Blood Pressure Control and Mortality Among US Veterans

Intensive blood pressure (BP) control reduces mortality and cardiovascular disease in clinical trials. However, real-world BP measurements often differ from standardized protocols. We evaluated the impact of real-world systolic BP on mortality among US Veterans.

We conducted a retrospective cohort study of Veterans with hypertension, defined by diagnostic codes, antihypertensive prescriptions, or ≥2 office BP readings ≥130/90 mm Hg in 2016 to 2017, with follow-up through March 2021. Systolic BP was treated as a time-dependent covariate and categorized into 7 groups: <110, 110-119, 120-129, 130-139, 140-149, 150-159, and ≥160 mm Hg. Discrete-time survival models assessed associations with all-cause mortality, adjusting for demographics, body mass index, and comorbidities. Stratified analyses were conducted based on cardiovascular disease and chronic kidney disease status.

Among >2.3 million Veterans (mean age, 66 years; 36% with diabetes; 22% with cardiovascular disease; and 19% with chronic kidney disease), the lowest mortality risk was observed in those with systolic BP of 130 to 139 mm Hg. In this cohort, adjusted hazard ratios for all-cause mortality per year in each systolic BP category were 1.29 for BP <110; 1.03 for BP 110 to 119; 0.88 for BP 120 to 129; 0.83 for BP 130 to 139; 0.86 for BP 140 to 149; and 0.89 for BP 150 to 159 mm Hg, compared with a year with BP ≥160 mm Hg. These associations remained consistent across cardiovascular disease and chronic kidney disease subgroups.

Veterans with routine systolic BP of 130 to 139 mm Hg had the lowest mortality. These findings suggest that a higher BP target may be appropriate in clinical practice, especially for older adults with comorbidities.