Korean Circ J.  2022 Jun;52(6):460-474. 10.4070/kcj.2021.0330.

Elevated On-Treatment Diastolic Blood Pressure and Cardiovascular Outcomes in the Presence of Achieved Systolic Blood Pressure Targets

• Kim DH
• Cho IJ
• Kim W
• Lee CJ
• Kim HC
• Shin JH
• Kang SH
• Jung MH
• Kwon CH
• Lee JH
• Kim HL
• Kim HM
• Cho I
• Kang DR
• Lee HY
• Chung WJ
• Kim KI
• Cho EJ
• Sohn IS
• Park S
• Shin J
• Ryu SK
• Kang SM
• Pyun WB
• Cho MC
• Kim JH
• Lee JH
• Ihm SH
• Sung KC

• KMID: 2530455
• DOI: http://doi.org/10.4070/kcj.2021.0330

Abstract

Background and Objectives
This study aimed to investigate the association between cardiovascular events and 2 different levels of elevated on-treatment diastolic blood pressures (DBP) in the presence of achieved systolic blood pressure targets (SBP).
Methods
A nation-wide population-based cohort study comprised 237,592 patients with hypertension treated. The primary endpoint was a composite of cardiovascular death, myocardial infarction, and stroke. Elevated DBP was defined according to the Seventh Report of Joint National Committee (JNC7; SBP <140 mmHg, DBP ≥90 mmHg) or to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) definitions (SBP <130 mmHg, DBP ≥80 mmHg).
Results
During a median follow-up of 9 years, elevated on-treatment DBP by the JNC7 definition was associated with an increased risk of the occurrence of primary endpoint compared with achieved both SBP and DBP (adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 1.05–1.24) but not in those by the 2017 ACC/AHA definition. Elevated ontreatment DBP by the JNC7 definition was associated with a higher risk of cardiovascular mortality (aHR, 1.42; 95% CI, 1.18–1.70) and stroke (aHR, 1.19; 95% CI, 1.08–1.30). Elevated on-treatment DBP by the 2017 ACC/AHA definition was only associated with stroke (aHR, 1.10; 95% CI, 1.04–1.16). Similar results were seen in the propensity-score-matched cohort.
Conclusion
Elevated on-treatment DBP by the JNC7 definition was associated a high risk of major cardiovascular events, while elevated DBP by the 2017 ACC/AHA definition was only associated with a higher risk of stroke. The result of study can provide evidence of DBP targets in subjects who achieved SBP targets.

Keyword

Blood pressure; Hypertension

Figure

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  Figure 1 The flow chart of the study population.CVD = cardiovascular disease; MI = myocardial infarction.

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  Figure 2 Mortality and cardiovascular events in subjects with DBP target by either the JNC7 or the 2017 ACC/AHA definitions. (A) Total study population, (B) After propensity-score matching, and (C) Subgroup analysis for MACE in total study population.ACC = American College of Cardiology; AHA = American Heart Association; CI = confidence interval; DBP = diastolic blood pressure; HR = hazard ratio; JNC7 = The Seventh Report of Joint National Committee; MACE = major adverse cardiac event; MI = myocardial infarction.*The p value <0.05 for hazard ratio. Hazard ratio calculated by Cox proportional hazards regression analysis after adjustments for age, household income, smoking, physical activity, alcohol consumption, body mass index, fasting serum glucose and total cholesterol levels, diabetes mellitus, classes of antihypertensive medications, and Charlson Comorbidity Index.

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  Figure 3 Associations between each endpoint and two different levels of elevated on-treatment DBPs in the presence of achieved SBPs, lowered by either the JNC7 or the 2017 ACC/AHA definition.Model 1 is adjusted for age and sex. Model 2 is adjusted for model 1+ household income, smoking, physical activity, alcohol consumption, body mass index, fasting serum glucose and total cholesterol levels, diabetes mellitus, use of aspirin or statin, classes of antihypertensive medications, and Charlson Comorbidity Index. Model 3 is adjusted for model 2 + time-varying systolic blood pressure.PS matched analysis is adjusted for age, household income, smoking, physical activity, alcohol consumption, body mass index, fasting serum glucose and total cholesterol levels, diabetes mellitus, use of aspirin or statin, classes of antihypertensive medications, and Charlson Comorbidity Index in propensity-score matched cohort.ACC = American College of Cardiology; AHA = American Heart Association; CI = confidence interval; DBP = diastolic blood pressure; HR = hazard ratio; JNC7 = The Seventh Report of Joint National Committee; MACE = major adverse cardiac event; MI = myocardial infarction; PS = propensity-score.*The p value <0.05 for hazard ratio.

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