High-normal blood pressure progression to hypertension in the Framingham Heart Study.
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This study sought to determine if individuals with high-normal blood pressure (diastolic blood pressure of 85-89 mm Hg) progress to hypertension more frequently than those with normal blood pressure (diastolic blood pressure less than 85 mm Hg), thus advancing to a higher cardiovascular risk category. Individuals from the Framingham Heart Study were placed in normal and high-normal blood pressure categories and followed for 26 years for the development of hypertension. With hypertension defined as a diastolic blood pressure of 95 mm Hg or greater or the initiation of antihypertensive therapy, 23.6% of men and 36.2% of women with normal blood pressure developed hypertension compared with 54.2% of men and 60.6% of women with high-normal blood pressure. The relative risk for the development of hypertension associated with high-normal blood pressure was 2.25 for men (95% confidence interval [CI], 1.8-2.8; p less than 0.0001) and 1.89 for women (95% CI, 1.5-2.3; p less than 0.0001). The age-adjusted relative risks estimated by the proportional hazards model were 3.36 for men and 3.37 for women (p less than 0.001). Among those risk factors examined, baseline systolic and diastolic blood pressure, Metropolitan relative weight, and change in weight over time were significant predictors of future hypertension in men and women whose initial blood pressure was normal. For men with high-normal blood pressure, systolic blood pressure and change in weight were identified as risk factors for future hypertension. These results indicate that the probability of individuals with blood pressure in the high-normal range developing hypertension is twofold to threefold higher than in those with normal blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)Keywords:
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The aim of this review was to examine the relative contributions of systolic and diastolic blood pressures to the risk of cardiovascular disease on the basis of epidemiologic evidence from the Framingham Heart Study and the change in attitudes toward systolic blood pressure that occurred during the course of the study. Historic texts were evaluated in comparison with data from the Framingham Heart Study, a prospective longitudinal analysis of the relation between blood pressure and occurrence of subsequent cardiovascular morbidity and mortality rates in a fixed cohort. Historically, systolic hypertension has been considered an innocent accompaniment to arterial stiffening, occurring as a compensatory phenomenon in the elderly. Epidemiologic data show that the development of hypertension is neither inevitable nor beneficial. The data also provide evidence that systolic pressure is more important than diastolic pressure as a determinant of cardiovascular sequelae. Mild or moderate elevations of systolic blood pressure, even when unaccompanied by diastolic pressure elevations, are associated with an increased risk of cardiovascular disease. Risk is increased further by the added presence of related metabolic disturbances such as dyslipidemia, glucose intolerance, insulin resistance, cardiac hypertrophy, and obesity. Over-reliance on diastolic blood pressure in assessing the risk of hypertension can be misleading. Systolic pressure constitutes a powerful predictor of cardiovascular disease and a valuable tool when incorporated within multivariate risk formulas for estimating the conditional probability of coronary and stroke events.
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A prediction model, developed in the Framingham Heart Study (FHS), has been proposed for use in estimating a given individual’s risk of hypertension. We compared this model with systolic blood pressure (SBP) alone and age-specific diastolic blood pressure categories for the prediction of hypertension. Participants in the Multi-Ethnic Study of Atherosclerosis, without hypertension or diabetes mellitus (n=3013), were followed for the incidence of hypertension (SBP ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg and/or the initiation of antihypertensive medication). The predicted probability of developing hypertension among 4 adjacent study examinations, with a median of 1.6 years between examinations, was determined. The mean (SD) age of participants was 58.5 (9.7) years, and 53% were women. During follow-up, 849 incident cases of hypertension occurred. The c statistic for the FHS model was 0.788 (95% CI: 0.773 to 0.804) compared with 0.768 (95% CI: 0.751 to 0.785; P =0.096 compared with the FHS model) for SBP alone and 0.699 (95% CI: 0.681 to 0.717; P <0.001 compared with the FHS model) for age-specific diastolic blood pressure categories. The relative integrated discrimination improvement index for the FHS model versus SBP alone was 10.0% (95% CI: −1.7% to 22.7%) and versus age-specific diastolic blood pressure categories was 146.0% (95% CI: 116.0% to 181.0%). Using the FHS model, there were significant differences between observed and predicted hypertension risks (Hosmer-Lemeshow goodness of fit: P <0.001); recalibrated and best-fit models produced a better model fit ( P =0.064 and 0.245, respectively). In this multiethnic cohort of US adults, the FHS model was not substantially better than SBP alone for predicting hypertension.
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Analysis of the Framingham Heart Study experience between 1958 and 1970 showed a progressive increase in the rate of treatment and control of hypertension. With cross-sectional criteria to define diastolic hypertension, the treatment rate rose from 35% in 1958 through 1960 to 69% in 1968 through 1970 (p less than .001), and the treatment rate for sustained hypertension rose from 55% in 1958 through 1960 to 85% in 1968 through 1970 (p less than .001). Treated hypertensive subjects had higher pretreatment values of blood pressure but not of other cardiovascular risk factors than untreated hypertensive subjects. Treatment was more successful in controlling hypertension in later years (p less than .001), but in all years treatment reduced systolic and diastolic blood pressure without causing significant changes in mean serum cholesterol or glucose levels. In treated hypertensive subjects, the 8 year predicted risk of coronary heart disease declined by 2.3 events per 100 people compared with that in untreated hypertensive subjects (p less than .0001). The observed incidence of coronary heart disease was consistent with these predictions and suggested that treatment may be especially beneficial in subjects who have systolic blood pressures of 180 mm Hg or higher and who are treated for more than 2 successive years.
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Information is limited regarding the risk of cardiovascular disease in persons with high-normal blood pressure (systolic pressure of 130 to 139 mm Hg, diastolic pressure of 85 to 89 mm Hg, or both).
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This paper reviews the evolution of attitudes toward the treatment and diagnosis of hypertension. In particular, there is a growing realization that elevated systolic pressure may be a more valuable measurement in evaluating and controlling hypertension than is generally acknowledged. A large number of epidemiologic studies in a wide variety of populations have revealed that systolic blood pressure exerts a stronger influence than diastolic blood pressure. The largest of these, the Framingham Heart Study, showed that in subjects with systolic hypertension, diastolic blood pressure was only weakly related to the risk of cardiovascular events, but in those with diastolic hypertension, the risk of these events was strongly influenced by the level of systolic pressure. Furthermore, cardiovascular event rates were found to increase steeply with systolic pressure and were higher in cases of isolated systolic hypertension than diastolic hypertension. Clinical trials produced similar results, again suggesting that a greater reliance should be placed on systolic pressure in evaluating the risk of cardiovascular problems. This review concludes that the health community needs to be reeducated to consider the importance of systolic and diastolic blood pressure in assessing appropriate management strategies for hypertensive patients.
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In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) published its ultimate guidelines for hypertension prevention and management (1). One of the key messages was the definition of a new category of blood pressure (BP) levels, i.e., prehypertension, that included individuals with a systolic BP of 120–139 mmHg or a diastolic BP of 80–89 mmHg. Patients with prehypertension were considered at increased risk for progression to hypertension and individuals in the 130/80 to 139/89 mmHg range were at twice the risk of developing hypertension than subjects with lower values (2). In the same year, the European Society of Hypertension and the European Society of Cardiology (ESH-ESC) published their guidelines for the management of arterial hypertension and, for the same range of BP, two different categories of BP were defined: normal BP (systolic BP of 120–129 mmHg, or diastolic BP of 80–84 mmHg) and high-normal BP (systolic BP of 130–139 mmHg, or diastolic BP of 85–89 mmHg) (3).
In 2007, the ESH-ESC committee decided against using the term “prehypertension” for several reasons (4). First, even in the Framingham study, the risk of developing hypertension was definitely higher in subjects with high-normal BP than in patients with normal BP (2,5), and therefore there is little reason to combine the two groups. Second, given the ominous significance of the word “hypertension” for the layman, the term “prehypertension” may, in many subjects, create anxiety and a request for unnecessary medical visits and examinations. Finally, although lifestyle changes recommended by the 2003 JNC VII guidelines for all prehypertensive individuals may be a valuable population strategy (1), in practice, this category is a highly differentiated one, with the extremes consisting of subjects with no need of any intervention (e.g., an …
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The arterial hypertension is admitted as a major risk factor for the ischemic cardiopathy (pectoral angina, myocardium infarct) and the cerebral apoplexy (1). The incidence of ischemic heart disease is 3 times higher to hypertensive patients, but at the same time it was not identified a critical threshold value at which blood pressure is a risk. The Framingham study (2) showed greater impact of elevated systolic blood pressure (SBP), namely, small or moderate increases in SBP, not accompanied by increases in diastolic blood pressure (DBP) is associated with an increased risk of cardiovascular disease.
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Hypertension is an established risk factor for cardiovascular disease morbidity and mortality. Randomized trials of antihypertensive therapy have demonstrated the benefits of treating diastolic blood pressure, and recently the value of treating isolated systolic blood pressure has also been established. There is an excess risk of cardiovascular disease in subjects with borderline isolated systolic hypertension. In fact, data from men screened for the Multiple Risk Factor Intervention Trial show that the great majority of excess deaths are in those with high-normal systolic blood pressure or with stage 1 hypertension, i.e., systolic blood pressure 130 to 159 mmHg. Similarly, data from the Framingham Heart Study and the Physicians' Health Study emphasize the importance of mild elevations of systolic blood pressure. As age increases the hemodynamic patterns of blood pressure change due to an increase in large artery stiffness, and borderline isolated systolic hypertension becomes the dominant form of hypertension. These facts make the prevention and control of borderline isolated systolic hypertension a key strategic challenge in the effort to prevent excess mortality attributable to blood pressure levels above normal.
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