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Cumulative Diastolic Blood Pressure Burden in Normal Systolic Blood Pressure and Cardiovascular Disease
So Mi Jemma Cho1,2,3, Hokyou Lee4, Satoshi Koyama1,2
1Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA (S.M.J.C., S.K., A.S., S.G., W.H., M.C.H., P.N.).
Insights
Elevated long-term diastolic blood pressure (BP) burden predicts major adverse cardiovascular events in individuals with normal systolic BP. This cumulative diastolic burden improves cardiovascular disease risk prediction beyond traditional factors.
Area of Science:
- Cardiology
- Preventive Medicine
- Public Health
Background:
- The clinical significance of isolated diastolic hypertension is debated.
- Current guidelines for blood pressure (BP) management have varying definitions for diastolic hypertension.
- The predictive value of long-term diastolic BP burden in individuals with normal systolic BP is not well-established.
Purpose of the Study:
- To investigate whether long-term diastolic BP burden predicts major adverse cardiovascular events (MACE).
- To assess the utility of cumulative diastolic burden in cardiovascular disease (CVD) risk stratification.
- To analyze MACE in participants with sustained and untreated normal systolic BP.
Main Methods:
- The Mass General Brigham Biobank cohort (n=15,979) was analyzed.
- Participants aged 18-64 without prior CVD, antihypertensives, or high systolic BP were included.
- Cumulative diastolic burden was calculated as the area under the curve for diastolic BP (DBP) ≥80 mm Hg over 5 years.
Main Results:
- A total of 2467 MACE occurred during a median follow-up of 3.5 years.
- Each SD increase in cumulative DBP was independently associated with a 6% increased risk of MACE (HR 1.06; 95% CI 1.02-1.10).
- Cumulative DBP modestly improved the discrimination of CVD risk (C-index from 0.74 to 0.75; P=0.037).
Conclusions:
- Cumulative diastolic BP burden may enhance cardiovascular disease risk stratification.
- This metric offers value beyond single DBP measurements and traditional risk factors.
- Long-term diastolic burden is a significant predictor of MACE in individuals with normal systolic BP.
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.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.