The 2017 American College of Cardiology and American Heart Association hypertension guidelines define normal blood pressure as a systolic reading of less than 120 mm Hg and a diastolic reading of less than 80 mm Hg.1 Higher levels of systolic and diastolic blood pressure have been associated with increased risk for cardiovascular disease (CVD).2–8 Some evidence suggests that systolic blood pressure may be a stronger predictor of risk than diastolic blood pressure.9–13
Rapsomaniki et al. assembled a cohort of 1.25 million individuals from electronic heath records to evaluate the effect of blood pressure with specific cardiovascular events.14 In this analysis, the lowest risk for CVD occurred when the systolic pressure was between 90 and 114 mm Hg and diastolic pressure was between 60 and 74 mm Hg. High systolic pressure was associated with a greater risk of angina, myocardial infarction, and peripheral artery disease compared to high diastolic pressure. But high diastolic pressure was associated with a higher risk of abdominal aortic aneurysm. People with blood pressures of 140/90 mm Hg or higher had a lifetime risk of cardiovascular disease of 63.3% (95% confidence interval [CI] [62.9 – 63.9]) compared with 46.1% (95% CI [45.5 – 46.8]) in people with normal blood pressure.
Even relatively young adults under the age of 40 with blood pressure levels above normal were found to be at greater risk of CVD events later in life.15 Yano et al. studied 4,851 adults in a prospective study starting in 1985. CVD events (coronary heart disease, heart failure, stroke, transient ischemic attacks, peripheral artery disease) were monitored over a median of 18.8 years. The incidence rate of CVD events for people with normal blood pressure at baseline was 1.37 (95% CI 1.07 – 1.75) compared to 2.74 (95% CI 1.78 – 4.20), 3.15 (95% CI 2.47 – 4.012) and 8.04 (95% CI 6.45 – 10.03) per 1,000 person-years in those with elevated blood pressure (systolic blood pressure 120-129 mm Hg and diastolic blood pressure <80 mm Hg), stage 1, (systolic blood pressure 130-139 mm Hg or diastolic blood pressure 80-89 mm Hg) and stage 2 hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg), respectively.
References
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018
- GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural , environmental and occupational , and metabolic risks or clusters of risks for 195 countries and territories, 1990 – 2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392 : 1923-1994.
- Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360 (9349): 1903-1913.
- Mosley WJ 2nd, Greenland P, Garside DB, Lloyd-Jones DM. Predictive utility of pulse pressure and other blood pressure measures for cardiovascular outcomes. Hypertension 2007; 49 (6): 1256-1264.
- Rutan GH, Kuller LH, Neaton JD, Wentworth DN, McDonald RH, Smith WM. Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial. Circulation 1988; 77 (3): 504-514.
- Sesso HD, Stampfer MJ, Rosner B, et al. Systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure as predictors of cardiovascular disease risk in Men. Hypertension 2000; 36 (5): 801-807.
- Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. Arch Intern Med 1993; 153 (5): 598-615.
- Tajeu GS, Booth JN 3rd, Colantonio LD, et al. Incident cardiovascular disease among adults with blood pressure <140/90 mm Hg. Circulation 2017; 136 (9): 798-812.
- Benetos A, Thomas F, Bean K, Gautier S, Smulyan H, Guize L. Prognostic value of systolic and diastolic blood pressure in treated hypertensive men. Arch Intern Med 2002; 162 (5): 577-581.
- Benetos A, Zureik M, Morcet J, et al. A decrease in diastolic blood pressure combined with an increase in systolic blood pressure is associated with a higher cardiovascular mortality in men. J Am Coll Cardiol 2000; 35 (3): 673-680.
- Benetos A, Thomas F, Safar ME, Bean KE, Guize L. Should diastolic and systolic blood pressure be considered for cardiovascular risk evaluation: a study in middle-aged men and women. J Am Coll Cardiol 2001; 37 (1): 163-168.
- Lindenstrom E, Boysen G, Nyboe J. Influence of systolic and diastolic blood pressure on stroke risk: a prospective observational study. Am J Epidem 1995; 142 (12): 1279-1290.
- Franklin SS, Gokhale SS, Chow VH, et al. Does low diastolic blood pressure contribute to the risk of recurrent hypertensive cardiovascular disease events? The Framingham Heart Study. Hypertension 2015; 65 (2): 299-305.
- Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet 2014; 383: 1899-1911.
- Yano Y, Reis JP, Colangelo LA, et al. Association of blood pressure classification in young adults using the 2017 American College of Cardiology/American Heart Association blood pressure guideline with cardiovascular events later in life. JAMA 2018; 320 (17): 1774-1782.
