Key result
SBP 120-140 mmHg links to optimal cardiovascular outcomes, while lower pressures associate with higher risk.
Why the study?
Pathophysiology varies by vascular territory, and evidence on associations of BP components with different manifestations of CV disease is unclear, impacting tailoring of BP targets.
Do specific levels of systolic and diastolic blood pressure associate differently with the risk of coronary, cerebrovascular, and peripheral vascular events in hypertensive adults?
Observational
Yes
Do specific levels of systolic and diastolic blood pressure associate differently with the risk of coronary, cerebrovascular, and peripheral vascular events in hypertensive adults?
In hypertensive adults, SBP of 120-140 mmHg and DBP of 80-90 mmHg appear optimal for minimizing the risk of CHD, stroke, and PAD, whereas lower pressures (SBP <120, DBP <60) may be harmful.
Supports caution against SBP <120 mmHg or DBP <60 mmHg in hypertensives; leaves open need for prospective RCTs to confirm component-specific targets.
Background Recent guidelines recommend lower blood pressure (BP) targets in hypertensive adults for reducing adverse cardiovascular (CV) outcomes. However, pathophysiology of CV events varies by vascular territory; and evidence on associations of BP components with different manifestations of CV disease is unclear. This discordance has implications for tailoring BP targets, particularly for those at high risk of a specific CV event. Purpose Examine risk patterns of CV outcomes: non-fatal (NF) myocardial infarction (MI) and fatal (F) coronary heart disease (CHD), NF/F-stroke and peripheral arterial disease (PAD) with systolic (S) and diastolic (D) components of BP among participants of 3 hypertension treatment trials. Methods In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), and Systolic Blood Pressure Intervention Trial (SPRINT), we developed separate Cox regression models relating hazard ratios (HR 95%CI) of CV outcomes with baseline continuous SBP (ref 120mmHg) and DBP (ref 60mmHg) using restricted cubic splines (5 knots at 5, 27.5, 50, 72.5 and 95 percentiles). Models were adjusted for CV risk factors, past CV disease, diabetes; antihypertensive and aspirin use; and randomised group. Associations with on-treatment achieved BPs, particularly in sub-groups of interest will be further evaluated. Results (Figure 1) SBP and CV outcomes A positive linear association of SBP with CHD was noted in ASCOT. In ALLHAT and SPRINT, risk began rising at ~150mmHg, with HRs remaining comparable at/below 1 down to 120mmHg, and risk increasing again in ALLHAT with SBP below 120mmHg producing a U-shape. Association of SBP with stroke was positively linear in ASCOT and ALLHAT, and U-shaped in SPRINT. In ALLHAT and SPRINT HRs of stroke were statistically significant from 140-150mmHg. Association of SBP with PAD was incremental in ASCOT till maximum risk at 190-195mmHg. In ALLHAT and SPRINT, HRs of PAD were near 1 between 120 to ~150mmHg, rising significantly with higher BP. DBP and CV outcomes DBP demonstrated weak association with CHD in ASCOT across the range of BP values. In ALLHAT and SPRINT, DBP<60mmHg appeared harmful; risk being lowest at ~85mmHg in ALLHAT; HRs remaining ~1 between 60-95mmHg in SPRINT before rising again to a U shape. In all 3 trials, incremental risk of stroke with DBP was only evident above 90-95mmHg. There was no obvious association between DBP and PAD in ASCOT, but inverse linear associations were noted in ALLHAT and SPRINT such that DBP<60mmHg carried potential risk while higher DBPs were protective. Conclusions Initial findings suggest that in hypertensive adults SBP 120-140mmHg may be equally favorable for CHD, Stroke and PAD; with SBP<120mmHg potentially harmful. DBP<60mmHg may carry increased risk of CHD, Stroke and PAD, while DBP between 80 and 90mmHg appears optimal. However, further on-treatment evaluation is pending.
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Ahmed et al. (2025) conducted an observational in Hypertension. Systolic and diastolic blood pressure vs. SBP 120mmHg and DBP 60mmHg (reference) was evaluated on Non-fatal MI and fatal CHD, non-fatal/fatal stroke, and peripheral arterial disease. In hypertensive adults, SBP of 120-140 mmHg and DBP of 80-90 mmHg appear optimal for minimizing cardiovascular risk, while SBP <120 mmHg and DBP <60 mmHg may be potentially harmful.
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