The Association of Blood Pressure Defined by the 2017 ACC/AHA Guidelines and Cardiovascular Disease Risk for Middle-Aged and Elderly People in China: A Cohort Study

Lu, Qingyang; Xie, Haijing; Gao, Xuefeng

doi:10.36660/abc.20230785

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Original Article • Arq. Bras. Cardiol. 121 (7) • July 2024 • https://doi.org/10.36660/abc.20230785i linkcopy

The Association of Blood Pressure Defined by the 2017 ACC/AHA Guidelines and Cardiovascular Disease Risk for Middle-Aged and Elderly People in China: A Cohort Study

Authorship SCIMAGO INSTITUTIONS RANKINGS

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: The Association of Blood Pressure Defined by the 2017 ACC/AHA Guidelines and Cardiovascular Disease Risk for Middle-Aged and Elderly People in China: A Cohort Study

Flow chart of the selected population. CVD: cardiovascular disease; SBP: systolic blood pressure; DBP: diastolic blood pressure.

Abstract

Background Cardiovascular disease (CVD) is a series of diseases affecting the heart or blood vessels.

Objectives To assess the relationship between blood pressure (BP) levels defined by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline and CVD/atherosclerotic cardiovascular disease (ASCVD) risk for middle-aged and elderly people in China.

Methods A total of 6,644 middle-aged and elderly people from the China Health and Retirement Longitudinal Study (CHARLS) were finally included. According to the 2017 ACC/AHA guideline, all subjects were divided into four groups: normal BP, elevated BP, stage 1 hypertension, and stage 2 hypertension. The outcome of this study was considered as the risk of CVD and ASCVD. Univariate and multivariate COX regression models were adopted to examine the relationship of the 2017 ACC/AHA BP classification with the risk of CVD. Univariate and multivariate logistic regression models were used to investigate the association between BP levels and ASCVD risk. Subgroup analyses based on age, gender, and use of antihypertensive drugs were performed. P<0.05 was accepted as statistically significant.

Results After adjusting all covariates, compared to middle-aged and elderly patients with normal BP, we found that patients with stage 1/2 hypertension were associated with a higher risk of CVD, separately. Simultaneously, we also observed a positive association between individuals with elevated BP, stage 1 hypertension, stage 2 hypertension, and higher ASCVD risk in the fully adjusted model. The result of subgroup analyses implied that the relationship between stage 1/2 hypertension and CVD/ high ASCVD was robust in different ages and genders, and participants without using antihypertensive drugs.

Conclusion BP classification under the 2017 ACC/AHA BP guidelines may apply to the Chinese population.

Cardiovascular Diseases; Hypertension; Middle Aged; Aged

Variables	Total (n=1945)	Normal BP group (n=677)	Elevated BP group (n=269)	Stage 1 hypertension group (n=585)	Stage 2 hypertension group (n=414)	p	Normality test
Age, years, M (Q1, Q3)	56.00 (51.00,62.00)	54.00 (50.00,60.00)	56.00 (51.00,62.00)	56.00 (51.00,62.00)	58.00 (52.00,66.00)	<0.001	<0.0001
Age, years, n (%)						<0.001
<60	1286 (66.12)	500 (73.86)	176 (65.43)	377 (64.44)	233 (56.28)
≥60	659 (33.88)	177 (26.14)	93 (34.57)	208 (35.56)	181 (43.72)
Gender, n (%)						0.786
Male	913 (46.94)	317 (46.82)	122 (45.35)	284 (48.55)	190 (45.89)
Female	1032 (53.06)	360 (53.18)	147 (54.65)	301 (51.45)	224 (54.11)
Height, cm, M (Q1, Q3)	156.40 (151.00,163.10)	157.00 (151.20,163.00)	157.10 (150.30,163.00)	156.70 (151.60,164.60)	155.25 (150.00,162.00)	0.382	0.0001
Weight, kg, M (Q1, Q3)	56.00 (49.50,63.30)	54.00 (48.10,60.50)	55.60 (49.60,62.90)	58.10 (51.00,66.20)	57.20 (49.50,64.70)	0.061	<0.0001
BMI, kg/m², M (Q1, Q3)	22.66 (20.52,25.21)	21.78 (19.91,23.97)	22.41 (20.69,25.23)	23.25 (21.17,26.14)	23.43 (21.05,26.25)	0.448	<0.0001
Drinking, n (%)	652 (33.52)	239 (35.30)	80 (29.74)	204 (34.87)	129 (31.16)	0.240
Smoking, n (%)	1335 (68.64)	465 (68.69)	197 (73.23)	388 (66.32)	285 (68.84)	0.251
Diabetes, n (%)	44 (2.26)	10 (1.48)	5 (1.86)	16 (2.74)	13 (3.14)	0.249
Dyslipidemia, n (%)	74 (3.80)	19 (2.81)	10 (3.72)	26 (4.44)	19 (4.59)	0.362
Depression, n (%)	13 (0.67)	4 (0.59)	3 (1.12)	2 (0.34)	4 (0.97)	0.428
Antihypertensive drugs, n (%)	296 (15.22)	34 (5.02)	23 (8.55)	120 (20.51)	119 (28.74)	<0.001
Insulin and hypoglycemic drugs, n (%)	44 (2.26)	10 (1.48)	5 (1.86)	16 (2.74)	13 (3.14)	0.249
Hypolipidemic drugs, n (%)	71 (3.65)	19 (2.81)	9 (3.35)	24 (4.10)	19 (4.59)	0.420
TC, mg/dL, M (Q1, Q3)	190.98 (167.40,214.95)	187.89 (166.62,208.76)	190.21 (161.60,212.24)	193.69 (168.17,219.98)	195.62 (171.65,220.36)	0.421	<0.0001
TG, mg/dL, M (Q1, Q3)	100.89 (73.46,146.02)	92.93 (69.03,129.21)	97.35 (70.80,144.26)	107.08 (77.88,150.45)	107.97 (77.00,163.73)	0.137	<0.0001
LDL, mg/dL, M (Q1, Q3)	114.05 (93.94,136.47)	111.73 (93.17,132.22)	111.73 (90.46,130.67)	115.98 (94.72,139.56)	117.53 (97.04,141.50)	0.635	<0.0001
HDL, mg/dL, M (Q1, Q3)	50.64 (40.98,60.31)	52.58 (42.91,61.47)	51.03 (40.98,61.08)	49.10 (40.59,59.15)	48.33 (40.21,59.92)	0.209	<0.0001
Glucose, mg/dL, M (Q1, Q3)	100.98 (93.06,111.60)	98.46 (91.80,107.82)	100.80 (92.16,111.42)	101.88 (94.32,112.86)	105.12 (94.68,116.28)	0.062	<0.0001

Subgroup analyses	Variables	7-year CVD		ASCVD (≥7.5%)
Subgroup analyses	Variables	HR (95%CI)	p	OR (95%CI)	p
Subgroup analysis I: Age<60	Normal BP	Ref		Ref
	Elevated BP	1.176 (0.820-1.686)	0.377	1.539 (0.888-2.669)	0.124
	Stage 1 hypertension	1.388 (1.048-1.837)	0.022	3.200 (2.048-4.999)	<0.001
	Stage 2 hypertension	1.886 (1.403-2.535)	<0.001	12.486 (6.905-22.576)	<0.001
Subgroup analysis I: Age≥60	Normal BP	Ref		Ref
	Elevated BP	1.384 (0.892-2.148)	0.147	3.806 (1.608-9.007)	0.002
	Stage 1 hypertension	1.593 (1.107-2.292)	0.012	5.261 (2.446-11.318)	<0.001
	Stage 2 hypertension	1.510 (1.039-2.194)	0.031	19.245 (7.168-51.668)	<0.001
Subgroup analysis II: Male	Normal BP	Ref	-	Ref
	Elevated BP	1.178 (0.820-1.692)	0.375	3.449 (1.878-6.336)	<0.001
	Stage 1 hypertension	1.325 (0.991-1.772)	0.057	14.612 (8.635-24.727)	<0.001
	Stage 2 hypertension	1.429 (1.049-1.945)	0.023	67.329 (37.550-120.726)	<0.001
Subgroup analysis II: Female	Normal BP	Ref	-	Ref
	Elevated BP	1.392 (0.903-2.148)	0.135	3.246 (2.380-4.426)	<0.001
	Stage 1 hypertension	1.591 (1.130-2.239)	0.008	4.902 (3.760-6.392)	<0.001
	Stage 2 hypertension	1.931 (1.350-2.762)	<0.001	12.288 (8.695-17.365)	<0.001
Subgroup analysis III: Without using antihypertensive drugs	Normal BP	Ref	-	Ref
	Elevated BP	1.287 (0.960-1.726)	0.091	2.963 (2.229-3.938)	<0.001
	Stage 1 hypertension	1.359 (1.064-1.736)	0.014	6.110 (4.777-7.815)	<0.001
	Stage 2 hypertension	1.504 (1.149-1.967)	0.003	23.147 (16.768-31.952)	<0.001
Subgroup analysis III: Using of antihypertensive drugs	Normal BP	Ref	-	Ref
	Elevated BP	0.846 (0.353-2.029)	0.708	3.229 (1.264-8.247)	0.014
	Stage 1 hypertension	1.265 (0.698-2.295)	0.439	4.631 (2.178-9.847)	<0.001
	Stage 2 hypertension	1.260 (0.696-2.281)	0.445	12.992 (5.921-28.505)	<0.001

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[TFN1001] BMI: body mass index; Tc: total cholesterol; TG: triglycerides; LDL: low-density lipoprotein; HDL: high-density lipoprotein.

Outcomes 1	Variables	Sample size, n (%)	Model 1		Model 2		Model 3
Outcomes 1	Variables	Sample size, n (%)	HR (95%CI)	p	HR (95%CI)	p	HR (95%CI)	p
CVD	Normal BP	147 (21.71)	Ref		Ref		Ref
	Elevated BP	78 (29.00)	1.382 (1.050-1.819)	0.021	1.279 (0.971-1.686)	0.080	1.246 (0.944-1.643)	0.120
	Stage 1 hypertension	201 (34.36)	1.702 (1.376-2.105)	<0.001	1.526 (1.228-1.896)	<0.001	1.379 (1.105-1.720)	0.004
	Stage 2 hypertension	166 (40.10)	2.076 (1.662-2.592)	<0.001	1.735 (1.381-2.179)	<0.001	1.479 (1.168-1.874)	0.001
Outcomes 2	Variables		Model 4		Model 5		Model 6
Outcomes 2	Variables		OR (95%CI)	p	OR (95%CI)	p	OR (95%CI)	p
ASCVD (≥7.5%)	Normal BP	/	Ref		Ref		Ref
	Elevated BP	/	2.178 (1.848-2.568)	<0.001	1.826 (1.213-2.749)	0.004	2.048 (1.645-2.550)	<0.001
	Stage 1 hypertension	/	3.371 (2.951-3.851)	<0.001	4.540 (3.190-6.459)	<0.001	3.627 (3.023-4.352)	<0.001
	Stage 2 hypertension	/	7.079 (6.096-8.221)	<0.001	13.881 (9.003-21.401)	<0.001	7.920 (6.410-9.786)	<0.001