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

Affiliations
  • 1Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 2Division of Cardiology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, College of Medicine, Ewha Womans University, Seoul, Korea
  • 3Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
  • 4Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
  • 5Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
  • 6Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
  • 7Cardiovascular Center, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
  • 8Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
  • 9Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
  • 10Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
  • 11Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
  • 12Department of Precision Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea
  • 13Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  • 14Division of Cardiology, Department of Internal Medicine, Gil Hospital, Gachon University, Incheon, Korea
  • 15Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
  • 16Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
  • 17Division of Cardiology, Department of Internal Medicine, Kyung Hee University at Gangdong, Seoul, Korea
  • 18Division of Cardiology, Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
  • 19Division of Cardiology, Department of Internal Medicine, Eulji Medical School of Medicine, Seoul, Korea
  • 20Division of Cardiology, Department of Internal Medicine, Eulji Medical School of Medicine, Seoul, Korea
  • 21Department of Biostatistics, Wonju College of Medicine, Yonsei University, Wonju, Korea
  • 22Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
  • 23Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

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

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

  • 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.

  • 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.


Cited by  1 articles

On-Treatment Diastolic Blood Pressure: When Is It Too High?
Jin Joo Park
Korean Circ J. 2022;52(6):475-477.    doi: 10.4070/kcj.2022.0126.


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