Abstract
Little is known about the impact of the 2017 ACC/AHA hypertension guideline on the distribution pattern of hypertension modalities (isolated systolic hypertension [ISH], isolated diastolic hypertension [IDH], and systolic‐diastolic hypertension [SDH]). This cross‐sectional study had the following objectives: to compare the prevalence of hypertension, ISH, IDH, and SDH, according to the definitions of the JNC 7 or the 2017 guideline; to determine the relative contribution of the systolic and the diastolic components for the diagnosis of hypertension; and to compare the metabolic profile of ISH, IDH, or SDH among new hypertensive individuals by the 2017 guideline. The authors retrospectively evaluated 33 594 patients (42 ± 10 years, 67% male) who underwent a routine health evaluation. Hypertensive patients not using antihypertensive medication were classified into ISH, IDH, or SDH using guideline‐defined thresholds. The prevalence of hypertension increased from 21.1% by the JNC 7 definition to 54.7% using the 2017 criteria (2.6‐fold increase). More profound increases were seen in the prevalence of IDH (8.7‐fold) and SDH (3.3‐fold), whereas the prevalence of ISH reduced from 1.1% (JNC 7) to 0.5% (2017 definition). Among patients with Stage 1 hypertension by the 2017 document, 85% had IDH and fewer metabolic abnormalities compared to those with SDH or ISH. The authors concluded that the 2017 guideline inflates the role of the diastolic component and diminishes the contribution of the systolic component for the diagnosis of hypertension. Individuals with Stage 1 hypertension by the 2017 guideline are metabolically heterogeneous and may have different long‐term prognoses.
Keywords: blood pressure, guideline, hypertension, isolated diastolic hypertension, isolated systolic hypertension, metabolic syndrome
1. INTRODUCTION
Medical guidelines exert a major influence on how patients are diagnosed and treated by their physicians. Guideline recommendations might undergo considerable changes upon updates. In the setting of arterial hypertension, the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) High Blood Pressure Guideline 1 modified several aspects of diagnosis and treatment of arterial hypertension. Among those changes, one controversial point was the establishment of a lower blood pressure threshold (130/80 mm Hg) to define arterial hypertension, replacing the traditional 140/90 mm Hg recommended by The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) 2 and other guidelines, including the highly influential European guideline. 3
Several studies have shown that the adoption of the 130/80 mm Hg threshold for the diagnosis of arterial hypertension would markedly increase its prevalence. 4 , 5 , 6 , 7 , 8 A less studied aspect is whether these newly labeled hypertensive individuals are so due to the systolic and/or the diastolic components. As well, it is unclear whether the metabolic profile differs among new hypertensive individuals with isolated elevation of systolic blood pressure (SBP), isolated elevation of diastolic blood pressure (DBP), or elevation of both SBP and DBP. This issue assumes relevance since hypertension is very often associated with other metabolic abnormalities and is a key component of the metabolic syndrome. Additionally, even the recommendation of pharmacologic treatment in such individuals is based on the metabolic profile and absolute cardiovascular risk. 1
Therefore, the present study had the following objectives: (a) to compare, in a clinical cohort, the prevalence of arterial hypertension and its modalities (isolated systolic hypertension [ISH], isolated diastolic hypertension [IDH], or systolic‐diastolic hypertension [SDH]), according to the definitions of the JNC 7 and the 2017 ACC/AHA Blood Pressure Guideline; (b) to determine the relative contribution of the SBP and the DBP for the diagnosis of arterial hypertension, according to each of the guidelines; (c) to compare the metabolic profile of individuals with ISH, IDH, or SDH among new hypertensive individuals by the 2017 ACC/AHA Guideline.
2. METHODS
2.1. Study design and participants
This was a retrospective, cross‐sectional study of patients who underwent a routine health evaluation as part of the executive screening program at the Hospital Israelita Albert Einstein (São Paulo‐SP, Brazil). The protocol for this program consists of an extensive clinical and laboratory evaluation, as previously described. 9 We included all individuals aged 18 years or older who visited our service between January 2009 and July 2018 (repeated visits were not included). We excluded patients with missing blood pressure readings.
This study was approved by the Ethics Research Committee of the Hospital Israelita Albert Einstein (CAAE 87867318.1.0000.0071). The Ethics Committee approved a waiver of the written informed consent based on the observational nature of the analyses, as well as the unfeasibility of obtaining the consent of a large number of participants retrospectively.
2.2. Blood pressure measurement and definition of arterial hypertension
Office blood pressure was obtained by a medical doctor during the consultation with the patient in the sitting position after a rest period of at least 5 minutes. A sphygmomanometer with wall aneroid gauge, periodically calibrated, was used to measure blood pressure by the classic auscultatory technique. SBP and DBP were recorded at the first and the last Korotkoff sounds, respectively. Blood pressure was measured in both arms with an appropriate cuff size, according to the patient's arm circumference. The average of the readings was annotated in the patient record and this level was considered in our analyses.
Arterial hypertension was defined in the presence of self‐reported current use of antihypertensive medication or high blood pressure on the day of the routine health evaluation, according to the JNC 7 or the 2017 ACC/AHA Blood Pressure Guideline, as shown in Table 1. We also classified individuals not taking antihypertensive medications into blood pressure categories as defined by the 2017 guideline, as follows: normal blood pressure (SBP < 120 mm Hg and DBP < 80 mm Hg), elevated blood pressure (SBP 120‐<130 mm Hg and DBP < 80 mm Hg), Stage 1 hypertension (SBP 130‐<140 mm Hg or DBP 80‐<90 mm Hg), and Stage 2 hypertension (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg). 1
TABLE 1.
Definitions of arterial hypertension and its modalities, according to the elevation of the systolic and/or the diastolic components
| JNC 7 | 2017 ACC/AHA High Blood Pressure Guideline | |
|---|---|---|
| Arterial hypertension | SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg | SBP ≥ 130 mm Hg and/or DBP ≥ 80 mm Hg |
| Isolated systolic hypertension | SBP ≥ 140 mm Hg and DBP < 90 mm Hg | SBP ≥ 130 mm Hg and DBP < 80 mm Hg |
| Isolated diastolic hypertension | SBP < 140 mm Hg and DBP ≥ 90 mm Hg | SBP < 130 mm Hg and DBP ≥ 80 mm Hg |
| Systolic‐diastolic hypertension | SBP ≥ 140 mm Hg and DBP ≥ 90 mm Hg | SBP ≥ 130 mm Hg and DBP ≥ 80 mm Hg |
Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; DBP, diastolic blood pressure; JNC 7, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure; SBP, systolic blood pressure.
Hypertensive patients not reporting current use of antihypertensive drug were also classified into three modalities (ISH, IDH, or SDH), according to elevation of SBP and/or DBP, considering the same thresholds used for the diagnosis of arterial hypertension (Table 1).
2.3. Cardiovascular risk estimation
We calculated the general Framingham risk score to estimate the risk of ischemic or hemorrhagic stroke, transient ischemic attack, peripheral vascular disease, heart failure, myocardial infarction, angina, or death from coronary artery disease in 10 years. 10 This equation considers the following variables: age, sex, SBP, use of antihypertensive drug, total cholesterol, high‐density lipoprotein cholesterol (HDL‐c), diabetes mellitus, and smoking.
2.4. Definition of metabolic syndrome and diabetes mellitus
Metabolic syndrome was defined according to the harmonized criteria of the Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; AHA; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. 11 Thus, metabolic syndrome was considered in the presence of at least three of the following factors: elevated waist circumference (≥94 cm in men, ≥80 cm in women), elevated plasma level of triglycerides (≥150 mg/dL), reduced plasma level of HDL‐c (<40 mg/dL in men, <50 mg/dL in women), elevated blood pressure (SBP ≥ 130 mm Hg, DBP ≥ 85 mm Hg or current use of antihypertensive medication), and elevated fasting plasma glucose (≥100 mg/dL or current drug treatment for elevated glucose).
Diabetes mellitus was considered in the presence of a self‐reported diagnosis, fasting plasma glucose ≥126 mg/dL, or glycated hemoglobin (A1c) ≥6.5%.
2.5. Statistical analysis
Categorical variables were expressed as the number of observations and proportions. Continuous variables were expressed either as means and standard deviations if normally distributed or medians and quartiles if non‐normally distributed. Normality was assessed by visual inspection of the distribution and calculation of the skewness (values between −1 and 1 were considered consistent with a normal distribution). The prevalence of arterial hypertension and its modalities (ISH, IDH, and SDH) was presented along with the corresponding 95% confidence intervals based on the binomial distribution.
The chi‐square test was used to compare proportions of categorical variables; for post hoc analyses, we conducted pairwise tests for 2‐dimensional matrixes (chi‐square or Fisher, when appropriate) and obtained adjusted P‐values by the false discovery rate (FDR) method. The one‐way analysis of variance (ANOVA) was used to compare normally distributed continuous variables, and the Tukey's honestly significant difference method was the procedure for the post hoc analyses of multiple comparisons. The Kruskal‐Wallis test was the method to compare non‐normally distributed continuous variables, and post hoc, pairwise comparisons were done by the Dunn's test. A P‐value < .050 was considered statistically significant.
The R software and Microsoft Office Excel tools were used for data management, statistical analyses, and graph construction.
3. RESULTS
3.1. Population and baseline characteristics
From 33 601 individuals initially identified in the database, we excluded seven patients with missing values of blood pressure. Thus, the final sample comprised 33 594 unique, predominantly healthy, white patients (Table 2). As expected, several metabolic factors showed a gradient across blood pressure categories, with more abnormal values in patients with Stage 2 hypertension and those reporting use of antihypertensive drug (Table 2).
TABLE 2.
Baseline characteristics of the sample, according to blood pressure categories as defined by the 2017 ACC/AHA Blood Pressure Guideline a
| Total (n = 33 594) | Blood pressure categories among patients not taking antihypertensive medication | Already taking antihypertensive medication (n = 4508) | ||||
|---|---|---|---|---|---|---|
| Normal BP (n = 13 884) | Elevated BP (n = 1347) | Stage 1 Hypertension (n = 11 267) | Stage 2 Hypertension (n = 2588) | |||
| Male sex | 22 333 (67) | 6960 (50) | 996 (74) | 8768 (78) | 2155 (83) | 3454 (77) |
| Age (y) | 42 ± 10 | 39 ± 9 | 42 ± 11 | 42 ± 9 | 45 ± 10 | 51 ± 10 |
| BMI (kg/m2) | 26.7 ± 4.5 | 24.6 ± 3.5 | 26.5 ± 3.6 | 27.4 ± 4.1 | 29.8 ± 5.0 | 29.5 ± 4.8 |
| Waist circumference (cm) | 92 ± 13 | 85 ± 11 | 92 ± 11 | 95 ± 12 | 101 ± 13 | 101 ± 13 |
| SBP (mm Hg) | 117 ± 13 | 107 ± 7 | 121 ± 2 | 120 ± 7 | 138 ± 12 | 128 ± 14 |
| DBP (mm Hg) | 77 ± 9 | 70 ± 5 | 72 ± 4 | 81 ± 2 | 92 ± 7 | 83 ± 9 |
| Diabetes mellitus | 1222 (4) | 136 (1) | 39 (3) | 285 (3) | 153 (6) | 609 (14) |
| Fasting glucose (mg/dL) | 85 (80‐91) | 83 (78‐88) | 85 (80‐91) | 86 (80‐91) | 88 (82‐95) | 90 (84‐98) |
| Total cholesterol (mg/dL) | 192 ± 37 | 187 ± 34 | 192 ± 37 | 196 ± 37 | 205 ± 40 | 189 ± 41 |
| LDL‐c (mg/dL) | 116 ± 33 | 112 ± 32 | 117 ± 34 | 121 ± 33 | 127 ± 34 | 113 ± 35 |
| HDL‐c (mg/dL) | 50 ± 14 | 54 ± 15 | 50 ± 13 | 48 ± 14 | 46 ± 12 | 46 ± 13 |
| Triglycerides (mg/dL) | 107 (76‐156) | 90 (67‐128) | 103 (76‐149) | 115 (83‐166) | 140 (99‐199) | 136 (98‐189) |
| Metabolic syndrome | 7549 (23) | 823 (6) | 145 (11) | 2443 (22) | 1454 (56) | 2684 (60) |
| Smoking | 3302 (10) | 1362 (10) | 154 (12) | 1120 (10) | 262 (10) | 404 (9) |
| ASCVD | 332 (1.0) | 29 (0.2) | 14 (1.0) | 40 (0.4) | 20 (0.8) | 229 (5.1) |
| 10‐y Framingham general cardiovascular risk (%) | 3.4 (1.7‐7.2) | 1.8 (1.0‐3.3) | 3.8 (2.1‐6.6) | 3.9 (2.3‐7.0) | 7.5 (4.2‐13.0) | 11.3 (6.5‐19.2) |
Data expressed as mean ± standard deviation, median (quartiles) or n (%).
Abbreviations: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; BP, blood pressure; DBP, diastolic blood pressure; HDL‐c, high‐density lipoprotein cholesterol; LDL‐c, low‐density lipoprotein cholesterol; SBP, systolic blood pressure.
Normal BP: SBP < 120 mm Hg and DBP < 80 mm Hg; Elevated BP: SBP 120‐<130 mm Hg and DBP < 80 mm Hg; Stage 1 Hypertension: SBP 130‐<140 mm Hg or DBP 80‐<90 mm Hg; Stage 2 Hypertension: SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.
3.2. Prevalence of arterial hypertension and the contribution of the systolic and the diastolic components for the diagnosis
Among the total sample, 4508 (13.4%) patients reported use of antihypertensive medication. Additional 2588 (7.7%) patients were considered hypertensive by the JNC 7 report, while another 13 855 (41.2%) individuals had a diagnosis of high blood pressure according to the 2017 ACC/AHA Guideline. Therefore, the global prevalence of arterial hypertension was 21.1% (20.7%‐21.6%) and 54.7% (54.1%‐55.2%) based on the definitions from the JNC 7 and the 2017 guideline, respectively (a 2.6‐fold increase, P < .001).
Excluding individuals not taking antihypertensive medication, the prevalence of IDH and SDH increased 8.7‐fold and 3.3‐fold, respectively, using the new 2017 criteria, whereas the proportion of ISH was very low under both definitions (Figure 1).
FIGURE 1.
Prevalence (95% confidence interval) of arterial hypertension subtypes, according to criteria based on The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) or the 2017 American College of Cardiology/American Heart Association (ACC/AHA) High Blood Pressure (BP) Guideline, among patients not treated with medication. IDH, isolated diastolic hypertension; ISH, isolated systolic hypertension; SDH, systolic‐diastolic hypertension. P < .001 for the frequency distribution of arterial hypertension subtypes according to the two criteria
Among hypertensive patients not on medication, the relative proportion of ISH drastically reduced, while the relative proportion of IDH markedly increased, in both women and men and all age groups, under the 2017 ACC/AHA Guideline, compared to the JNC 7 criteria (Figure 2). Even in older patients, the proportion of ISH decreased from more than half in men and more than one third in women, under the JNC 7, to less than one fifth according to the 2017 criteria (Figure 2).
FIGURE 2.
Frequency distribution of arterial hypertension subtypes among patients not taking antihypertensive medication diagnosed with arterial hypertension as defined by The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) or the 2017 American College of Cardiology/American Heart Association (ACC/AHA) High Blood Pressure Guideline, according to sex and age group. IDH, isolated diastolic hypertension; ISH, isolated systolic hypertension; SDH, systolic‐diastolic hypertension. P < .001 in all scenarios
3.3. Metabolic profile of patients with Stage 1 hypertension according to the 2017 ACC/AHA High Blood Pressure Guideline
Among patients not on antihypertensive drug, not considered hypertensive by the JNC 7, but diagnosed with Stage 1 hypertension under the 2017 ACC/AHA Guideline, 84.6% (83.9%‐85.3%) had IDH, 14.3% (13.7%‐15.0%) had SDH, and only 1.1% (0.9%‐1.3%) had ISH.
Patients with IDH were younger, had lower plasma levels of triglycerides, lower prevalence of diabetes and metabolic syndrome, and lower calculated cardiovascular risk, compared to those with ISH or SDH (Table 3 and Table S1). While most patients with IDH showed 0 or 1 altered component of the metabolic syndrome, the presence of 3, 4, or 5 altered factors was far more frequent in those with ISH or SDH than in those with IDH (Figure 3).
TABLE 3.
Comparison of patients with isolated diastolic hypertension (IDH), systolic‐diastolic hypertension (SDH), or isolated systolic hypertension (ISH), among those diagnosed with Stage 1 hypertension as defined by the 2017 ACC/AHA High Blood Pressure Guideline (systolic blood pressure 130‐<140 mm Hg or diastolic blood pressure 80‐<90 mm Hg)
| IDH (n = 9535) | SDH (n = 1611) | ISH (n = 121) | P | |
|---|---|---|---|---|
| Male sex | 7334 (77) | 1343 (83) | 91 (75) | <.001 |
| Age (y) | 41 ± 9 | 45 ± 10 | 50 ± 14 | <.001 |
| BMI (kg/m2) | 27.2 ± 4.0 | 28.7 ± 4.5 | 27.3 ± 4.6 | <.001 |
| Waist circumference (cm) | 94 ± 11 | 98 ± 12 | 95 ± 12 | <.001 |
| SBP (mm Hg) | 118 ± 6 | 131 ± 2 | 131 ± 2 | <.001 |
| DBP (mm Hg) | 81 ± 2 | 82 ± 3 | 72 ± 4 | <.001 |
| Diabetes mellitus | 194 (2) | 81 (5) | 10 (8) | <.001 |
| Fasting glucose (mg/dL) | 85 (80‐91) | 88 (82‐94) | 88 (81‐95) | <.001 |
| Total cholesterol (mg/dL) | 196 ± 37 | 200 ± 39 | 195 ± 37 | <.001 |
| LDL‐c (mg/dL) | 121 ± 33 | 123 ± 34 | 116 ± 29 | .004 |
| HDL‐c (mg/dL) | 48 ± 13 | 47 ± 13 | 48 ± 13 | <.001 |
| Triglycerides (mg/dL) | 113 (81‐163) | 128 (93‐186) | 124 (85‐181) | <.001 |
| Metabolic syndrome | 1598 (17) | 786 (49) | 59 (49) | <.001 |
| Smoking | 944 (10) | 166 (10) | 10 (8) | .737 |
| 10‐y Framingham general cardiovascular risk (%) | 3.6 (2.1‐6.2) | 6.5 (3.7‐11.2) | 8.1 (4.2‐14.1) | <.001 |
Data expressed as mean ± standard deviation, median (quartiles) or n (%).
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; HDL‐c, high‐density lipoprotein cholesterol; LDL‐c, low‐density lipoprotein cholesterol; SBP, systolic blood pressure.
FIGURE 3.
Percentage of patients with 0, 1, 2, 3, 4, or 5 components of the metabolic syndrome, according to the modality of arterial hypertension, among individuals diagnosed with Stage 1 hypertension as defined by the 2017 ACC/AHA High Blood Pressure Guideline. IDH, isolated diastolic hypertension; ISH, isolated systolic hypertension; SDH, systolic‐diastolic hypertension. P < .001
Conversely, compared to individuals with normal or elevated blood pressure, those with Stage 1 IDH were more frequently male, had higher body mass index and waist circumference, more elevated triglycerides level, lower HDL‐c, and a higher likelihood of having metabolic syndrome (Table S1).
4. DISCUSSION
The main findings of this study were as follows: the 130/80 mm Hg threshold recommended by the 2017 ACC/AHA Blood Pressure Guideline resulted in a 2.6‐fold increase in the prevalence of arterial hypertension, compared to the traditional, commonly used 140/90 mm Hg; the vast majority (85%) of newly labeled hypertensive individuals by the 2017 guideline had DBP between 80 and <90 mm Hg and SBP < 130 mm Hg, that is, IDH; the 2017 guideline inflates the contribution of the diastolic component and drastically diminishes the relevance of the systolic component for the diagnosis of arterial hypertension in both men and women, and in all age groups, including the elderly; patients with Stage 1 hypertension according to the 2017 guideline are metabolically heterogeneous, with fewer metabolic abnormalities seen in the majority with IDH than in those with SDH or ISH.
The 2.6‐fold increase in the prevalence of arterial hypertension with the new 130/80 mm Hg threshold is higher than the increase reported in other studies (~1.4‐fold increase in the USA, China, and Spain 4 , 5 , 6 ; 1.8‐fold increase in Canada and the Republic of Korea 7 , 12 ; and 2.3‐fold increase in Bangladesh). 8 As well, we found a substantial 8.7‐fold increase in the prevalence of IDH (from 3.9% to 34.1%) with the new 2017 guideline criterion, which is higher than the rises reported by Cho et al 12 in a Korean population (from 5.2% to 17.9%, a 3.4‐fold increase) and by McEvoy et al 13 in the United States (from 1.3% to 6.5%, a 5‐fold increase). These discrepancies may be explained by the inherent differences of the populations studied, by the fact that our sample was not representative of the general Brazilian population, and by methodological issues related to the protocol to measure blood pressure.
Our data reveal that the new hypertensive individuals under the 2017 guideline, that is, those with Stage 1 hypertension, have different metabolic profiles, according to the categorization into IDH, SDH, or ISH. The expressive lower rate of metabolic syndrome in those with IDH can be partially explained by their younger age and by the 130/85 mm Hg cut‐off blood pressure value for the diagnosis of metabolic syndrome, once all patients with SDH or ISH reach this threshold, while many patients with IDH (those with DBP between 80 and <85 mm Hg) do not. However, as seen in Table 3, other metabolic factors, such as triglycerides, body mass index, waist circumference, and diabetes, are less altered in patients with Stage 1 IDH, especially when compared to those with SDH. These results partially agree with those reported by Cho et al, 12 who found a lower prevalence of diabetes in individuals with Stage 1 IDH, compared to other subtypes, but observed a higher plasma level of triglycerides in those with IDH, compared to individuals with ISH.
We detected a gradient in the prevalence of metabolic syndrome, increasing from 11% in elevated blood pressure to 17% in Stage 1 IDH, then to 49% in Stage 1 SDH or ISH, then to 56% in Stage 2 hypertension (Tables 2 and 3). Considering that metabolic syndrome enhances the risk of cardiovascular outcomes and all‐cause mortality, 14 it is conceivable that individuals with Stage 1 IDH may have a better long‐term prognosis than those with Stage 1 SDH or ISH. Moreover, although some cohort studies have demonstrated that Stage 1 hypertension, as defined by the 2017 guideline, is associated with a higher risk of future cardiovascular events compared to normal blood pressure, 15 , 16 IDH was not significantly associated with a wide array of outcomes in longitudinal analyses of the Atherosclerosis Risk in Communities (ARIC) Study and other external cohorts. 13 Indeed, there is evidence that the DBP elevation is a less stronger predictor of cardiovascular risk than the rise in SBP, 17 , 18 and the hazard of a DBP of 80‐89 mm Hg, compared to <80 mm Hg, was shown to be very small when the SBP is <130 mm Hg in a multivariable‐adjusted analysis of a large Korean population. 19
Putting together, the sharp, disproportionate increase in the new diagnoses of IDH under the new guideline, the more favorable metabolic phenotype of IDH compared to SDH and ISH, and the evidence that IDH per se may not increase the risk of hard events constitute arguments that question the appropriateness of the 80 mm Hg DBP cut‐off established in the 2017 guideline.
Our study has the strength of including a large number of patients, which allowed us to perform credible subgroup analyses. Conversely, the study has several limitations. Our study population was very specific, composed predominantly of white individuals with high socioeconomic status, therefore, not representative of the general population. To minimize the bias caused by this phenomenon, we reported subgroup analyses according to sex and age. Also, blood pressure was measured only in 1 day and not confirmed by 24‐hour ambulatory monitoring; thus, we could not account for the white‐coat effect or masked hypertension. Finally, as a cross‐sectional investigation, we were able to make only associations and not prognostic implications of hypertension subtypes.
In conclusion, we found that the 2017 ACC/AHA hypertension guideline increases the prevalence of arterial hypertension by a factor of 2.6, compared to the JNC 7 report, which is mainly due to a marked increase in the diagnoses of Stage 1 IDH. Individuals with Stage 1 hypertension by the 2017 guideline are metabolically heterogeneous; a more benign profile in the majority with IDH, compared with those with SDH or ISH, may translate into a better long‐term prognosis.
CONFLICT OF INTEREST
Raul D. Santos—consulting, research, speaker: Ache, Akcea, Amgen, AstraZeneca, Biolab, Esperion, Kowa, Merck, MSD, Novo Nordisk, Pfizer, Sanofi‐Regeneron. Other authors: None.
AUTHOR CONTRIBUTIONS
Fernando H. Y. Cesena involved in conception, design of the work; acquisition, analysis, and interpretation of data; and writing of the manuscript. Fernando C. Nary involved in interpretation of data and revising the manuscript critically for important intellectual content. Raul D. Santos involved in interpretation of data and revising the manuscript critically for important intellectual content. Marcio S. Bittencourt involved in interpretation of data and revising the manuscript critically for important intellectual content.
Supporting information
Table S1
Cesena FHY, Nary FC, Santos RD, Bittencourt MS. The contribution of the systolic and diastolic components for the diagnosis of arterial hypertension under the 2017 ACC/AHA Guideline and metabolic heterogeneity among individuals with Stage 1 hypertension. J Clin Hypertens. 2020;22:1192–1199. 10.1111/jch.13907
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Associated Data
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Supplementary Materials
Table S1