Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg

Abstract

Background Data from before the 2000s indicate the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP)≥140/90 mmHg. Over the past several decades, BP declined and hypertension control has improved. Methods We estimated the percentage of incident CVD events that occur at SBP/DBP<140/90 mmHg in a pooled analysis of three contemporary US cohorts: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, the Multi-Ethnic Study of Atherosclerosis (MESA), and the Jackson Heart Study (JHS) (n=31,856; REGARDS=21,208; MESA=6,779; JHS=3,869). Baseline study visits were conducted in 2003–2007 for REGARDS, 2000–2002 for MESA, and 2000–2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or non-fatal stroke, non-fatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study. Results Over a mean follow-up of 7.7 years, 2,584 participants had incident CVD events. Overall, 63.0% (95%CI: 54.9%–71.1%) of events occurred in participants with SBP/DBP<140/90 mmHg; 58.4% (95%CI: 47.7%–69.2%) and 68.1% (95%CI: 60.1%–76.0%) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP<140/90 mmHg among those <65 years (66.7% 95%CI: 60.5%–73.0%) and ≥65 years (60.3% 95%CI: 51.0%–69.5%), women (61.4%; 95%CI: 49.9%–72.9%) and men (63.8%; 95%CI: 58.4%–69.1%), and for whites (68.7%; 95%CI: 66.1%–71.3%), blacks (59.0%; 95%CI: 49.5%-68.6%), Hispanics (52.7% 95%CI: 45.1%–60.4%) and Chinese-Americans (58.5%; 95%CI: 45.2%–71.8%). Among participants taking antihypertensive medication with SBP/DBP<140/90 mmHg, 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 one and 19.5% (95%CI: 18.5%–20.5%) met the Systolic Blood Pressure Intervention Trial eligibility criteria and may benefit from a SBP target goal of 120 mmHg. Conclusions While higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP<140/90 mmHg. Although absolute risk and cost-effectiveness should be considered, additional CVD risk reduction measures for adults with SBP/DBP<140/90 mmHg at high risk for CVD may be warranted.

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“…Pooled data from three studies from the 2000s reveal a majority of CV events occurring in patients with BP < 140/90 (Table 1). 6 …”

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