Cardiovascular Disease in Adults Without Hypertension

Study Questions:

What is the incidence of cardiovascular disease (CVD) in patients with well controlled blood pressure (systolic [SBP] and diastolic [DBP] <140/90 mm Hg)?


The authors pooled data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke), MESA (Multi-Ethnic Study of Atherosclerosis), and JHS (Jackson Heart Study) (n = 31,856). Baseline study visits were conducted between 2003 and 2007, with standardized measures of blood pressure. The primary outcome was incident CVD (adjudicated), defined by the first occurrence of fatal or nonfatal stroke, nonfatal myocardial infarction, fatal coronary artery disease, or heart failure.


Over a mean follow-up of 7.7 years, 2,584 patients developed incident CVD events. Overall, 63.0% (95% confidence interval [CI], 54.9%-71.1%) occurred in patients with SBP/DBP <140/90 mm Hg. Within this group, 58.4% (95% CI, 47.7%-69.2%) of all CVD events occurred among patients taking antihypertensive medications, and 68.1% (95% CI, 60.1%-76.0%) occurred among patients not taking antihypertensive medications. Among patients taking antihypertensive medications with SBP/DBP <140/90 mm Hg, 76.6% (95% CI, 75.8%-77.5%) were eligible for statin treatment, but only 33.2% (95% CI, 32.1%-34.3%) were taking a statin medication. Of patients taking antihypertensive medications with SBP/DBP <140/90 mm Hg, only 19.5% (95% CI, 18.5%-20.5%) of patients with SBP between 120-139 mm Hg met the SPRINT (Systolic Blood Pressure Intervention Trial) eligibility criteria and would potentially benefit from a target SBP of 120 mm Hg.


The authors concluded that while higher blood pressure levels are associated with increased CVD risk, the majority of CVD events occur in US adults with SBP/DBP <140/90 mm Hg.


Since the early 1990s, the mean blood pressure in US adults has declined significantly. These authors demonstrate that in modern cohorts, the majority of CVD events occur in patients with “controlled” blood pressure (SBP/DBP <140/90 mm Hg). As the authors demonstrate, further efforts at CVD risk reduction are needed, including initiation of statin therapy in more eligible patients. However, the applicability of the SPRINT trial is more limited, with only approximately 20% of patients meeting that study’s eligibility criteria.

Clinical Topics: Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Determination, Coronary Artery Disease, Diastole, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Myocardial Infarction, Primary Prevention, Risk Reduction Behavior, Stroke, Systole

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