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Cardiovascular events according to blood pressure thresholds recommended by ACC/AHA
Gowsini Joseph1,2,3,4, Vi Thanh Pham5, Per Kragh Andersen5
1Department of Cardiology, Zealand University Hospital, Roskilde, Denmark.
Insights
The ACC/AHA definition of Stage 1 hypertension does not increase cardiovascular risk compared to normal blood pressure. However, the ESC/ESH definition identifies individuals with a genuinely elevated risk for cardiovascular events.
Area of Science:
- Cardiology
- Public Health
- Hypertension Research
Background:
- Current hypertension guidelines differ: ACC/AHA defines Stage 1 hypertension as SBP 130-139 mmHg or DBP 80-89 mmHg.
- ESC/ESH guidelines define hypertension as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg.
- The clinical significance of the ACC/AHA Stage 1 hypertension definition regarding future cardiovascular risk remains under investigation.
Purpose of the Study:
- To evaluate if the ACC/AHA definition of hypertension identifies individuals at increased risk for cardiovascular outcomes.
- To compare the cardiovascular risk associated with different blood pressure classifications under ACC/AHA guidelines.
Main Methods:
- A Danish prospective cardiovascular study included 19,721 participants (aged 20-98 years) examined up to five times between 1976 and 2015.
- Blood pressure levels were categorized according to ACC/AHA guidelines: Normal, Elevated, Stage 1, and Stage 2 hypertension.
- 10-year cardiovascular event risk was calculated, accounting for repeated measures, covariates, and competing risks.
Main Results:
- The 10-year risk for cardiovascular events in Stage 1 hypertension (14.1%) was not significantly different from that in normal blood pressure (12.8%) (p=0.19).
- Stage 2 hypertension showed a significantly higher 10-year risk (19.4%) compared to normal, elevated, and Stage 1 hypertension (p<0.001).
- The 10-year risk of cardiovascular death in Stage 1 hypertension (6.6%) was not significantly different from normal blood pressure (5.7%) (p=0.33).
Conclusions:
- Stage 1 hypertension, per ACC/AHA guidelines, does not confer an elevated risk for future cardiovascular events compared to normal blood pressure.
- The ESC/ESH definition of hypertension effectively identifies individuals at increased risk for cardiovascular events.
- Current ACC/AHA guidelines for Stage 1 hypertension may require re-evaluation regarding risk stratification for cardiovascular outcomes.
Aim:
The latest guidelines from ACC/AHA define hypertension at systolic blood pressure (SBP) 130-139 mmHg or diastolic blood pressure (DBP) 80-89 mmHg in contrast to guidelines from ESC/ESH defining hypertension at SBP ≥ 140 mmHg or DBP ≥ 90 mmHg. The aim was to determine whether the ACC/AHA definition of hypertension identifies persons at elevated risk for future cardiovascular outcome.
Methods:
In a Danish prospective cardiovascular study, 19,721 white men and women aged 20-98 years were examined up to five occasions between 1976 and 2015. The population was followed until December 2018. The ACC/AHA definition of the BP levels were applied: Normal: SBP <120 mmHg and DBP <80 mmHg, Elevated: SBP 120-129 mmHg and DBP <80 mmHg, Stage 1: SBP 130-139 mmHg or DBP 80-89 mmHg, Stage 2: SBP ≥140 mmHg or DBP ≥90 mmHg. Absolute 10-year risk was calculated taking repeated examinations, covariates, and competing risk into account.
Results:
For all outcomes, the 10-year risk in stage 1 hypertension did not differ significantly from risk in subjects with normal BP: The 10-year risk of cardiovascular events in stage 1 hypertension was 14.1% [95% CI 13.2;15.0] and did not differ significantly from the risk in normal BP at 12.8% [95% CI 11.1;14.5] (p = 0.19). The risk was highest in stage 2 hypertension 19.4% [95% CI 18.9;20.0] and differed significantly from normal BP, elevated BP, and stage 1 hypertension (p < 0.001). The 10-year risk of cardiovascular death was 6.6% [95% CI 5.9;7.4] in stage 1 hypertension and did not differ significantly from the risk in normal BP at 5.7% [95% CI 4.1;7.3] (p = 0.33).
Conclusions:
Stage 1 hypertension as defined by the ACC/AHA guidelines has the same risk for future cardiovascular events as normal BP. In contrast, the definition of hypertension as suggested by ESC/ESH identifies patients with elevated risk of cardiovascular events.
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