Blood Pressure Guidelines Research Articles

Blood pressure and 10-year all-cause mortality: Findings from the PERU MIGRANT Study

Background The long-term impact of elevated blood pressure on mortality outcomes has been recently revisited due to proposed changes in cut-offs for hypertension. This study aimed at assessing the association between high blood pressure levels and 10-year mortality using the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) and the American College of Cardiology and the American Heart Association (ACC/AHA) 2017 blood pressure guidelines. Methods Data analysis of the PERU MIGRANT Study, a prospective ongoing cohort, was used. The outcome of interest was 10-year all-cause mortality, and exposures were blood pressure categories according to the JNC-7 and ACC/AHA 2017 guidelines. Log-rank test, Kaplan-Meier and Cox regression models were used to assess the associations of interest controlling for confounders. Hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated. Results A total of 976 records, mean age of 60.4 (SD: 11.4), 513 (52.6%) women, were analyzed. Hypertension prevalence at baseline almost doubled from 16.0% (95% CI 13.7%–18.4%) to 31.3% (95% CI 28.4%–34.3%), using the JNC-7 and ACC/AHA 2017 definitions, respectively. Sixty three (6.4%) participants died during the 10-year follow-up, equating to a mortality rate of 3.6 (95% CI 2.4–4.7) per 1000 person-years. Using JNC-7, and compared to those with normal blood pressure, those with pre-hypertension and hypertension had 2.1-fold and 5.1-fold increased risk of death, respectively. Similar mortality effect sizes were estimated using ACC/AHA 2017 for stage-1 and stage-2 hypertension. Conclusions Blood pressure levels under two different definitions increased the risk of 10-year all-cause mortality. Hypertension prevalence doubled using ACC/AHA 2017 compared to JNC-7. The choice of blood pressure cut-offs to classify hypertension categories need to be balanced against the patients benefit and the capacities of the health system to adequately handle a large proportion of new patients.

The total and direct effects of systolic and diastolic blood pressure on cardiovascular disease and longevity using Mendelian randomisation

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guidelines lowered the hypertension threshold to ≥ 130/80 mmHg, but the role of diastolic BP remains contested. This two-sample mendelian randomisation study used replicated genetic variants predicting systolic and diastolic BP applied to the UK Biobank and large genetic consortia, including of cardiovascular diseases and parental lifespan, to obtain total and direct effects. Systolic and diastolic BP had positive total effects on CVD (odds ratio (OR) per standard deviation 2.15, 95% confidence interval (CI) 1.95, 2.37 and OR 1.91, 95% CI 1.73, 2.11, respectively). Direct effects were similar for systolic BP (OR 1.83, 95% CI 1.48, 2.25) but completely attenuated for diastolic BP (1.18, 95% CI 0.97, 1.44), although diastolic BP was associated with coronary artery disease (OR 1.24, 95% CI 1.03, 1.50). Systolic and diastolic BP had similarly negative total (− 0.20 parental attained age z-score, 95% CI − 0.22, − 0.17 and − 0.17, 95% CI − 0.20, − 0.15, respectively) and direct negative effects on longevity. Our findings suggest systolic BP has larger direct effects than diastolic BP on CVD, but both have negative effects (total and direct) on longevity, supporting the 2017 ACC/AHA guidelines lowering both BP targets.

Suboptimal control of cardiovascular risk factors in myocardial infarction survivors in a cardiac rehabilitation program

Introduction and objectivesAs short-term mortality continues to decrease after myocardial infarction (MI), secondary prevention strategies attain increasing relevance. This study aimed at assessing the control of cardiovascular (CV) risk factors, including dyslipidemia, hypertension and diabetes, in a contemporary cohort of MI survivors who completed an exercise-based cardiac rehabilitation (EBCR) program. MethodsObservational, retrospective cohort study including patients admitted to a tertiary center with acute MI between November 2012 and April 2017, who completed a phase II EBCR program after discharge. Achievement of low-density lipoprotein (LD) cholesterol, blood pressure and HbA1c guideline recommended targets was assessed. Lipid profile parameters were assessed and compared at three time points (hospitalization, beginning and end of the program). ResultsA total of 379 patients were included. Mean age was 58.8±10.6 years; 81% were male. Considering the European Society of Cardiology's guidelines on contemporary data collection, 61%, 87% and 71% achieved the recommended LDL cholesterol, blood pressure and HbA1c targets, respectively, at the end of the program. Combining all three risk factors, 42% achieved the recommended targets. High-sensitivity C-reactive protein decreased between the beginning and the end of the program [0.14 (0.08-0.29) mg/L to 0.12 (0.06-0.26) mg/L; p<0.001]. ConclusionDespite contemporary management strategies, including enrollment in a structured EBCR program, a substantial number of patients presented suboptimal control of CV risk factors. Considering the dyslipidemia, hypertension and diabetes results, less than half of the enrolled individuals achieved the recommended targets. These findings highlight a pivotal unmet need which could be particularly relevant in improving CV outcomes by enhancing secondary prevention profiles.

Different hypertension thresholds and cognitive decline: a pooled analysis of three ageing cohorts

BackgroundThe 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for high blood pressure (BP) in adults came up with a new definition of hypertension with a threshold BP level of 130/80 mmHg. But the 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines adhered to a conventional hypertension definition as BP ≥ 140/90 mmHg. We aimed to compare the trajectories of cognitive decline between participants with BP < 130/80 mmHg in all BP measurement waves and others with all BP < 140/90 mmHg.MethodsThis pooled analysis involved middle-aged and older participants from three nationally representative ageing cohorts, including the Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA), and the China Health Retirement Longitudinal Study (CHARLS). Participants were divided into the Normal (BP < 130/80 mmHg on all occasions throughout the study), the Borderline (BP < 140/90 mmHg on all occasions throughout the study but not in the Normal group), and the High (the rest of participants) BP groups. Global cognitive Z score was calculated from tests on memory, executive function, and orientation.ResultsA total of 17,590 participants (HRS 6964, median follow-ups 12 years; ELSA 5334, median follow-ups 16 years; CHARLS 5292, median follow-ups 7 years) were included. No significant difference in global cognitive decline rate was detected between the Normal and the borderline groups (men, pooled β = − 0.006 standard deviation [SD]/year; 95% confidence interval [CI], − 0.020 to 0.008; P = 0.377; women, pooled β = 0.006 SD/year; 95% CI − 0.005 to 0.018; P = 0.269). Participants in the High group had a significantly faster cognitive decline (men, pooled β = − 0.011 SD/year; 95% CI − 0.020 to − 0.002; P = 0.013; women, pooled β = − 0.017 SD/year; 95% CI − 0.026 to − 0.008; P < 0.001) than that in the Borderline group.ConclusionsIndividuals in the Borderline group did not experience significantly faster cognitive decline compared with those in the Normal group. It might not be necessary for individuals with borderline BP (between 130/80 and 140/90 mmHg) to initiate antihypertension therapy in consideration of cognitive decline.

The Importance of Cardiorespiratory vs. Muscular Fitness in Reducing the Odds of Hypertension in War Veterans: A Population-Based Study.

Purpose: The purpose of the study was to examine separate and combined associations between cardiorespiratory fitness (CRF) and musculoskeletal fitness (MF) with hypertension. Methods: In this cross-sectional study, participants were 764 men and women aged 45–75 years, who were part of the Homeland War between 1990 to 1995 (33.5% women). CRF included the 2-min step test, while MF was consisted of push-ups in 30 s, chair-stands in 30 s and sit-ups in 30 s. The prevalence of hypertension was defined according to new American College of Cardiology and American Hearts Association Blood Pressure Guidelines for systolic and diastolic blood pressure of ≥130 mmHg and/or ≥80 mmHg. Results: In models adjusted for sex, age, fatness and fasting blood glucose, we found a graded inverse association between CRF and MF with hypertension. Less cardiorespiratory and muscular fit individuals were more likely to have hypertension. When CRF and MF were combined, individuals with high MF and low CRF, low MF and high CRF and low MF and CRF were 1.77, 2.15 and 7.09 more likely to have of hypertension. Conclusion: Both CRF and MF are associated with the prevalence of hypertension, while the magnitude of the associations between MF and hypertension was more pronounced.

Health Screening and Updated Blood Pressure Guidelines and Their Application for the Certified Personal Trainer

ABSTRACT Certified National Strength and Conditioning Association personal trainers are “health/fitness professionals who, using an individualized approach, assess, motivate, educate, and train clients regarding their health and fitness needs. They design safe and effective exercise programs, provide the guidance to help clients achieve their personal health/fitness goals, and respond appropriately in emergency situations. Recognizing their area of expertise, personal trainers refer clients to other health care professionals when appropriate.” The design of safe and effective exercise programs includes the need to stay current with published research and changes to relevant exercise guidelines. The purpose of this article is to provide a brief overview of recent changes to the exercise preparticipation health screen, application of the physical activity readiness questionnaire for everyone (PAR-Q+), updated blood pressure guidelines, and recommendations for program design given these changes.

Risk of atrial fibrillation in young adults aged 20 to 39 years with isolated diastolic, isolated systolic, and systolic-diastolic hypertension: a nationwide population-based study

Abstract Background There is limited evidence regarding the comparative risks of incident atrial fibrillation (AF) associated with stage 1 isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH), especially amongst young adults aged 20–39 years. Purpose To evaluate the association between early-stage of hypertension and AF in young adults aged 20–39 years. Methods From the Korean nationwide health screening database, 2,958,544 subjects aged 20–39 years who were not prescribed antihypertensive medication at the index examination in 2009 were included. Subjects were categorized into eight groups according to the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines: normal BP, elevated BP, stage 1 IDH, stage 1 ISH, stage 1 SDH, stage 2 IDH, stage 2 ISH, and stage 2 SDH. The primary outcome was new-onset AF during follow-up. Results During a median follow-up of 8.3 years, 7,347 subjects had incident AF (incidence rate, 0.3 per 1,000 person-years). Compared to the normal BP group, stage 1 IDH (adjusted hazard ratio [aHR], 1.160; 95% confidence interval [CI], 1.086–1.240) and stage 1 SDH (1.250; 1.165–1.341) were associated with higher risks of incident AF, but not stage 1 ISH. Stage 2 IDH, ISH, and SDH were associated with higher risks of incident AF by 24%, 37%, and 61%, respectively (Figure). Conclusion Among young adults, stage 1 IDH and SDH were associated with higher risks of incident AF compared to normal BP. The risk of incident AF with stage 2 IDH was similar to that of stage 1 SDH. Optimal BP control including diastolic BP is crucial for preventing new-onset AF, even amongst young adults. Funding Acknowledgement Type of funding sources: None.

Association between blood pressure classification using the 2017 American College of Cardiology/American Heart Association blood pressure guideline and hypertensive retinopathy

Abstract Purpose We aimed to explore the association of blood pressure (BP) classification using the 2017 American College of Cardiology/ American Heart Association Guideline and the prevalence of hypertensive retinopathy using a nationwide epidemiological database. Methods This study is a retrospective observational cross-sectional analysis using the health claims database of the JMDC between 2005 and 2020. We analyzed 280,599 participants who did not take anti-hypertensive medications. Each participant was categorized as having normal BP (systolic BP [SBP] &amp;lt;120 mm Hg and diastolic BP [DBP] &amp;lt;80 mm Hg; n=159,524); elevated BP (SBP 120–129 mm Hg and DBP &amp;lt;80 mm Hg; n=35,603); stage 1 hypertension (SBP 130–139 mm Hg or DBP 80–89 mm Hg; n=54,795); or stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg; n=30,677). Retinal photography at health check-up was classified as normal, grade 1, grade 2, grade 3, or grade 4 according to the Keith-Wagener-Barker system. Results Median (interquartile range) age was 46 (40–53) years, and 50.4% were men. Hypertensive retinopathy which was defined as ≥ Keith-Wagener-Barker system grade 1, was observed in 16,836 participants (6.0%). Multivariable logistic regression analysis showed that, compared with normal BP, elevated BP (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.23–1.38), stage 1 hypertension (OR 1.71, 95% CI 1.64–1.79), and stage 2 hypertension (OR 4.10, 95% CI 3.93–4.28) were associated with higher prevalence of hypertensive retinopathy. Even among 92,121 participants without obesity, high waist circumference, diabetes mellitus, dyslipidemia, cigarette smoking, and alcohol drinking, multivariable logistic regression analysis showed that, compared with normal BP, elevated BP (odds ratio 1.34, 95% CI 1.19–1.51), stage 1 hypertension (OR 1.79, 95% CI 1.61–1.98), and stage 2 hypertension (OR 4.42, 95% CI 4.00–4.92) were associated with higher prevalence of hypertensive retinopathy. The association between BP category and hypertensive retinopathy was observed in all subgroups stratified by age or sex. Conclusion Our investigation showed that the prevalence of hypertensive retinopathy increased with the blood pressure category, suggesting that atherosclerotic change could start even in elevated BP and stage 1 hypertension. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

Risk of Atrial Fibrillation in Young Adults With Isolated Diastolic, Isolated Systolic, and Systolic-Diastolic Hypertension.

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Alcohol Consumption and Systemic Hypertension (from the Third National Health and Nutrition Examination Survey)

Epidemiological studies have established the association between excessive alcohol consumption and systemic hypertension (SH). However, there are conflicting reports of the association of low to moderate alcohol consumption with SH. The objective of the study was to examine the associations of alcohol consumption and blood pressure categories using the 2017 American College of Cardiology/American Heart Association high blood pressure guidelines. This analysis included 17,059 participants from the Third National Health and Nutrition Examination Survey. Alcohol consumption was ascertained by way of a questionnaire. Blood pressure (mm Hg) was measured during the in-home interview and the participant's visit to the mobile examination center. We used multivariable logistic regression models to examine cross-sectional associations of alcohol consumption and blood pressure categories based on new American College of Cardiology/American Heart Association High Blood Pressure guidelines. Models were adjusted for age, gender, income, and cardiovascular risk factors. Compared with never drinkers, moderate drinkers (7 to 13 drinks/week) had increased odds of prevalent stage 1 and stage 2 SH (odds ratio [95% confidence interval] 1.51 [1.22 to 1.87] and 1.55 [1.20 to 2.00]). Similarly, there were significantly higher odds of prevalent stage 1 and stage 2 SH among heavy drinkers (≥14 drinks/week) (odds ratio [95% confidence interval] 1.65 [1.33 to 2.05] and 2.46 [1.93 to 3.14]). We did not find any association between alcohol consumption and elevated blood pressure category. Response bias must be considered because alcohol consumption was self-reported. Our study indicates the need for further research to understand the potential mechanisms by which alcohol consumption increases the risk of SH. In conclusion, this analysis from a population-based survey showed an association between moderate and heavy alcohol consumption and a higher prevalence of SH.

Cardiac Rehabilitation and Resting Blood Pressure: MONTANA OUTCOMES PROJECT CARDIAC REHABILITATION REGISTRY FINDINGS.

Exercise-based cardiac rehabilitation (CR) is essential for treating cardiovascular disease, and modifying risk factor modification, including hypertension. Because the causes of hypertension and benefits of CR are faceted, we examined the influence of phase II CR on resting blood pressure (BP). Outcomes straddle the release of the updated BP guidelines, and study emphases included CR session number, sex, race/ethnicity, insurance provider, and referring diagnosis. Patient files of 31 885 individuals uploaded to the Montana Outcomes Project registry indicated that lowered systolic and diastolic BP were further improved after the release of the revised BP guidelines. The CR session number was proportional to improvements in diastolic BP. Blood pressure improved independent of sex, although female patients exhibited lower diastolic BP before and after CR. Race/ethnicity analyses indicated that Asian and White patients experienced drops in systolic and diastolic BP, while diastolic BP was improved in Hispanic patients. Neither American Indian nor Black patients exhibited statistically altered BP. Medicare, Veterans Administration, and privately insured patients had lowered systolic and diastolic BP, while Medicaid patients had lower diastolic BP, and the uninsured had lower systolic BP. Blood pressure outcomes were generally improved independent of the primary referring diagnosis, while those with peripheral artery disease showed no improvements. Findings demonstrate that phase II CR is highly effective in the control of BP, although improvements are not equally distributed to all individuals according to differences in sex, race/ethnicity, and access to insurance-funded health care.

Predicted cardiovascular risk for United States adults with diabetes, chronic kidney disease, and at least 65 years of age.

The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends using 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk to guide decisions to initiate antihypertensive medication. We included adults aged 40-79 years from the National Health and Nutrition Examination Survey 2013-2018 (n = 8803). We computed 10-year predicted ASCVD risk using the Pooled Cohort risk equations. Clinical CVD was self-reported. Analyses were conducted overall and among those with stage 1 hypertension, defined by a mean SBP of 130-139 mmHg or DBP of 80-89 mmHg. In subgroups defined by diabetes, chronic kidney disease (CKD), and age at least 65 years, we estimated the proportion of United States adults with high ASCVD risk (i.e. 10-year predicted ASCVD risk ≥10% or clinical CVD) and estimated age-adjusted probability of having high ASCVD risk. Among United States adults, an estimated 72.3, 64.5, and 83.9 of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. Among United States adults with stage 1 hypertension, an estimated 55, 36.7, and 72.6% of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. The probability of having high ASCVD risk increased with age and exceeded 50% for United States adults with diabetes and CKD at ages 52 and 57 years, respectively. For those with stage 1 hypertension, these ages were 55 and 64 years, respectively. Most United States adults with diabetes, CKD, or age at least 65 years had high ASCVD risk. However, many with stage 1 hypertension did not.

Relationship Between Body Composition, Cardiorespiratory Fitness, And Blood Pressure Following Clinical Practice Guidelines In Children

PURPOSE: To examine the association between selected body composition, cardiorespiratory fitness, and blood pressure categories using the 2017 AAP and Fourth Report clinical practice guidelines in children. METHODS: Descriptive cross-sectional study of 1754 (boys = 630; 35.9% and girls = 1124; 64.1%) aged between 9 and 18 years in Ado-Ekiti, Southwest Nigeria participated in the study. Anthropometry, physiological, and aerobic capacity parameters were determined using the standard protocols of ISAK, ACSM, and multistage fitness test (20-meter shuttle run), respectively. Regression analyses were performed to examine the association of selected body composition, aerobic capacity, and blood pressure categories. All p-values were set at ≤0.05. RESULTS: Mean triceps skinfold, subscapular skinfold, body fat percentage, upper arm relaxed, hip circumference, systolic and diastolic blood pressure were significantly higher among boys compared to girls (p < 0.001). Furthermore, the number of shuttle runs and predicted VO2max was significantly higher in girls compared to boys (p < 0.001). Based on the AAP guidelines for systolic blood pressure, the results showed that being a male child and hypotensive is associated with a higher significant reduction in subscapular skinfold (OR = 0.708; CI = 0.526, 0.952; p = 0.022), upper arm relaxed (OR = 0.802; CI = 0.730, 0.882; P < 0.000), and VO2max (OR = 0.737; CI = 0.609, 0.892; p = 0.002) as compared to female gender (where gender is coded as one for male and two for female). Elevated wise, the results showed that being a male is associated with a higher significant increase in upper arm relaxed (OR = 1.156; CI = 1.048, 1.274; P = 0.004) and VO2max (OR = 1.644; CI = 1.334, 2.025; p < 0.000) while boys in the hypertension category have a higher likelihood of having a higher value for upper arm relaxed (OR = 1.183; CI = 1.069, 1.310; p = 0.001) as compared to girls. The same trend of association in AAP guidelines was observed in the Fourth Report protocol. CONCLUSIONS: There was a significant association between selected body composition, aerobic capacity, and blood pressure categories. The findings suggest that blood pressure categories could be influenced by body composition and aerobic capacity. The findings highlight the necessity to scale up obesity prevention in children and adolescents.

Prevalence of Hypertension Among Pregnant Women When Using the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines and Association With Maternal and Fetal Outcomes

(Abstracted from JAMA Netw Open 2021;4:e213808) Until 2017, the American College of Cardiology (ACC), American Heart Association (AHA), and American College of Obstetricians and Gynecologists (ACOG) had a common threshold for diagnosing hypertension: a blood pressure of 140/90 mm Hg or higher. That year, based on the outcomes of randomized trials on nonpregnant adults, the ACC-AHA lowered its recommended threshold to 130/80 mm Hg or higher.

Obesity-Related Hypertension in Pediatrics, the Impact of American Academy of Pediatrics Guidelines

The prevalence of primary hypertension in pediatric patients is increasing, especially as a result of the increased prevalence of obesity in children. New diagnostic guidelines for blood pressure were published by the American Academy of Pediatrics (AAP) in 2017 to better define classes of hypertension in children. The aim of our study is to evaluate the impact of new guidelines on diagnosis of hypertension in pediatrics and their capacity to identify the presence of cardiovascular and metabolic risk. Methods: Retrospective clinical and laboratory data from 489 overweight and obese children and adolescents were reviewed. Children were classified according to the 2004 and 2017 AAP guidelines for systolic and diastolic blood pressure. Lipid profile and glucose metabolism data were recorded; triglyceride/HDL ratio (TG/HDL) was calculated as an index of endothelial dysfunction. Hepatic steatosis was detected using the ultrasonographic steatosis score. Results: Children with elevated blood pressure increased from 12.5% with the 2004 AAP to 23.1% with the 2017 AAP criteria (p < 0.001). There was a statistically significant increase in children with high blood pressure in all age groups according to the new cut-off values. Notably, the diagnosis of hypertension according to 2017 AAP criteria had a greater positive association with Hepatic Steatosis (rho 0.2, p < 0.001) and TG/HDL ratio (rho 0.125, p = 0.025). Conclusions: The 2017 AAP tables offer the opportunity to better identify overweight and obese children at risk for organ damage, allowing an earlier and more impactful prevention strategy to be designed.

Lifestyle Behaviors Among Adults Recommended for Ambulatory Blood Pressure Monitoring According to the 2017 ACC/AHA Blood Pressure Guideline.

The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends ambulatory BP monitoring to exclude white coat hypertension (WCH) among adults with office systolic BP (SBP)/diastolic BP (DBP) of 130-159/80-99 mm Hg, and masked hypertension (MHT) among adults with office SBP/DBP of 120-129/75-79 mm Hg after a 3-month trial of lifestyle modification. We estimated the proportion of individuals with ideal lifestyle factors among those who meet these office BP criteria. We analyzed data from participants not taking antihypertensive medication in the Coronary Artery Risk Development in Young Adults (CARDIA) and Jackson Heart Study (JHS) who met the office BP criteria for screening for WCH (CARDIA n = 490, JHS n = 873) and MHT (CARDIA n = 486, JHS n = 614). We estimated the prevalence of lifestyle factors including ideal body mass index (BMI), physical activity, diet, and alcohol use among participants who met office BP criteria for WCH or MHT screening. Among participants who met office BP criteria for WCH screening, 15.5% in CARDIA and 3.6% in JHS had 3 or more ideal lifestyle factors. Among participants who met office BP criteria for MHT screening, 22.6% in CARDIA and 4.7% in JHS had 3 or more ideal lifestyle factors. Ideal BMI, diet, and physical activity were present in less than half of participants in each sample. Few participants who met office BP criteria for the screening of WCH or MHT had ideal lifestyle factors.

Improving Blood Pressure Accuracy in the Outpatient Adolescent Setting

Hypertension (HTN) is increasing in the pediatric population, and hypertensive children become hypertensive adults. Blood pressure (BP) is often overlooked due to factors including distrust in readings, lack of time in visits, and discomfort prescribing antihypertensive medications. The objective of our multistage, clinically based quality improvement project was to improve BP measurement and HTN diagnosis and intervention in adolescents. Study investigators performed interventions in an adolescent medicine clinic at Children's Hospital Colorado (ages 12-24 years), which included equipment inventory, mapping clinic processes, manual/automated BP training for staff, education of faculty/staff on guidelines, and creation/implementation of updated best practice alerts (BPAs) based on age-appropriate guidelines for stage 1, 2 HTN in patients younger/older 18years. With equipment updates, medical assistant manual BP certifications, educational sessions for faculty/staff, and creation of a BPA with instruction before the go-live date, confidence in using automated and manual BP measurements increased for faculty/staff. The number of unique patient visits presenting with elevated BPs decreased significantly in the postintervention period reflecting the education/training. Staff used the new order set minimally, but there was an increase in correct diagnoses of elevated BP and laboratory workup. Having appropriate equipment while introducing BP guideline education in the ambulatory setting with electronic health record reminders and utility of BPAs can decrease erroneous BP values saving providers and staff encounter time. Real-time alerts can aid in accurate diagnosis rates and improved intervention for youth with elevated BP readings. Providers still inconsistently interact with order sets despite such parameters.

Mean Arterial Pressure and Chronic Kidney Disease Progression in the CKiD Cohort.

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Association of Blood Pressure Classification Using the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline With Risk of Heart Failure and Atrial Fibrillation.

Heart failure (HF) and atrial fibrillation (AF) are growing in prevalence worldwide. Few studies have assessed to what extent stage 1 hypertension in the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines is associated with incident HF and AF. Analyses were conducted with a nationwide health claims database collected in the JMDC Claims Database between 2005 and 2018 (n=2 196 437; mean age, 44.0±10.9 years; 58.4% men). No participants were taking antihypertensive medication or had a known history of cardiovascular disease. Each participant was categorized as having normal BP (systolic BP <120 mm Hg and diastolic BP <80 mm Hg; n=1 155 885), elevated BP (systolic BP 120-129 mm Hg and diastolic BP <80 mm Hg; n=337 390), stage 1 hypertension (systolic BP 130-139 mm Hg or diastolic BP 80-89 mm Hg; n=459 820), or stage 2 hypertension (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg; n=243 342). Using Cox proportional hazards models, we identified associations between BP groups and HF/AF events. We also calculated the population attributable fractions to estimate the proportion of HF and AF events that would be preventable if participants with stage 1 and stage 2 hypertension were to have normal BP. Over a mean follow-up of 1112±854 days, 28 056 incident HF and 7774 incident AF events occurred. After multivariable adjustment, hazard ratios for HF and AF events were 1.10 (95% CI, 1.05-1.15) and 1.07 (95% CI, 0.99-1.17), respectively, for elevated BP; 1.30 (95% CI, 1.26-1.35) and 1.21 (95% CI, 1.13-1.29), respectively, for stage 1 hypertension; and 2.05 (95% CI, 1.97-2.13) and 1.52 (95% CI, 1.41-1.64), respectively, for stage 2 hypertension versus normal BP. Population attributable fractions for HF associated with stage 1 and stage 2 hypertension were 23.2% (95% CI, 20.3%-26.0%) and 51.2% (95% CI, 49.2%-53.1%), respectively. The population attributable fractions for AF associated with stage 1 and stage 2 hypertension were 17.4% (95% CI, 11.5%-22.9%) and 34.3% (95% CI, 29.1%-39.2%), respectively. Both stage 1 hypertension and stage 2 hypertension were associated with a greater incidence of HF and AF in the general population. The American College of Cardiology/American Heart Association BP classification system may help identify adults at higher risk for HF and AF events.

New findings bearing on the prevention, detection and management of high blood pressure.

Hypertension is the foremost risk factor for cardiovascular disease (CVD) and death. This review highlights recent findings that apply to the prevention, detection, and management of high blood pressure (BP), in the context of the 2017 American College of Cardiology/American Heart Association BP guideline. Several new findings on the association of BP measurement with CVD outcomes are now available. (1) Beginning with a systolic BP (SBP) as low as 90 mm Hg, coronary artery calcium deposition and the risk of incident atherosclerotic CVD (ASCVD) increased in stepwise fashion with increasing SBP levels within the normal range in adults at low risk for ASCVD. (2) Isolated diastolic hypertension was not associated with ASCVD, heart failure, or chronic kidney disease. (3) Nocturnal BP appeared to be better associated with CVD outcomes than office or daytime BP. (4) In a head-to-head comparison, home BP monitoring had higher reliability and predictive value than office or ambulatory BP to detect left ventricular hypertrophy, an intermediate form of hypertension-related target organ damage. In addition, new information indicates that autonomous aldosterone production is present in a substantially larger percentage of adults with hypertension than previously recognized. Finally, intensive BP lowering is associated with a significant reduction in the incidence of mild cognitive impairment, a precursor of dementia. Ongoing research has made significant progress in the prevention, detection, and management of high BP, clarifying, amplifying, and/or supporting the 2017 ACC/AHA BP guideline recommendations.