Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
JAMA. 2019 Aug 6;322(5):409-420. doi: 10.1001/jama.2019.9811.
Blood pressure (BP) is a known risk factor for overall mortality and cardiovascular (CV)-specific fatal and nonfatal outcomes. It is uncertain which BP index is most strongly associated with these outcomes.
To evaluate the association of BP indexes with death and a composite CV event.
DESIGN, SETTING, AND PARTICIPANTS: Longitudinal population-based cohort study of 11 135 adults from Europe, Asia, and South America with baseline observations collected from May 1988 to May 2010 (last follow-ups, August 2006-October 2016).
Blood pressure measured by an observer or an automated office machine; measured for 24 hours, during the day or the night; and the dipping ratio (nighttime divided by daytime readings).
Multivariable-adjusted hazard ratios (HRs) expressed the risk of death or a CV event associated with BP increments of 20/10 mm Hg. Cardiovascular events included CV mortality combined with nonfatal coronary events, heart failure, and stroke. Improvement in model performance was assessed by the change in the area under the curve (AUC).
Among 11 135 participants (median age, 54.7 years, 49.3% women), 2836 participants died (18.5 per 1000 person-years) and 2049 (13.4 per 1000 person-years) experienced a CV event over a median of 13.8 years of follow-up. Both end points were significantly associated with all single systolic BP indexes (P < .001). For nighttime systolic BP level, the HR for total mortality was 1.23 (95% CI, 1.17-1.28) and for CV events, 1.36 (95% CI, 1.30-1.43). For the 24-hour systolic BP level, the HR for total mortality was 1.22 (95% CI, 1.16-1.28) and for CV events, 1.45 (95% CI, 1.37-1.54). With adjustment for any of the other systolic BP indexes, the associations of nighttime and 24-hour systolic BP with the primary outcomes remained statistically significant (HRs ranging from 1.17 [95% CI, 1.10-1.25] to 1.87 [95% CI, 1.62-2.16]). Base models that included single systolic BP indexes yielded an AUC of 0.83 for mortality and 0.84 for the CV outcomes. Adding 24-hour or nighttime systolic BP to base models that included other BP indexes resulted in incremental improvements in the AUC of 0.0013 to 0.0027 for mortality and 0.0031 to 0.0075 for the composite CV outcome. Adding any systolic BP index to models already including nighttime or 24-hour systolic BP did not significantly improve model performance. These findings were consistent for diastolic BP.
In this population-based cohort study, higher 24-hour and nighttime blood pressure measurements were significantly associated with greater risks of death and a composite CV outcome, even after adjusting for other office-based or ambulatory blood pressure measurements. Thus, 24-hour and nighttime blood pressure may be considered optimal measurements for estimating CV risk, although statistically, model improvement compared with other blood pressure indexes was small.
血压（BP）是整体死亡率和心血管（CV）特定死亡和非致命结局的已知风险因素。目前尚不确定哪种 BP 指数与这些结果的相关性最强。
评估 BP 指数与死亡和复合 CV 事件的关系。
设计、地点和参与者：这是一项来自欧洲、亚洲和南美洲的 11535 名成年人的纵向基于人群的队列研究，基线观察数据收集于 1988 年 5 月至 2010 年 5 月（最后一次随访为 2006 年 8 月至 2016 年 10 月）。
由观察者或自动办公机器测量的血压；测量 24 小时、白天或夜间；以及下降比（夜间读数除以白天读数）。
多变量调整后的风险比（HR）表示与 20/10mmHg 的 BP 增量相关的死亡或 CV 事件的风险。心血管事件包括 CV 死亡率与非致命性冠状动脉事件、心力衰竭和中风相结合。通过曲线下面积（AUC）的变化来评估模型性能的改善。
在 11535 名参与者（中位年龄 54.7 岁，49.3%为女性）中，2836 名参与者死亡（每 1000 人年 18.5 人），2049 名参与者（每 1000 人年 13.4 人）经历了 CV 事件中位随访时间为 13.8 年。两个终点均与所有单一收缩压指标显著相关（P<0.001）。对于夜间收缩压水平，总死亡率的 HR 为 1.23（95%CI，1.17-1.28），CV 事件的 HR 为 1.36（95%CI，1.30-1.43）。对于 24 小时收缩压水平，总死亡率的 HR 为 1.22（95%CI，1.16-1.28），CV 事件的 HR 为 1.45（95%CI，1.37-1.54）。在调整任何其他收缩压指标后，夜间和 24 小时收缩压与主要结局的相关性仍然具有统计学意义（HR 范围为 1.17[95%CI，1.10-1.25]至 1.87[95%CI，1.62-2.16]）。包含单一收缩压指标的基本模型对死亡率的 AUC 为 0.83，对 CV 结果的 AUC 为 0.84。将 24 小时或夜间收缩压添加到包含其他 BP 指数的基本模型中，死亡率和复合 CV 结局的 AUC 分别增加了 0.0013 至 0.0027 和 0.0031 至 0.0075。将任何收缩压指数添加到已经包含夜间或 24 小时收缩压的模型中并不会显著改善模型性能。这些发现与舒张压一致。
在这项基于人群的队列研究中，较高的 24 小时和夜间血压测量值与死亡和复合 CV 结局的风险增加显著相关，即使在调整了其他基于办公室或动态血压测量值后也是如此。因此，24 小时和夜间血压可能被认为是估计 CV 风险的最佳测量值，尽管从统计学上讲，与其他血压指标相比，模型改善很小。
