Can Antihypertensive Treatment Restore the Risk of Cardiovascular Disease to Ideal Levels?: The Coronary Artery Risk Development in Young Adults (CARDIA) Study and the Multi-Ethnic Study of Atherosclerosis (MESA)

Abstract

Background: It is unclear whether antihypertensive treatment can restore cardiovascular disease risk to the risk level of persons with ideal blood pressure (BP) levels.

Methods and results: Data from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Coronary Artery Risk Development in Young Adults (CARDIA) study were analyzed. Outcomes were compared among participants without or with antihypertensive treatment at 3 BP levels: <120/<80 mm Hg, systolic BP 120 to 139 mm Hg or diastolic BP 80 to 89 mm Hg (120 to 129/≤80 mm Hg for participants with diabetes), and systolic BP ≥140 or diastolic BP ≥90 mm Hg (systolic BP ≥130 or diastolic BP ≥80 mm Hg for participants with diabetes). Among MESA participants aged ≥50 years at baseline, those with BP <120/<80 mm Hg on treatment had higher left ventricular mass index, prevalence of estimated glomerular filtration rate <60 mL/min per 1.73 m(2), prevalence of coronary calcium score >100, and twice the incident cardiovascular disease rate over 9.5 years of follow-up than those with BP <120/<80 mm Hg without treatment. In CARDIA at year 25, persons with BP <120/<80 mm Hg with treatment had much longer exposure to higher BP and higher risk of end-organ damage and subclinical atherosclerosis than those with BP <120/<80 mm Hg without treatment. An exploratory analysis suggested that when cumulative systolic BP was high (eg, >3000 mm Hg-years in 25 years), the increase in left ventricular mass index accelerated.

Conclusions: The data suggest that based on the current approach, antihypertensive treatment cannot restore cardiovascular disease risk to ideal levels. Emphasis should be placed on primordial prevention of BP increases to further reduce cardiovascular disease morbidity and mortality.

Keywords: antihypertensive treatment; cardiovascular disease risk; cumulative blood pressure; end‐organ damage.

Figure 1

Age-, race-, and sex-adjusted BP over time by Y25 BP level and antihypertensive treatment status. Mean BP for CARDIA participants at Y25: (A) BP <120/<80 mm Hg. (B) SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg (or SBP 120 to 129 with DBP <80 mm Hg for people with diabetes), (C) BP ≥140/≥90 mm Hg (or BP ≥130/≥80 mm Hg for people with diabetes). The number of participants in each group is given in Table 2. BP indicates blood pressure; CARDIA, Coronary Artery Risk Development in Young Adults; DBP, diastolic blood pressure; SBP, systolic blood pressure; Y25, year 25.

Figure 2

Adjusted relationship by spline regression between LVMI and 25-year cumulative systolic blood pressure in untreated CARDIA participants (n=1990). Spline (solid line) with 95% pointwise confidence band (dotted lines) is adjusted for year 25 age, sex, race, body mass index, smoking status, diabetes, low-density lipoprotein cholesterol, and cholesterol medication. The slopes at the break point of 2885 cumulative mm Hg–years were estimated to be 0.5 g/m^2.7 per 100 mm Hg–years (95% CI 0.2 to 0.8) before 2885 mm Hg–years and after 2885 mm Hg–years is 1.4 g/m^2.7 per 100 mm Hg–years (95% CI 0.7 to 2.1). CARDIA indicates Coronary Artery Risk Development in Young Adults; LVMI, left ventricular mass index.