Nutrition Examination Survey data to calculate guideline-specific hypertension prevalence and treatment implications on 59,767 adults aged 20 years or older by sex and age.

Results

The prevalence of hypertension was markedly higher 46.3% by the ACC/AHA guideline due to the lowered BP cutoff than 25.9% by the KSH guideline; the increase was most pronounced in young adults. Yet, there was only a marginal 1.6% increase in the percentage of adults suggested pharmacological approach by the ACC/AHA guideline, but selectively in the older subgroups. Overall, 45.6% of Korean adults treated for hypertension failed to meet BP goal according to the KSH guideline; the underachievement extended to 61.7% of participants according to the ACC/AHA guideline.

Conclusions

The lowered BP threshold, 130/80 mmHg, by the 2017 ACC/AHA guideline, in conjuncture with 10-year risk calculation largely driven by age, would increase pharmacological treatment preferentially in very old individuals, while increasing prevalence and uncontrolled rate mostly in younger subgroups. Adoption of lower BP cutoff to the KSH guideline would require validated cardiovascular disease risk assessment tools accounting for risk distributions specific to Korean population.