Controlled hypertension confers CV event risk, but physical activity may help
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Controlled hypertension was associated with higher risk for major adverse cardiac and cerebrovascular events and all-cause mortality compared with normotension, according to results published in Heart.
However, physical activity mitigated some of the risk in the controlled hypertension population, according to the researchers.
“Current guidelines suggest moderate or moderate to vigorous physical activity as one of the lifestyle modification strategies for patients with hypertension. On the other hand, evidence showing whether physical activity should be equally emphasized even for patients with controlled hypertension is relatively scarce,” Sehoon Park, MD, from the department of biomedical sciences at Seoul National University College of Medicine, South Korea, and the department of internal medicine at the Armed Forces Capital Hospital in Gyeonggi-do, South Korea, and colleagues wrote. “Our findings suggest that reducing average BP values may not be the sole benefit of exercising, and the benefits of physical activity may be present in those who already achieved normal BP values or even in those without hypertension.”
For the observational cohort study, researchers evaluated 220,026 individuals aged 40 to 60 years from the prospective UK Biobank (UKB) cohort and from the retrospective Korean National Health Insurance Service (KNHIS) cohort. Both study groups were stratified into normotension (UKB, n = 161,405; KNHIS, n = 3,122,890), controlled hypertension (systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg; UKB, n = 18,844; KNHIS, n = 383,828) and uncontrolled hypertension (UKB, n = 39,777; KNHIS, n = 86,484).
The primary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality. Major adverse cardiac and cerebrovascular events were defined as MI, cardiac death and ischemic stroke in the UKB cohort and MI, revascularization and acute ischemic stroke in the KNHIS cohort.
In the controlled hypertension group, compared with individuals with normotension, there was a significantly higher risk for major adverse cardiac and cerebrovascular events in the UKB cohort (adjusted HR = 1.73; 95% CI, 1.55-1.92) and the KNHIS cohort (aHR = 1.46; 95% CI, 1.43-1.49) and all-cause mortality in the UKB cohort (aHR = 1.28; 95% CI, 1.18-1.39) and the KNHIS cohort (aHR = 1.29; 95% CI, 1.26-1.32).
Participants in the controlled hypertension group not involved in any moderate or moderate to vigorous physical activity had elevated risk for poor outcomes (P < .001 for all except P = .08 for major adverse cardiac and cerebrovascular events in frequent exercisers in the UKB cohort), which was similar to or higher than the risk for poor outcomes in patients with uncontrolled hypertension who were involved in physical activity, according to the researchers.
“The importance of moderate or moderate to vigorous physical activity may be consistently emphasized, even for patients with hypertension who have reached target BP levels or for individuals with normotension,” the researchers wrote.
Perspective
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Michael A. Weber, MD, FACP, FACC, FAHA
Park and colleagues have employed large, prospective patient cohorts from the U.K. and Korea to perform an observational study of major CV outcomes in individuals classified as normotensive, controlled hypertension (BP < 140/90 mm Hg) and uncontrolled hypertension. Not surprisingly, patients with controlled hypertension were found to have residual risk for major outcomes and to have significantly higher event rates than the normotensive patients.
There are two main reasons. No. 1, BP in the controlled groups in the two cohorts were higher than their respective normotensive groups by 6/3 mm Hg and 4/4 mm Hg, differences that across large cohorts would explain highly significant differences in event rates. Indeed, had contemporary evidence-based criteria been used to define control in this analysis, 130/80 mm Hg rather than 140/90 mm Hg — in essence, learning from the SPRINT trial — there might not have been major outcomes differences between the normotensive and controlled hypertension groups.
No. 2, even though reducing BP is critical in protecting against adverse outcomes in hypertension, it may take considerable time for the structural vascular abnormalities that underlie hypertension to be reversed. Indeed, in a previous clinical trial with up to a 5-year follow-up, fatal CV outcome rates in patients who required multidrug regimens to control their BP were not different from those in patients who remained uncontrolled despite receiving similar therapy.
Lessons learned? Achieve the < 130/80 mm Hg target — if tolerated — when treating hypertension, and ensure that concomitant therapies such as dealing with lipid disorders and glucose intolerance are aggressively addressed.
The article from Park and colleagues also reports that patients with uncontrolled hypertension who exercised regularly had lower major CV event rates than controlled patients who didn’t exercise. Observational findings like these, although interesting, can be difficult to interpret since people who exercise regularly may also be more likely to observe other beneficial lifestyle and dietary practices and to be more adherent to their prescribed medications. Overall, this new article draws attention to important unresolved issues in the long-term management of hypertension.
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