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Prognostic Value of Systolic and Diastolic Blood Pressure in Treated Hypertensive Men
Athanase Benetos, MD, PhD;
Frédérique Thomas, PhD;
Kathryn Bean, MA, MPH;
Sylvie Gautier, MD;
Harold Smulyan, MD;
Louis Guize, MD
Arch Intern Med. 2002;162:577-581.
ABSTRACT
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Background The aim of this study was to assess the cardiovascular risk in hypertensive
subjects according to systolic blood pressure (SBP) and diastolic blood pressure
(DBP) levels.
Methods The study sample consisted of 4714 hypertensive men, treated by their
physician, who had a standard health checkup at the d'Investigations Préventives
et Cliniques Center, Paris, France, between 1972 and 1988. Cardiovascular
disease (CVD) and coronary heart disease (CHD) mortality were assessed for
a mean period of 14 years.
Results Among treated subjects, 85.5% presented uncontrolled values for SBP
( 40 mm Hg) and/or DBP (90 mm Hg). After adjustment for age and associated
risk factors, these subjects presented an increased risk for CVD mortality
(risk ratio [RR], 1.66; 95% confidence interval [CI], 1.04-2.64) and for CHD
mortality (RR, 2.35; 95% CI, 1.03-5.35) compared with controlled subjects.
After adjustment for age, associated risk factors, and DBP, and compared with
subjects with SBP under 140 mm Hg, the RR for CVD mortality was 1.81 (95%
CI, 1.04-3.13) in subjects with SBP between 140 and 160 mm Hg and 1.94 (95%
CI, 1.10-3.43) in subjects with SBP over 160 mm Hg. By contrast, after adjustment
for SBP levels, CVD risk was not associated with DBP. Compared with subjects
with DBP under 90 mm Hg, RR for CVD mortality was 1.17 (95% CI, 0.80-1.70)
in subjects with DBP between 90 and 99 mm Hg and 1.03 (95% CI, 0.67-1.56)
in subjects with DBP over 100 mm Hg. Similar results were observed for CHD
mortality.
Conclusions In hypertensive men treated in clinical practice, SBP is a good predictor
of CVD and CHD risk. Diastolic blood pressure, which remains the main criterion
used by most physicians to determine drug efficacy, appears to be of little
value in determining cardiovascular risk. Evaluation of risk in treated individuals
should take SBP rather than DBP values into account.
INTRODUCTION
THE SIXTH Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure1
and the recent report of the World Health Organization/International Society
of Hypertension2 classified blood pressure
(BP) into stages based on either systolic (SBP) or diastolic (DBP) levels.
Both classifications define the lowest SBP and DBP levels as being optimal,
and the highest levels of both as having the highest cardiovascular morbidity
and mortality rates. In the past few years, the importance of SBP has been
emphasized, especially in older subjects,3-4
and more recently, it has been proposed that DBP values could be the best
predictor of cardiovascular risk in younger subjects5
and SBP or pulse pressure in older subjects.
It has been suggested that SBP should be under 140 mm Hg and that DBP
be under 90 mm Hg for all treated hypertensive subjects, unless diabetes or
target organ damage are present, in which case lower BP levels (<130/85
mm Hg) should be targeted.1-2
Observational studies from several countries have demonstrated that among
treated hypertensive individuals, the proportion of those who are well controlled
is less than 30%,6-7 and a recent
survey in the United Kingdom indicated that only 6% of hypertensive subjects
presented BP levels below the limit of 140/90 mm Hg.8
One of the reasons for these results may be the relative complexity
of the guidelines that include SBP and/or DBP in the various classifications.
In addition, physicians may not be convinced that the results found among
hypertensive subjects participating in controlled studies, which show the
benefits of low BP levels (<140/90 mm Hg), are applicable to hypertensive
subjects treated in their everyday clinical practices.
In this observational study, the prognostic value of SBP and DBP levels
on cardiovascular mortality, especially coronary heart disease (CHD) mortality
in hypertensive subjects, treated in "everyday" clinical practice, was assessed.
The study sample consisted of 4714 treated hypertensive men from the Centre
d'Investigations Préventives et Cliniques (IPC) cohort.
METHODS
THE IPC POPULATION
The subjects were examined at the IPC Center. The IPC Center is subsidized
by the French National Health Care system (Sécurité Sociale-Caisse
Nationale d'Assurance Maladie) and provides all working and retired persons
and their families with a free medical examination every 5 years. It is one
of the largest medical centers of this kind in France, having carried out
approximately 20 000 to 25 000 examinations per year since 1970
for people living in the Paris area.9-10
Supine BP was measured 3 times in the right arm after a 10-minute rest
period, using a manual sphygmomanometer. The mean of the last 2 measurements
was calculated. The first and the fifth Korotkoff phases were used to define
SBP and DBP. Tobacco use (current consumption of more than 10 cigarettes per
day), and personal history of diabetes and hypertension were assessed with
a self-administered questionnaire. Total cholesterol was measured at the IPC
Center under fasting conditions, the day of the examination.
The IPC Center received approval from the national ethics committee
(Comité National d'Informatique et des Libertés) to conduct
these analyses. All subjects included in this analysis gave their informed
consent at the time of the examination. Among these subjects, 75% were white-collar
workers. Based on the national statistics on mortality, our cohort presented
a 30% lower mortality rate than the general French population. This may be
explained by the fact that people who come for a medical examination are generally
healthy and motivated. Interestingly, when compared with the national data,
the distribution of the different causes of mortality in our cohort was identical
to that of the general population.
In the present analysis, all treated hypertensive men (n = 4714) who
had an examination at the IPC Center between 1972 and 1988 were included.
Upon study entry, among the 4714 subjects, 112 (2.4%) had concurrent cardiovascular
disease (CVD), and the percentage of CVD did not vary according to SPB or
DBP groups.
For all subjects, mortality data were obtained for a 9- to 25-year period
(mean ± SD, 14.0 ± 4.2 years) that extended from the time of
inclusion through December 1997. These data were obtained from the mortality
records at the Institut National de Statistiques et d'Etudes Economiques,
following a previously established procedure.9-10
Causes of mortality, taken from the death certificates, were provided by INSERM's
(Institut National de la Santé et de la Recherche Médicale)
Department of Mortality Studies (Unit SC 8). Causes of death were codified
according to the eighth revision of the International Classification
of Diseases until 1978 and the ninth revision thereafter. Cardiovascular-related
deaths were coded 390-459, and 798 for sudden death. Coronary-related deaths
were coded 410-414, and 798 for sudden death.
DATA ANALYSIS
In the present analysis, we used the current cut points proposed by
the International Society of Hypertension and the World Health Organization.
Subjects were considered as controlled by treatment when SBP was under 140
mm Hg and DBP was under 90 mm Hg (Table
1). Subjects were also divided into groups according to SBP (<140,
140-159, 160 mm Hg) or DBP (<90, 90-99, 100 mm Hg) to assess the
specific roles of SBP and DBP, respectively (Table 2 and Table 3).
Differences in clinical characteristics and mortality rates according to BP
levels were studied using either the t test or the  2 test. Analyses were carried out to evaluate risk ratios (RRs) and
95% confidence intervals (CIs) for CVD mortality using a Cox proportional
hazard regression analysis. Multivariate models including age, total cholesterol,
smoking, and diabetes were used to evaluate adjusted RR. The associations
between SBP and CVD or CHD mortality were also considered after adjustment
for DBP, and the associations between DBP and CVD or CHD mortality were also
considered after adjustments for SBP.
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Table 1. Mortality Rates and Risk Ratios in Men With Controlled and
Uncontrolled Hypertension*
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Table 2. Mortality Rates and Adjusted Risk Ratios for CVD Mortality
According to SBP and DBP Groups in Men Treated for Hypertension*
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Table 3. Mortality Rates and Adjusted Risk Ratios for CHD Mortality
According to SBP and DBP Groups in Men Treated for Hypertension*
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All statistical analyses were carried out using the SAS statistical
software package (SAS Institute Inc, Cary, NC).
RESULTS
In the study population, age (mean ± SD) was 52 ± 11 years;
SBP, 152 ± 18 mm Hg; and DBP, 94 ± 12 mm Hg. Only 14.5% of the
patients presented controlled values for both SBP and DBP, 10.8% presented
uncontrolled values for SBP alone, 4.2% presented uncontrolled values for
DBP alone, and 70.5% of the treated hypertensive men presented uncontrolled
values for both. Compared with subjects with controlled BP values, those with
high BP values had a statistically significant increase in multivariate-adjusted
RR for CVD mortality (1.66; 95% CI, 1.04-2.64) and for CHD mortality (2.35;
95% CI, 1.03-5.35) (Table 1).
Table 2 shows CVD mortality
rates and adjusted RRs according to the SBP and DBP categories. There was
a 4-fold increase in unadjusted CVD mortality rates in subjects with SBP of
160 mm Hg or higher compared with subjects with SBP under 140 mm Hg. After
adjustment for age, there was a 2.2-fold increase in CVD mortality (Figure 1, A). As shown in Figure 1, the relationship between SBP and CVD risk was linear.
The group with SBP between 140 and 159 mm Hg showed a 63% (P<.01) increase in age-adjusted CVD mortality compared with the
group with SBP under 140 mm Hg. After adjustment for age and associated risk
factors, the risk for CVD mortality increased in the group with SBP between
140 and 160 mm Hg by almost 70% compared with the group with SBP under 140
mm Hg (Table 2). In the group
with SBP of 160 mm Hg or higher, RR for CVD mortality was 2.5 times greater
than in the reference group. After complementary adjustment for DBP levels,
the risk of CVD mortality was still significantly higher in the group with
SBP over 140 mm Hg compared with the group with SBP under 140 mm Hg.
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Age-adjusted cardiovascular disease (CVD) and coronary heart disease
(CHD) mortality rates according to systolic blood pressure (SBP) (A) and diastolic
blood pressure (DBP) (B) levels in men treated for hypertension.
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When subjects were classified according to DBP levels, those with DBP
over 100 mm Hg showed less than a 2-fold increase in CVD mortality compared
with subjects with DBP under 90 mm Hg (Table 2). After adjustment for age, the relationship between DBP
levels and CVD mortality was not significant (Figure 1, B). After adjustment for age and associated risk factors,
the risk for CVD mortality in the group with DBP between 90 and 99 mm Hg did
not increase significantly, whereas in the group with DBP over 100 mm Hg,
it increased by 60% (Table 2).
However, after adjustment for SBP, there was no association between DBP levels
and CVD mortality.
The role of SBP and DBP on cardiovascular mortality was not influenced
by age (interaction term age x SBP, P = .44
and age x DBP, P = .80).
Table 3 shows CHD mortality
rates and adjusted RRs according to the SBP and DBP categories (Figure 1). Based on SBP and DBP levels, very similar results to
those observed for CVD mortality were found. Once again, the roles of SBP
and DBP in CHD mortality were not influenced by age (interaction term age
x SBP, P = .65 and age x DBP, P = .54).
The association between pulse pressure and CVD mortality and CHD mortality
was also evaluated. The results from these analyses showed that pulse pressure
had the same predictive value as SBP (data not shown).
COMMENT
Our data show that more than 85% of the treated hypertensive men had
uncontrolled SBP or DBP levels. Among them, most (70%) had high levels of
both SBP and DBP, followed by those with high SBP and controlled DBP. This
clearly confirms that, as measured in a clinical setting, a controlled BP,
especially SBP, is uncommon. The most important result of this study is that
cardiovascular mortality, especially CHD mortality, is much higher in uncontrolled
hypertensive men than in controlled hypertensive men, and that SBP levels,
but not DBP levels, can predict CVD risk independent of age.
It is well documented that reducing BP is associated with a decrease
in the risk of coronary and cerebrovascular complications. A meta-analysis
of 14 controlled clinical trials demonstrated that lowering DBP by 6 mm Hg
reduced cerebrovascular morbidity and mortality by 42% and the risk of CHD
by 14%.11 The Hypertension Optimal Treatment
trial also confirmed that reduction in DBP with treatment decreased CVD risk
by 30%.12 Although the benefits of reducing
DBP were clearly shown in numerous controlled studies in younger and older
patients with systolic-diastolic hypertension, recent findings suggest that
normalization of SBP rather than DBP should be the main goal of antihypertensive
treatment.13-16
The benefits of treating high SBP, especially in older subjects, were established
by the Systolic Hypertension in the Elderly Program13
and the Systolic Hypertension Europe14 trials
in older subjects with isolated systolic hypertension, but also in patients
with an increase in both SBP and DBP.15-16
Our results were obtained from subjects who were not a part of a specific
research program and were followed up by their own physicians. This study
can therefore better evaluate the long-term CVD risk in hypertensive subjects
followed up and treated by their physicians according to the standard clinical
practice. Under these conditions that reflect the regular treatment of French
hypertensive persons, we confirmed the results of several studies showing
that getting SBP to goal levels is much more difficult than controlling DBP
levels.6-8,17
The new element provided by our study is that lack of SBP control may be a
major determinant of the increased morbidity and mortality in treated hypertensive
persons reported by other population studies.18-19
Also, under these circumstances, the level of DBP in treated men does not
seem to be of a significant prognostic value.
As shown in Table 2 and Figure 1, CVD mortality was 60% higher in
men with DBP values over 100 mm Hg compared with those with DBP values under
90 mm Hg. However, this was mainly because most subjects with high DBP also
had high SBP; thus, after adjustment for SBP, DBP levels lost all predictive
value. On the other hand, the RR for adjusted CVD and CHD mortality was approximately
2.5 times higher in treated hypertensive men with SBP values over 160 mm Hg
compared with those with SBP values under 140 mm Hg. It is important to note
that the predictive value of SBP remained significant even after adjustment
for DBP levels. It is also interesting to point out that the presence of an
SBP between 140 and 160 mm Hg (corresponding to a "mild" increase in SBP)
under treatment is accompanied by a 2-fold increase in CVD and CHD age-adjusted
mortality compared with treated subjects with well-controlled SBP levels.
This result is important in terms of public health since a large proportion
of treated hypertensive persons fall into this group (44.5% in our study).
The role of SBP and DBP in predicting CVD and CHD risk in our population
was not influenced by age. However, it has previously been reported in a general
population that DBP better reflects the CVD risk in younger subjects and that
SBP better reflects the risk in older subjects.5
These differences may be explained by the fact that low DBP in treated subjects
may not have the same significance as low DBP in untreated subjects. Diastolic
BP levels are influenced by arterial or arteriolar alterations in opposite
ways: an increase in peripheral vascular resistance leads to an elevation
in DBP, whereas stiffening of large arteries can contribute to a decrease
in DBP.20-21 Since stiffness is
a major sign of arterial aging, it could also be suggested that subjects receiving
treatment have a more advanced arterial age than chronological age. This could
explain why what is found for older subjects in the general population is
observed even in younger treated hypertensive subjects.
There were some study limitations. Although the age range of this population
was very large (19-91 years), the large majority of subjects were middle-aged
men (52 ± 11 years), with fewer individuals at the extremes. Therefore,
it is possible that the lack of interaction between age and the role of SBP
or DBP may not be valid in younger (<40 years) or older (>65 years) subjects.
Another limitation is that we included only men. In previous studies that
included both normotensive and hypertensive subjects of the IPC Center cohort,
the predominant roles of SBP and pulse pressure were observed in men, but
not in women.22-23 Due to the
lower CVD mortality rates in women, especially CHD mortality rates, the lack
of statistical power prevented us from carrying out the same analyses in women.
It is also important to note that single-visit BP measurements could
overestimate the percentage of uncontrolled treated subjects. However, this
study clearly shows that under these circumstances, similar to those faced
by physicians in the follow-up of their treated hypertensive patients, an
SBP value over 140 mm Hg is strongly associated with high CVD mortality in
treated men.
The lack of predictive value of DBP may be because patients with high
DBP levels were subsequently more likely to receive more aggressive treatment
than those with high SBP. This was especially true in the 1980s when isolated
systolic hypertension was not uniformly treated. Although this hypothesis
could partially explain the observed lack of predictive value of DBP, all
recent studies show that the high DBP values were not normalized in a majority
of treated hypertensive subjects.6-8
Therefore, it cannot be assumed that subjects with high DBP levels were subsequently
normalized and that this was the reason for the lack of association between
DBP levels and CVD and CHD mortality.
In conclusion, in treated hypertensive men, SBP is a good predictor
of CVD and CHD risk. Diastolic BP, which remains the main criterion used by
most physicians in determining drug efficacy, appears to be of little value
in determining CVD risk. Our results show that in clinical practice, a well-controlled
SBP (<140 mm Hg) should be the goal of antihypertensive treatment.
AUTHOR INFORMATION
Accepted for publication July 17, 2001.
This study was supported by grants from Bristol-Myers Squibb Laboratories
and INSERM, Paris, France. We thank the Caisse Nationale d'Assurance Maladie
for supporting this study.
Corresponding author and reprints: Athanase Benetos, MD, PhD, Centre
d'Investigations Préventives et Cliniques, 6/14 rue de la Pérouse,
75116 Paris, France (e-mail: benetos{at}ipc.asso.fr).
From the Centre d'Investigations Préventives et Cliniques (Drs
Benetos, Thomas, and Guize and Ms Bean) and Institut de la Santé et
de la Recherche Médicale U337 (Drs Benetos and Gautier), Paris, France;
and Department of Medicine, State University of New York, Upstate Medical
University, New York, NY (Dr Smulyan).
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