Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes
IMPORTANCE: Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes. OBJECTIVE: To evaluate the association of BP indexes with death and a composite C...
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| Published in: | JAMA : the journal of the American Medical Association Vol. 322; no. 5; pp. 409 - 420 |
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| Main Authors: | , , , , , , , , , , , , , , , , , , , , , , , , , |
| Format: | Journal Article |
| Language: | English |
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American Medical Association
06-08-2019
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| Abstract | IMPORTANCE: Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes. OBJECTIVE: To evaluate the association of BP indexes with death and a composite CV event. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal population-based cohort study of 11 135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016). EXPOSURES: Blood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings). MAIN OUTCOMES AND MEASURES: Multivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC). RESULTS: Among 11 135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P < .001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP. CONCLUSIONS AND RELEVANCE: In this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small. |
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| AbstractList | ImportanceBlood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes.ObjectiveTo evaluate the association of BP indexes with death and a composite CV event.Design, Setting, and ParticipantsLongitudinal population-based cohort study of 11 135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016).ExposuresBlood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings).Main Outcomes and MeasuresMultivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC).ResultsAmong 11 135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P < .001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP.Conclusions and RelevanceIn this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small. This population-based cohort study uses predictive value of blood pressure indexes and compares the accuracy and incremental values of manual vs automated and daytime vs nighttime blood pressure readings for estimating risk of cardiovascular events and mortality. IMPORTANCE: Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes. OBJECTIVE: To evaluate the association of BP indexes with death and a composite CV event. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal population-based cohort study of 11 135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016). EXPOSURES: Blood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings). MAIN OUTCOMES AND MEASURES: Multivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC). RESULTS: Among 11 135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P < .001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP. CONCLUSIONS AND RELEVANCE: In this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small. ImportanceBlood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes. ObjectiveTo evaluate the association of BP indexes with death and a composite CV event. Design, Setting, and ParticipantsLongitudinal population-based cohort study of 11135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016). ExposuresBlood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings). Main Outcomes and MeasuresMultivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC). ResultsAmong 11135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P<.001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP. Conclusions and RelevanceIn this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small. Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes. To evaluate the association of BP indexes with death and a composite CV event. Longitudinal population-based cohort study of 11 135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016). Blood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings). Multivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC). Among 11 135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P < .001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP. In this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small. |
| Author | Stolarz-Skrzypek, Katarzyna Kawecka-Jaszcz, Kalina Yang, Wen-Yi Boggia, José Thijs, Lutgarde Wang, Ji-Guang Malyutina, Sofia Sandoya, Edgardo Melgarejo, Jesus D Jeppesen, Jørgen Casiglia, Edoardo Lind, Lars Filipovský, Jan Li, Yan Narkiewicz, Krzysztof Dolan, Eamon Maestre, Gladys E Ohkubo, Takayoshi Verhamme, Peter Asayama, Kei Imai, Yutaka Staessen, Jan A O’Brien, Eoin Hansen, Tine W Zhang, Zhen-Yu Wei, Fang-Fei |
| AuthorAffiliation | 14 Faculty of Medicine, Charles University, Pilsen, Czech Republic 16 Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China 21 Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands 11 Institute of Internal and Preventive Medicine and Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russian Federation 18 Hypertension Unit, Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland 4 Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay 12 Department of Medicine, University of Padua, Padua, Italy 6 Tohoku Institute for Management of Blood Pressure, Sendai, Japan 13 Section of Geriatrics, Department of Public Health and Caring Sciences, Upp |
| AuthorAffiliation_xml | – name: 4 Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay – name: 13 Section of Geriatrics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden – name: 7 Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan – name: 16 Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China – name: 8 Department of Medicine, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark – name: 19 Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland – name: 17 Asociación Española Primera en Salud, Montevideo, Uruguay – name: 20 Centre for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium – name: 14 Faculty of Medicine, Charles University, Pilsen, Czech Republic – name: 12 Department of Medicine, University of Padua, Padua, Italy – name: 10 The First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland – name: 1 Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium – name: 2 Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China – name: 6 Tohoku Institute for Management of Blood Pressure, Sendai, Japan – name: 5 The Steno Diabetes Center Copenhagen, Gentofte, and Center for Health, Capital Region of Denmark, Copenhagen, Denmark – name: 15 Department of Biomedical Sciences, Division of Neuroscience and Department of Human Genetics, University of Texas Rio Grande Valley School of Medicine, Brownsville – name: 11 Institute of Internal and Preventive Medicine and Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russian Federation – name: 18 Hypertension Unit, Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland – name: 9 Cambridge University Hospitals, Addenbrook’s Hospital, Cambridge, United Kingdom – name: 3 Laboratorio de Neurociencias and Instituto Cardiovascular, Universidad del Zulia, Maracaibo, Venezuela – name: 21 Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands |
| Author_xml | – sequence: 1 givenname: Wen-Yi surname: Yang fullname: Yang, Wen-Yi – sequence: 2 givenname: Jesus D surname: Melgarejo fullname: Melgarejo, Jesus D – sequence: 3 givenname: Lutgarde surname: Thijs fullname: Thijs, Lutgarde – sequence: 4 givenname: Zhen-Yu surname: Zhang fullname: Zhang, Zhen-Yu – sequence: 5 givenname: José surname: Boggia fullname: Boggia, José – sequence: 6 givenname: Fang-Fei surname: Wei fullname: Wei, Fang-Fei – sequence: 7 givenname: Tine W surname: Hansen fullname: Hansen, Tine W – sequence: 8 givenname: Kei surname: Asayama fullname: Asayama, Kei – sequence: 9 givenname: Takayoshi surname: Ohkubo fullname: Ohkubo, Takayoshi – sequence: 10 givenname: Jørgen surname: Jeppesen fullname: Jeppesen, Jørgen – sequence: 11 givenname: Eamon surname: Dolan fullname: Dolan, Eamon – sequence: 12 givenname: Katarzyna surname: Stolarz-Skrzypek fullname: Stolarz-Skrzypek, Katarzyna – sequence: 13 givenname: Sofia surname: Malyutina fullname: Malyutina, Sofia – sequence: 14 givenname: Edoardo surname: Casiglia fullname: Casiglia, Edoardo – sequence: 15 givenname: Lars surname: Lind fullname: Lind, Lars – sequence: 16 givenname: Jan surname: Filipovský fullname: Filipovský, Jan – sequence: 17 givenname: Gladys E surname: Maestre fullname: Maestre, Gladys E – sequence: 18 givenname: Yan surname: Li fullname: Li, Yan – sequence: 19 givenname: Ji-Guang surname: Wang fullname: Wang, Ji-Guang – sequence: 20 givenname: Yutaka surname: Imai fullname: Imai, Yutaka – sequence: 21 givenname: Kalina surname: Kawecka-Jaszcz fullname: Kawecka-Jaszcz, Kalina – sequence: 22 givenname: Edgardo surname: Sandoya fullname: Sandoya, Edgardo – sequence: 23 givenname: Krzysztof surname: Narkiewicz fullname: Narkiewicz, Krzysztof – sequence: 24 givenname: Eoin surname: O’Brien fullname: O’Brien, Eoin – sequence: 25 givenname: Peter surname: Verhamme fullname: Verhamme, Peter – sequence: 26 givenname: Jan A surname: Staessen fullname: Staessen, Jan A |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/31386134$$D View this record in MEDLINE/PubMed https://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-393617$$DView record from Swedish Publication Index |
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| Snippet | IMPORTANCE: Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain... Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index... Importance Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which... ImportanceBlood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which... This population-based cohort study uses predictive value of blood pressure indexes and compares the accuracy and incremental values of manual vs automated and... |
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| SubjectTerms | Adult Blood pressure Blood Pressure - physiology Blood Pressure Determination - methods Blood Pressure Monitoring, Ambulatory Cardiovascular diseases Cardiovascular Diseases - epidemiology Cardiovascular Diseases - etiology Circadian Rhythm Death Fatalities Female Health risk assessment Health risks Heart Heart diseases Humans Hypertension - complications Hypertension - diagnosis Hypertension - mortality Longitude Longitudinal Studies Male Middle Aged Mortality Night Nighttime Original Investigation Performance indices Population studies Proportional Hazards Models Risk analysis Risk Factors Statistical analysis |
| Title | Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes |
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