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Association Between Blood Pressure Level and the Risk of Myocardial Infarction, Stroke, and Total Mortality
The Cardiovascular Health Study
Bruce M. Psaty, MD, PhD;
Curt D. Furberg, MD, PhD;
Lewis H. Kuller, MD, DrPH;
Mary Cushman, MD;
Peter J. Savage, MD;
David Levine, MD;
Daniel H. O'Leary, MD;
R. Nick Bryan, MD;
Melissa Anderson, MS;
Thomas Lumley, PhD
Arch Intern Med. 2001;161:1183-1192.
Background Recent reports have drawn attention to the importance of pulse pressure
as a predictor of cardiovascular events. Pulse pressure is used neither by
clinicians nor by guidelines to define treatable levels of blood pressure.
Methods In the Cardiovascular Health Study, 5888 adults 65 years and older were
recruited from 4 US centers. At baseline in 1989-1990, participants underwent
an extensive examination, and all subsequent cardiovascular events were ascertained
and classified.
Results At baseline, 1961 men and 2941 women were at risk for an incident myocardial
infarction or stroke. During follow-up that averaged 6.7 years, 572 subjects
had a coronary event, 385 had a stroke, and 896 died. After adjustment for
potential confounders, systolic blood pressure (SBP), diastolic blood pressure
(DBP), and pulse pressure were directly associated with the risk of incident
myocardial infarction and stroke. Only SBP was associated with total mortality.
Importantly, SBP was a better predictor of cardiovascular events than DBP
or pulse pressure. In the adjusted model for myocardial infarction, a 1-SD
change in SBP, DBP, and pulse pressure was associated with hazard ratios (95%
confidence intervals) of 1.24 (1.15-1.35), 1.13 (1.04-1.22), and 1.21 (1.12-1.31),
respectively; and adding pulse pressure or DBP to the model did not improve
the fit. For stroke, the hazard ratios (95% confidence intervals) were 1.34
(1.21-1.47) with SBP, 1.29 (1.17-1.42) with DBP, and 1.21 (1.10-1.34) with
pulse pressure. The association between blood pressure level and cardiovascular
disease risk was generally linear; specifically, there was no evidence of
a J-shaped relationship. In those with treated hypertension, the hazard ratios
for the association of SBP with the risks for myocardial infarction and stroke
were less pronounced than in those without treated hypertension.
Conclusion In this population-based study of older adults, although all measures
of blood pressure were strongly and directly related to the risk of coronary
and cerebrovascular events, SBP was the best single predictor of cardiovascular
events.
From the Cardiovascular Health Research Unit, Departments of Medicine,
Epidemiology and Health Services, University of Washington, Seattle (Dr Psaty);
Department of Public Health Sciences, Wake Forest University School of Medicine,
Winston-Salem, NC (Dr Furberg); Department of Epidemiology, University of
Pittsburgh, Pittsburgh, Pa (Dr Kuller); Departments of Medicine and Pathology,
University of Vermont, Colchester (Dr Cushman); Epidemiology and Biometry
Program, Division of Epidemiology and Clinical Applications, National Heart,
Lung, and Blood Institute, Bethesda, Md (Dr Savage); Department of Medicine,
The Johns Hopkins University, Baltimore, Md (Dr Levine); Department of Radiology,
Tufts-New England Medical Center, Boston, Mass (Dr O'Leary); Department of
Radiology, University of Pennsylvania, Philadelphia (Dr Bryan); and Department
of Biostatistics, University of Washington, Seattle (Ms Anderson and Dr Lumley).
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