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Increased BP confers greater risk for death, HF hospitalization in black adults
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Black individuals in all age groups are at elevated risk for mortality and hospitalization due to HF with increases in systolic BP, even by small amounts, new data show.
In 2014, guidelines were released by the panel convened for the Eighth Joint National Committee (JNC) that increased the recommended target BP for adults aged at least 60 years without other medical conditions from < 140/90 mm Hg to < 150/90 mm Hg. The effects of this recommendation on black adults are unclear due to limited data, Tiffany C. Randolph, MD, a cardiologist at Cone Health Medical Group HeartCare in Greensboro, North Carolina, and colleagues wrote in the study background.
“Given that tighter BP control has been associated with lower mortality and lower likelihood of developing progressive disease, many have questioned the potential health impact of liberalizing hypertension goals that previously were achieved in only 50% of patients in clinical practice,” the researchers wrote. “The Association of Black Cardiologists and the Working Group on Women’s Cardiovascular Health published a statement of concern regarding these new guidelines, citing the disproportionate burden of hypertension among black patients and its role as a risk factor for mortality and incident [CVD] with differential effects on black patients, such as stroke, HF and [chronic kidney disease].”
Randolph and colleagues analyzed high BP and the risk for death and hospitalization for HF in 5,280 black participants (36.5% men; median age, 56 years; 60% with hypertension diagnosis) from the Jackson Heart Study from 2000 to 2011. Median follow-up was 9 years for death and 7 years for HF hospitalization.
After multivariable adjustment, every 10 mm Hg increase in systolic BP was associated with an increase in risk for mortality (HR = 1.12; 95% CI, 1.06-1.17) and HF hospitalization (HR = 1.07; 95% CI, 1-1.14).
In relation to age, when systolic BP increased by 10 mm Hg, participants younger than 60 years had a higher risk for mortality (HR = 1.26; 95% CI, 1.13-1.42) than participants aged at least 60 years (HR = 1.09; 95% CI, 1.03-1.15).
“This observational study should make us question whether the current JNC guidelines have identified the optimal target for [BP] control in the African American population,” Randolph said in a press release. “To fully answer this question, we will need additional large randomized controlled trials that enroll a diverse population. Until then, providers will have to continue assessing risk and working with patients to set [BP] goals based on all the available data and individual patient concerns.” – by Cassie Homer
Disclosure: Randolph reports receiving a grant from the NIH. Please see the full study for a list of the other researchers’ relevant financial disclosures.
Perspective
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Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASH
The study confirms what we have seen in the general population of adults with hypertension: That elevated BP has a linear, consistent, persistent relationship to CVD, with BPs greater than the optimal of < 120 mm Hg systolic/80 mm Hg diastolic showing more heart disease, kidney disease and overall mortality in observational studies.
The International Society on Hypertension in Blacks in its two working-group reports (Flack JM, et al. Hypertension. 2010;doi:10.1161/HYPERTENSIONAHA.110.152892) recognized the need for more intensive BP reduction in black individuals, although the randomized clinical evidence for that has been limited. Nevertheless, based on observational data and the high burden of CVD including MI, HF, chronic kidney disease and especially stroke, most clinicians who treat these high-risk patients have been concerned with the potential unintended consequence of loosening BP targets in this population. Indeed, a commentary on which I was an author (Krakoff LR, et al. J Am Coll Cardiol. 2016;doi:10.1016/j.jacc.2014.06.014) published prior to the SPRINT data cautioned against overenthusiastic interpretation of the report from members of JNC 8, since we believed efforts to de-escalate BP goals would especially adversely affect African Americans, who have disproportionate degrees of CVD and CKD directly related to hypertension. The new SPRINT analyses appear to confirm the benefit of more intensive BP reduction across a wide range of populations, including black individuals, with no specific interaction by race. SPRINT confirms our observational data that higher BPs even beyond the somewhat arbitrary 140 mm Hg systolic/90 mm Hg diastolic definition of hypertension are an indication of increased CV risk, which may be curtailed by more intensive BP reduction.
We are expected to have even more specific subgroup analyses from the SPRINT cohort that will clarify the benefit of intensive BP reduction in black patients with hypertension who are over the age of 50 years and have additional high-risk status. In the interim, efforts to control BP to the Million Hearts goal of < 140 mm Hg/90 mm Hg for a wide range of patients, including those over age 60 years but perhaps younger than 80 years, would allow for a more appropriate control of BP than loosening the BP goal to 150 mm Hg systolic for persons 60 years and older, especially for high-risk black individuals.
The effort to control BP in the final analysis must be done on a 1:1 basis with each individual taking into account his or her response to intensive antihypertensive treatment. In patients with underlying coronary disease who have marked falls in diastolic BP to < 60 mm Hg, especially if accompanied by symptoms of chest pain, dizziness or weakness, perhaps less vigorous BP reduction would be appropriate. However, for the wide range of middle-aged and older African Americans, lower BP appears to be superior to a less-intense goal attainment.
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