Cardiovascular Disease and Mortality in Adults Aged ≥60 Years According to Recommendations by the American College of Cardiology/American Heart Association and American College of Physicians/American Academy of Family Physicians

Abstract

In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians/American Academy of Family Physicians (ACP/AAFP) published blood pressure guidelines. Adults recommended antihypertensive medication initiation or intensification by the ACP/AAFP guideline receive the same recommendation from the ACC/AHA guideline. However, many adults ≥60 years old are recommended to initiate or intensify antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline. We compared atherosclerotic cardiovascular disease event rates according to antihypertensive treatment recommendations in the ACC/AHA and ACP/AAFP guidelines among adults ≥60 years old with systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) and the JHS (Jackson Heart Study). Among 4311 participants not taking antihypertensive medication at baseline, 11.4%, 61.2%, and 27.4% were recommended antihypertensive medication initiation by neither guideline, the ACC/AHA but not the ACP/AAFP guideline, and both guidelines, respectively. Atherosclerotic cardiovascular disease event rates (95% CI) for these groups were 3.4 (1.6-5.2), 18.0 (16.1-19.8), and 25.3 (21.9-28.6) per 1000 person-years, respectively. Among 7281 participants taking antihypertensive medication at baseline, 57.9% and 42.1% were recommended antihypertensive medication intensification by the ACC/AHA but not the ACP/AAFP guideline and both guidelines, respectively. Atherosclerotic cardiovascular disease event rates (95% CI) for these groups were 18.2 (16.7-19.7) and 33.0 (30.5-35.4) per 1000 person-years, respectively. In conclusion, adults recommended initiation or intensification of antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline have high atherosclerotic cardiovascular disease risk that may be reduced through treatment initiation or intensification.

Keywords: adults; blood pressure; coronary heart disease; hypertension; stroke.

Figure 1:

Recommendations for initiation and intensification of antihypertensive medication by the 2017 ACC/AHA blood pressure guideline and the 2017 ACP/AAFP blood pressure guideline. * All adults recommended antihypertensive medication initiation or intensification by the ACP/AAFP guideline are also recommended treatment initiation or intensification by the ACC/AHA guideline. However, based on differences in the ACC/AHA and ACP/AAFP guidelines, many adults ≥ 60 years of age may be recommended to initiate or intensify antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline ^† -At this level of systolic blood pressure, no one is recommended for antihypertensive medication initiation or intensification by neither guideline. ^‡ --At this level of systolic blood pressure, no one is recommended for antihypertensive medication initiation or intensification by the ACC/AHA but not the ACP/AAFP guideline. ^§ ---At this level of systolic blood pressure, no one is recommended for antihypertensive medication initiation or intensification by both guidelines. ^|| 10-year risk of atherosclerotic cardiovascular disease represents the risk for a coronary heart disease or stroke event within 10-years and was calculated using the Pooled Cohort risk equations. ^¶ For the current study, known vascular disease included history of myocardial infarction, stroke, or coronary revascularization. AAFP = American Academy of Family Physicians; ACC = American College of Cardiology; ACP = American College of Physicians; ACR = albumin-to-creatinine ratio; AHA = American Heart Association; ASCVD = atherosclerotic cardiovascular disease; DBP = diastolic blood pressure; eGFR = estimated glomerular filtration rate; SBP = systolic blood pressure; TIA = transient ischemic attack