The Relationship of Systolic and Diastolic Blood Pressure to Cardiovascular Disease Risk: Observational Data
Prevalence of Hypertension in the US
Percent hypertensive
18-29
Based on NHANES III (phase 1 and 2)
Hypertension defined as blood pressure ?140/90 mmHg or treatment
30-39
40-49
50-59
60-69
70-79
80+
Age
3 %
9 %
18 %
38 %
51 %
66 %
72 %
JNC-VI. Arch Intern Med. 1997;157:2413-2446.
Risk of hypertension (%)
Residual lifetime risk of developing hypertension among people with blood pressure <140/90 mmHg
Years
Lifetime Risk of Developing Hypertension Beginning at Age 65
Men
Women
Vasan RS, et al. JAMA. 2002; 287:1003-1010.
Copyright 2002, American Medical Association.
Mortality According to Blood Pressure in Men Age 50 to 69
Society of Actuaries. Blood Pressure Study, 1939.
Ratio (%) of actual to expected mortality
Systolic blood pressure (mmHg)
Diastolic blood
pressure (mmHg)
Age-adjusted annual incidence of CHD per 1000
Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease (CHD) at baseline
Systolic blood pressure (mmHg)
Blood Pressure and Risk for Coronary Heart Disease in Men
Diastolic blood pressure (mmHg)
Age 65-94
Age 35-64
Age 65-94
Age 35-64
Framingham Heart Study, 30-year Follow-up. NHLBI, 1987.
Relative risk of
CHD mortality
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
<112 <71
Risk of CHD Death According to SBP and DBP in MRFIT
Decile
112- 71-
118- 76-
121- 79-
125- 81-
129- 84-
132- 86-
137- 89-
142- 92-
>151 >98
(lowest 10%)
(highest 10%)
SBP (mmHg)
DBP (mmHg)
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
CHD=coronary heart disease
Relative risk of stroke death
<112 <71
Risk of Stroke Death According to SBP and DBP in MRFIT
Decile
112- 71-
118- 76-
121- 79-
125- 81-
129- 84-
132- 86-
137- 89-
142- 92-
>151 >98
(lowest 10%)
(highest 10%)
SBP (mmHg)
DBP (mmHg)
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
He J, et at. Am Heart J. 1999;138:211-219.
Copyright 1999, Mosby Inc.
Age-adjusted annual CVD event rate per 1000
Wilking SV et al. JAMA. 1988;260:3451-3455.
Men
Women
Isolated Systolic Hypertension and CVD Risk in Framingham
ISH BP ?160/<95 mmHg
BP <140/95 mmHg
82
43
33
2.4
18
2.5
CVD=cardiovascular disease ISH=isolated systolic hypertension
P<0.001 for difference between both men and women with ISH and blood pressure (BP) <140/95 mmHg
The Relationship of Hypertension Treatment to CVD Risk Reduction: Introduction
Incidence of cardiovascular disease
120
Hypertension Treatment Effect Mirrors Observational Data
140
160
180
200
220
Observational Data
Treatment Effect
Systolic blood pressure (mmHg)
Landmark Clinical Trials Hypertension Treatment and Cardiovascular Disease Outcomes
1967 – VA Cooperative Study on DBP 115-129
1970 – VA Cooperative Study on DBP 90-114
1979 – HDFP
1980 – Australian Trial, Oslo Trial
1985 – MRC I, EWPHE
1991 – SHEP, STOP-Hypertension
1992 – MRC II in the elderly
1997 – Syst-Eur
2002 – LIFE
2002 – ALLHAT
Relative Risk for Coronary Heart Disease
Odds ratios and 95% confidence intervals
0
0.5
1
1.5
2
0.79 (0.69 to 0.90)
He J, et al. Am Heart J. 1999; 138:211-219.
Copyright 1999, Mosby, Inc.
Active treatment better than placebo
Active treatment worse than placebo
Relative Risk for Stroke
0
0.5
1
1.5
2
0.63 (0.55 to 0.72)
Odds ratios and 95% confidence intervals
Active treatment better than placebo
Active treatment worse than placebo
He J, et al. Am Heart J. 1999; 138:211-219.
Copyright 1999, Mosby, Inc.
The Veterans Administration Cooperative Study on Antihypertensive Agents
The VA Cooperative Study, 1967
VA Cooperative Study Group. JAMA. 1967;202:1028-1034.
HCTZ=hydrochlorothiazide
-12
12
The VA Cooperative Study, 1967: Change in Systolic and Diastolic Blood Pressure
Change in Systolic BP (mmHg)
Percent of patients
Percent of patients
Change in Diastolic BP (mmHg)
-76
-60
-44
-28
0
28
Decrease (-)
(+) Increase
Active drugs
Placebo
Active drugs
Placebo
VA Cooperative Study Group. JAMA. 1967;202:1028-1034.
Copyright ?1967, American Medical Association.
-12
12
-76
-60
-44
-28
0
28
Decrease (-)
(+) Increase
The VA Cooperative Study, 1967: Assessable Morbid/Fatal Events
VA Cooperative Study Group. JAMA. 1967;202:1028-1034.
*P<0.001 active drug therapy vs placebo
The VA Cooperative Study, 1967: Conclusions
The actively treated group experienced a reduction in multiple hypertension-related endpoints
21 morbid/fatal events on placebo
1 morbid/fatal event on active therapy
VA Cooperative Study Group. JAMA. 1967;202:1028-1034.
The VA Cooperative Study, 1970
VA Cooperative Study Group. JAMA. 1970;213:1143-1152.
The VA Cooperative Study, 1970: Assessable Morbid/Fatal Events
VA Cooperative Study Group. JAMA. 1970;213:1143-1152.
*P<0.001 active drug therapy vs placebo
The VA Cooperative Study, 1970: Conclusions
Active treatment reduced fatal and nonfatal endpoints
A subsequent analysis revealed that benefits were statistically significant only for those with baseline diastolic blood pressure 105-114 mmHg
VA Cooperative Study Group. Circulation. 1972; 45 (5):991-1004.
VA Cooperative Study Group. JAMA. 1970;213:1143-1152.
The European Working Party on High Blood Pressure in the Elderly, 1985
The European Working Party on High Blood Pressure in the Elderly, 1985
Amery A, et al. Lancet. 1985;1:1349-1354.
Survival free of event (%)
Year of follow-up
EWPHE Cardiovascular Mortality On-Treatment Analysis
Active (n=416)
Placebo (n=424)
P=0.023
Amery A, et al. Lancet. 1985;1:1349-1354.
Reprinted with permission from Elsevier Science.
EWPHE=European Working Party on High Blood Pressure in the Elderly
EWPHE Conclusions
Active treatment reduced cardiovascular (CV) mortality, largely due to a reduction in cardiac mortality
Older patients (>60 yrs old) with combined systolic and diastolic hypertension who received active therapy experienced 29 fewer CV events and 14 fewer CV deaths per 1,000 patient-years of treatment
Amery A, et al. Lancet. 1985;1:1349-1354.
EWPHE=European Working Party on High Blood Pressure in the Elderly
The Hypertension Detection and Follow-up Program, 1979
The Hypertension Detection and Follow-up Program, 1979
HDFP Cooperative Group. JAMA. 1979;242:2562-2571.
Cumulative mortality (%)
0
1
3
6
Year of follow-up
HDFP Mortality Rates Entire Cohort
2
4
5
Referred Care
Stepped Care
HDFP=Hypertension Detection and Follow-up Program
*P<0.01
HDFP Cooperative Group. JAMA. 1979;242:2562-2571.
(n=5,456)
(n=5,485)
*
0
1
3
6
2
4
5
Cumulative mortality (%)
HDFP Mortality Rates Diastolic BP 90?104 mmHg
Referred Care
Stepped Care
HDFP=Hypertension Detection and Follow-up Program
Year of follow-up
*P<0.01
HDFP Cooperative Group. JAMA. 1979;242:2562-2571.
(n=3,822)
(n=3,903)
*
BP=blood pressure
HDFP Conclusions
Overall, stepped care (SC) compared to referred care (RC) reduced total mor