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Original Investigation
June 10, 2020

Association of Normal Systolic Blood Pressure Level With Cardiovascular Disease in the Absence of Risk Factors

Author Affiliations
  • 1Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland
  • 2National Institute for Preventive Cardiology and National University of Ireland, Galway Campus, Galway, Ireland
  • 3Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
  • 4Cardiovascular Health Research Unit, Departments of Medicine, and Epidemiology, and Health Services, University of Washington, Seattle
  • 5Kaiser Permanente Washington Health Research Institute, Seattle
  • 6Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 7Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California
  • 8Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 9Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Cardiol. Published online June 10, 2020. doi:10.1001/jamacardio.2020.1731
Key Points

Question  Is there an association between normal systolic blood pressure values as currently defined and atherosclerotic cardiovascular disease among persons without traditional cardiovascular disease risk factors?

Findings  In this cohort study including 1457 participants without atherosclerotic cardiovascular disease, beginning with a systolic blood pressure level of 90 mm Hg, there was a stepwise increase in the prevalence of traditional atherosclerotic cardiovascular disease risk factors, coronary artery calcium, and the risk of atherosclerotic cardiovascular disease. For every 10-mm Hg increase in systolic blood pressure, there was a 53% higher risk for atherosclerotic cardiovascular disease.

Meaning  These results highlight the importance of primordial prevention to maintain optimal systolic blood pressure levels as well as optimal values of other traditional atherosclerotic cardiovascular disease, all of which generally have similar trajectories of risk within conventionally considered normal ranges.


Importance  The risk of atherosclerotic cardiovascular disease (ASCVD) at currently defined normal systolic blood pressure (SBP) levels in persons without ASCVD risk factors based on current definitions is not well defined.

Objective  To examine the association of SBP levels with coronary artery calcium and ASCVD in persons without hypertension or other traditional ASCVD risk factors based on current definitions.

Design, Setting, and Participants  A cohort of 1457 participants free of ASCVD from the Multi-Ethnic Study of Atherosclerosis who were without dyslipidemia (low-density lipoprotein cholesterol level ≥160 mg/dL or high-density lipoprotein cholesterol level <40 mg/dL), diabetes (fasting glucose level ≥126 mg/dL), treatment for hyperlipidemia or diabetes, or current tobacco use, and had an SBP level between 90 and 129 mm Hg. Participants receiving hypertension medication were excluded. Coronary artery calcium was classified as absent or present and adjusted hazard ratios (aHRs) were calculated for incident ASCVD. The study was conducted from March 27, 2018, to February 12, 2020.

Exposures  Systolic blood pressure.

Main Outcomes and Measures  Presence or absence of coronary artery calcium and incident ASCVD events.

Results  Of the 1457 participants, 894 were women (61.4%); mean (SD) age was 58.1 (9.8) years and mean (SD) follow-up was 14.5 (3.9) years. There was an increase in traditional ASCVD risk factors, coronary artery calcium, and incident ASCVD events with increasing SBP levels. The aHR for ASCVD 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 to 99 mm Hg, the aHR for ASCVD risk was 3.00 (95% CI, 1.01-8.88) for SBP levels 100 to 109 mm Hg, 3.10 (95% CI, 1.03-9.28) for SBP levels 110 to 119 mm Hg, and 4.58 (95% CI, 1.47-14.27) for SBP levels 120 to 129 mm Hg.

Conclusions and Relevance  Beginning at an SBP level as low as 90 mm Hg, there appears to be a stepwise increase in the presence of coronary artery calcium 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.