Hypertension-Mediated Organ Damage: Prevalence, Correlates, and Prognosis in the Community

Abstract

Background: Guidelines emphasize screening people with elevated BP for the presence of end-organ damage.

Methods: We characterized the prevalence, correlates, and prognosis of hypertension-mediated organ damage (HMOD) in the community-based Framingham Study. 7898 participants (mean age 51.6 years, 54% women) underwent assessment for the following HMOD: electrocardiographic and echocardiographic left ventricular hypertrophy, abnormal brain imaging findings consistent with vascular injury, increased carotid intima-media thickness, elevated carotid-femoral pulse wave velocity, reduced kidney function, microalbuminuria, and low ankle-brachial index. We characterized HMOD prevalence according to blood pressure (BP) categories defined by four international BP guidelines. Participants were followed up for incidence of cardiovascular disease.

Results: The prevalence of HMOD varied positively with systolic BP and pulse pressure but negatively with diastolic BP; it increased with age, was similar in both sexes, and varied across BP guidelines based on their thresholds defining hypertension. Among participants with hypertension, elevated carotid-femoral pulse wave velocity was the most prevalent HMOD (40%-60%), whereas low ankle-brachial index was the least prevalent (<5%). Left ventricular hypertrophy, reduced kidney function, microalbuminuria, increased carotid intima-media thickness, and abnormal brain imaging findings had an intermediate prevalence (20%-40%). HMOD frequently clustered within individuals. On follow-up (median, 14.1 years), there were 384 cardiovascular disease events among 5865 participants with concurrent assessment of left ventricular mass, carotid-femoral pulse wave velocity, kidney function, and microalbuminuria. For every BP category above optimal (referent group), the presence of HMOD increased cardiovascular disease risk compared with its absence.

Conclusions: The prevalence of HMOD varies across international BP guidelines based on their different thresholds for defining hypertension. The presence of HMOD confers incremental prognostic information regarding cardiovascular disease risk at every BP category.

Keywords: blood pressure; cardiovascular diseases; epidemiology; hypertension; prevalence.

Figure 1.

Prevalence of HMOD (by type) by different BP guidelines. Left Panel: ACC-AHA 2017 guidelines; Right Panel: ESC-ESH guidelines. ABI= ankle-brachial index, ASE= American society of Echocardiography, CIMT= carotid intimal-medial thickness. ECG= electrocardiogram. Echo= echocardiographic. eGFR= estimated glomerular filtration rate, LVH= left ventricular hypertrophy, MRI= magnetic resonance imaging, PWV= carotid-femoral pulse wave velocity, UACR= urine albumin to creatinine ratio.

Figure 2.

Association of blood pressure component with the prevalence of HMOD: logistic regression models adjusted for age, sex, total/HDL cholesterol ratio, smoking, and diabetes. Panel A, results for systolic and diastolic BP (mutually adjusted). Panel B. results for PP (adjusted for mean arterial pressure).

Figure 3.

Cumulative incidence of CVD according to the 2017 ACC-AHA BP categories (Left Panel) and the 2018 ESC-ESH BP groupings (Right Panel) stratified by presence versus absence of HMOD.