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Association of Normal Systolic BP With CVD and Absence of Risk Factors
Quick Takes
- The definition of hypertension (<130/80 mm Hg) for treatment, both lifestyle and drug, is based on controlled trials and observational studies.
- There is an association with coronary artery disease defined by coronary calcification and ASCVD events and low normal systolic BP in persons without other major risk factors.
- Primordial and primary prevention focusing on lifestyle intervention should begin at an early age in persons with what has been considered normal blood pressure even without other major risk factors.
Study Questions:
Is there an association of systolic blood pressure (sBP) levels with coronary artery calcium (CAC) and atherosclerotic cardiovascular disease (ASCVD) in persons without hypertension or other traditional ASCVD risk factors based on current definitions?
Methods:
A cohort of 1,457 participants free of ASCVD from the Multi-Ethnic Study of Atherosclerosis were included. Inclusion criteria included no dyslipidemia (low-density lipoprotein cholesterol [LDL-C] ≥160 mg/dl or high-density lipoprotein cholesterol <40 mg/dl), fasting blood sugar ≥126 mg/dl, treatment for hyperlipidemia or diabetes, or current tobacco use, and an sBP level between 90 and 129 mm Hg. Participants receiving hypertension medication were excluded. CAC was classified as absent or present and adjusted hazard ratios (aHRs) were calculated for incident ASCVD. The study was conducted from March 27, 2018–February 12, 2020.
Results:
Of the 1,457 participants, 894 were women (61.4%); mean age was 58.1 (9.8) years and mean follow-up was 14.5 (3.9) years. Overall, the mean sBP was 111 (10) mm Hg, and the median 10-year ASCVD risk was 3.0% (1.1-6.7%). There was an increase in traditional ASCVD risk factors, CAC, and incident ASCVD events with increasing sBP levels. About 27% of those with sBP 90-99 mm Hg had CAC which increased linearly to 65% in those with sBP 120-129 mm Hg. The aHR for ASCVD events was 1.53 (95% CI, 1.17-1.99) for every 10-mm Hg increase in sBP levels. Compared with persons with sBP levels 90-99 mm Hg, the aHR for ASCVD was 3.00 for sBP levels 100-109 mm Hg, 3.10 for sBP levels 110-119 mm Hg, and 4.58 for sBP levels 120-129 mm Hg.
Conclusions:
Beginning at an sBP level as low as 90 mm Hg, there appears to be a stepwise increase in the presence of CAC and the risk of incident ASCVD with increasing sBP levels. These results highlight the importance of primordial prevention for sBP level increase and other traditional ASCVD risk factors, which generally seem to have similar trajectories of graded increase in risk within values traditionally considered to be normal.
Perspective:
That the risk of ASCVD is linked to duration and magnitude of risk (cigarette smoking [pack-years], LDL-C in heterozygous familial hypercholesterolemia [from birth], and type 2 diabetes mellitus [worse by early onset]) has been well established. But the impact of sBP in early adulthood and the sBP cut-point for risk has not been known. This novel study supports the need for screening young adults for ASCVD risk and having periodic follow-up with optimization of lifestyle for primordial and primary prevention at sBP lower than prehypertension (sBP ≥120 mm Hg).
Clinical Topics: Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Lipid Metabolism, Nonstatins, Diet, Hypertension
Keywords: Atherosclerosis, Blood Glucose, Blood Pressure, Cholesterol, HDL, Cholesterol, LDL, Diabetes Mellitus, Fasting, Hyperlipidemias, Hypertension, Life Style, Prehypertension, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Young Adult
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