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Original Investigation
January 28, 2020

Association of Isolated Diastolic Hypertension as Defined by the 2017 ACC/AHA Blood Pressure Guideline With Incident Cardiovascular Outcomes

Author Affiliations
  • 1National Institute for Prevention and Cardiovascular Health, School of Medicine, National University of Ireland Galway, Galway, Ireland
  • 2Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 3Welch Center for Prevention, Epidemiology and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Houston Methodist DeBakey Heart and Vascular Center, Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas
  • 5Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA. 2020;323(4):329-338. doi:10.1001/jama.2019.21402
Key Points

Question  What is the prevalence of isolated diastolic hypertension (IDH) in the United States when defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) blood pressure guideline vs the 2003 Joint National Committee (JNC7) guideline and what is the prognosis of individuals with IDH by the 2017 ACC/AHA definition?

Findings  In a nationally representative US cross-sectional study that included 9590 adults, the estimated prevalence of IDH based on the 2017 ACC/AHA guideline vs the JNC7 guideline was 6.5% vs 1.3%, respectively. In a longitudinal analysis that included 8703 adults, there was no significant association between IDH as defined by the 2017 ACC/AHA guideline and incident atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease.

Meaning  IDH as defined by the 2017 ACC/AHA blood pressure guideline may not be associated with increased risk for cardiovascular outcomes.

Abstract

Importance  In the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline, the definition of hypertension was lowered from a blood pressure (BP) of greater than or equal to 140/90 to greater than or equal to 130/80 mm Hg. The new diastolic BP threshold of 80 mm Hg was recommended based on expert opinion and changes the definition of isolated diastolic hypertension (IDH).

Objective  To compare the prevalence of IDH in the United States, by 2017 ACC/AHA and 2003 Joint National Committee (JNC7) definitions, and to characterize cross-sectional and longitudinal associations of IDH with outcomes.

Design, Setting, and Participants  Cross-sectional analyses of the National Health and Nutrition Examination Survey (NHANES 2013-2016) and longitudinal analyses of the Atherosclerosis Risk in Communities (ARIC) Study (baseline 1990-1992, with follow-up through December 31, 2017). Longitudinal results were validated in 2 external cohorts: (1) the NHANES III (1988-1994) and NHANES 1999-2014 and (2) the Give Us a Clue to Cancer and Heart Disease (CLUE) II cohort (baseline 1989).

Exposures  IDH, by 2017 ACC/AHA (systolic BP <130 mm Hg, diastolic BP ≥80 mm Hg) and by JNC7 (systolic BP <140 mm Hg, diastolic BP ≥90 mm Hg) definitions.

Main Outcomes and Measures  Weighted estimates for prevalence of IDH in US adults and prevalence of US adults recommended BP pharmacotherapy by the 2017 ACC/AHA guideline based solely on the presence of IDH. Risk of incident atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD) in the ARIC Study.

Results  The study population included 9590 adults from the NHANES (mean [SD] baseline age, 49.6 [17.6] years; 5016 women [52.3%]) and 8703 adults from the ARIC Study (mean [SD] baseline age, 56.0 [5.6] years; 4977 women [57.2%]). The estimated prevalence of IDH in the NHANES was 6.5% by the 2017 ACC/AHA definition and 1.3% by the JNC7 definition (absolute difference, 5.2% [95% CI, 4.7%-5.7%]). Among those newly classified as having IDH, an estimated 0.6% (95% CI, 0.5%-0.6%) also met the guideline threshold for antihypertensive therapy. Compared with normotensive ARIC participants, IDH by the 2017 ACC/AHA definition was not significantly associated with incident ASCVD (n = 1386 events; median follow-up, 25.2 years; hazard ratio [HR], 1.06 [95% CI, 0.89-1.26]), HF (n = 1396 events; HR, 0.91 [95% CI, 0.76-1.09]), or CKD (n = 2433 events; HR, 0.98 [95% CI, 0.65-1.11]). Results were also null for cardiovascular mortality in the 2 external cohorts (eg, HRs of IDH by the 2017 ACC/AHA definition were 1.17 [95% CI, 0.87-1.56] in the NHANES [n = 1012 events] and 1.02 [95% CI, 0.92-1.14] in CLUE II [n = 1497 events]).

Conclusions and Relevance  In this analysis of US adults, the estimated prevalence of IDH was more common when defined by the 2017 ACC/AHA BP guideline compared with the JNC7 guideline. However, IDH was not significantly associated with increased risk for cardiovascular outcomes.

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