P5727All-cause mortality and cardiovascular death according to blood pressure thresholds recommended by ACC/AHA
Authors: Joseph G , Marott J L , Sogaard P , Biering-Sorensen T , Johansen M B , Nielsen G , Jensen G B , Mogelvang R 
Published: October 2019

Abstract

Background
The cut-off values for defining hypertension remains a matter of debate. Recently published guidelines from American College of Cardiology (ACC) /American Heart Association (AHA) defines hypertension at blood pressure (BP) of ≥130/80 in contrast to guidelines from European Society of Cardiology (ESC) defining hypertension as BP≥140/90. Adopting the ACC/AHA recommendation will lead to higher prevalence of hypertension in the general population and probably unnecessary medical treatment of persons at a low cardiovascular risk.

Aim
We aimed to explore whether the new definition of hypertension as defined from the ACC/AHA guidelines is associated with higher risk of mortality and cardiovascular death in the general population compared to their definition of normal BP.

Methods
A random sample of 20,000 Caucasian men and women aged 20–98 years were examined in a prospective cardiovascular population study. The population sample went through four examinations in 1976–78, 1981–83, 1991–94, and 2001–03. We defined the blood pressure levels according to the ACC/AHA guidelines: normal <130/80mmHg; Stage 1 hypertension: 130–139/80–89 mmHg; Stage II hypertension: ≥140/90 mmHg. The population was followed until April 2018 or until death. Cox regression with time varying covariates was performed. The analysis was adjusted for following confounders: age, sex, body mass index, level of daily physical activity, previous cardiovascular disease, diabetes, educational status, smoking status, cardiac medication, cholesterol, and calendar time. Univariable and multivariable analyses were performed. Primary outcome was all-cause mortality. Secondary outcome was cardiovascular death defined as death from acute myocardial infarction, stroke, or heart failure.

Results
All outcomes were assessed according to the ACC/AHA BP thresholds. Primary outcome: Considering normal BP (<130/80 mmHg) as reference, we did not find higher mortality in stage 1 hypertension (130–139/80–89 mmHg) in the multivariable analyses [HR 0.98 (95% CI: 0.93–1.05), p=0.67]. In stage 2 hypertension (≥140/90 mmHg), the mortality was significantly higher [HR 1.13 (95% 1.07–1.20), p<0.001]. We found the same pattern for the secondary outcome: The risk of cardiovascular death in stage 1 hypertension (130–139/80–89 mmHg) did not differ significantly from normal BP (<130/80 mmHg) [HR 1.08 (95% CI: 0.95–1.22), p=0.25]. In stage 2 hypertension (≥140/90 mmHg), cardiovascular death was significantly higher [HR 1.50 (95% CI 1.35–1.66), p<0.001].
Mortality in BP thresholds by ACC/AHA

Conclusion
Hypertension as defined by the ACC/AHA guidelines is not associated with higher all-cause mortality or cardiovascular death in the general population. Applying ACC/AHA guidelines might lead to unnecessary medical treatment of a low-risk population. In contrast, the ESC-definition of hypertension refers to a high-risk population in terms of all-cause mortality and cardiovascular death.

Acknowledgement/Funding
Danish Heart Foundation