Level of Blood Pressure Control and Cardiovascular Events
What is the relative value of the blood pressure (BP) goals using the Eighth Joint National Committee (<150/90 for age ≥60 years and <140/90 mm Hg for <60 years, diabetes, or chronic kidney disease [CKD]) compared to that in SPRINT (Systolic Blood Pressure Intervention Trial) of <120 mm Hg on cardiovascular (CV) outcomes in Korean men and women with hypertension (HTN)?
Data were used from the Korean National Health and Nutrition Examination Survey (KNHANES) of 2008-2013 (n = 13,346), and the Korean National Health Insurance Service (NHIS) health exam cohort of 2007 (n = 67,965), to estimate the proportion of subjects who would meet BP goals of each of the criterion, and to compare risks of major CV events (composite of nonfatal myocardial infarction [MI], nonfatal stroke, or death from CV causes) associated with different BP control goals. HTN was defined as a physician diagnosis, patient-reported BP treatment, or BP ≥130 mm Hg. The Framingham and Korean-derived risk equations were used to estimate the rates of CV events according to the different levels of BP control, and provided similar outcome. Multivariable models were adjusted for age/sex, CV risk factors, treatments, diabetes, and CKD.
Of the 13,346 participants with HTN, 12.6% would meet the target BP in SPRINT compared to 71.9% who would meet the target in the 2014 recommendations. Similar estimates of proportions were found in the 11.0 million Korean adults with HTN. Using the actual outcome data from NHIS, the 10-year predicted cardiovascular (CV) risks were lowest in the intensive control group (below SPRINT BP goals with median 112 mm Hg), intermediate in the less-intensive group (above SPRINT goals, but below 2014 recommendation goals), and highest in the uncontrolled group (above 2014 recommendations with median 150 mm Hg) (6.15%, 7.65%, and 9.39%, respectively; p < 0.001). After multivariable adjustment, less-intensive and uncontrolled groups showed greater risk of major CV events (hazard ratios 1.17 and 1.62, respectively; p for trend < 0.001) than the intensive group.
Substantially fewer hypertensive adults would meet SPRINT BP goals than the 2014 recommendations. Decreased risk of major CV events is associated with stricter BP control.
It is important to realize that all outcome data were observational and estimates were projected to the entire Korean population from KNHANES. The findings are simply hypothesis-generating and should not be used to more readily accept the SPRINT study data. In SPRINT, the benefit was limited to CV mortality and heart failure with no significant difference in risk of MI or stroke, which was a major surprise. In contrast, in the Korean estimates of outcome, there was a reduction in MI and strokes, but not in CV or overall mortality, and the analysis was not limited to the SPRINT criteria of adults >50 years old with no diabetes or prior heart failure.
Keywords: Blood Pressure, Diabetes Mellitus, Heart Failure, Hypertension, Mortality, Myocardial Infarction, Primary Prevention, Renal Insufficiency, Risk Factors, Stroke
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