Hypertension Subtypes and Diabetes: Joint Associations in the National Health and Nutrition Examination Survey

Diabetes mellitus (DM) is associated with increased arterial stiffness indicated by isolated systolic hypertension (ISH). Whether the prevalence of ISH and other hypertension (HTN) subtypes differs by DM status and how they relate to outcomes remains unclear.

The objective of the study was to compare by DM status the association of HTN subtypes with cardiovascular disease (CVD) and all-cause mortality.

The authors included data from the National Health and Nutrition Examination Survey with mortality follow-up until 2019. The authors used HTN thresholds of 130/80 mm Hg to define ISH, isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH). The incidence of CVD and all-cause mortality was examined among hypertensive subtypes using multivariable Cox regression.

A total of 52,385 individuals (projected to 207 million) were included, of which 12% (25 M) had DM. In those with vs without DM, 23% vs 57% were normotensive, 5% vs 9% had IDH, 39% vs 18% had ISH, and 16% vs 13% had SDH (all P < 0.01). Analyses adjusted for age, sex, and other risk factors showed significantly increased risks for CVD and all-cause mortality with ISH (HR: 1.19; P < 0.01 and HR: 1.15; P < 0.01, respectively) and SDH (HR: 1.29; P < 0.01 and HR: 1.18; P < 0.01) but not IDH in patients without DM (HR: 0.76; P = 0.32 and HR: 0.86; P = 0.20); in patients with DM, this risk was increased in patients with ISH (HR: 1.57; P < 0.01 and HR: 1.46; P < 0.01], SDH (HR: 2.11; P < 0.01 and HR: 1.68; P < 0.01), and IDH (HR: 3.65; P < 0.01 and HR: 1.97; P < 0.01) (interaction P < 0.01 for all subtypes by DM status).

HTN subtypes were significantly associated with increased CVD and all-cause mortality in patients with DM more strongly than in those without DM, suggesting greater importance of controlling all HTN subtypes in those with DM.