NIH Public Access: Author Manuscript

NIH Public Access
Author Manuscript
Circulation. Author manuscript; available in PMC 2009 October 7.
Published in final edited form as:
NIH-PA Author Manuscript
Circulation. 2008 October 7; 118(15): 1558–1566. doi:10.1161/CIRCULATIONAHA.107.723593.
Hypertension Subtype and Risk of Cardiovascular Disease in

Chinese Adults
Tanika N. Kelly, MPH1, Dongfeng Gu, MD, MSc4, Jing Chen, MD, MSc1,3, Jian-feng Huang,
MD4, Ji-chun Chen, MD4, Xiufang Duan, MD4, Xigui Wu, MD4, C. Lillian Yau, PhD2, Paul K.
Whelton, MD, MSc5, and Jiang He, MD, PhD1,3
1 Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine,
New Orleans, LA, USA

2Department of Biostatistics, Tulane University School of Public Health and Tropical Medicine, New
Orleans, LA, USA
3 Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
4Cardiovascular Institute and Fuwai Hospital of the Chinese Academy of Medical Sciences and
Peking Union Medical College, Beijing, China
5 President’s Office, Loyola University Medical Center, Maywood, IL, USA
Abstract
Background—We examined the relationship between hypertension subtype and cardiovascular
disease (CVD) incidence and mortality in Chinese adults.
Methods and Results—We conducted a prospective cohort study in a nationally representative
sample of 169,871 Chinese men and women aged 40 years and older. Data on systolic (SBP) and
diastolic blood pressure (DBP) and other variables were obtained at a baseline examination in 1991
using standard protocols. Follow-up evaluation was conducted in 1999–2000, with a response rate
of 93.4%. Hypertension subtypes were defined as combined systolic and diastolic hypertension
(SDH: SBP≥140 and DBP≥90 mm Hg), isolated systolic hypertension (ISH: SBP≥140 and DBP<90
mm Hg), isolated diastolic hypertension (IDH: SBP<140 and DBP≥90 mm Hg), and two categories
of treated hypertension (SBP<140 and DBP<90 mm Hg or SBP≥140 and/or DBP≥90 mm Hg). After
excluding participants with missing BP values, 169,577 adults were included in the analyses.
Compared to normotensives, relative risks (95% confidence interval) of CVD incidence and mortality
were 2.73 (2.60–2.86) and 2.53 (2.39–2.68) for SDH, 1.78 (1.69–1.87) and 1.68 (1.58–1.78) for ISH,
1.59 (1.43–1.76) and 1.45 (1.27–1.65) for IDH, 2.01 (1.64–2.48) and 1.61 (1.28–2.03) for treated
hypertension with SBP<140 and DBP<90 mm Hg, and 3.37 (3.07–3.69) and 2.88 (2.60–3.19) for
treated hypertension with SBP≥140 and/or DBP≥90 mm Hg, respectively, after adjustment for
important covariables.
Conclusions—Our results indicate that all hypertension subtypes are associated with significantly
increased risk of CVD in Chinese adults. Primary prevention of hypertension should be a public
health priority in the Chinese population.
Corresponding Authors: Jiang He, MD, PhD, Department of Epidemiology, Tulane University School of Public Health and Tropical
Medicine, 1430 Tulane Avenue SL18, New Orleans, LA 70112, Phone: 504-988-5165, FAX: 504-988-1568, Email: jhe@tulane.edu Or
Dongfeng Gu, MD, MSc, Division of Population Genetics and Prevention, Cardiovascular Institute and Fu Wai Hospital, 167 Beilishi
Road, Beijing 100037, China, gudongfeng@vip.sina.com.
Disclosure
We declare that we have no conflict of interest related to this work.
Kelly et al. Page 2
Keywords
hypertension; cardiovascular disease; relative risk; Chinese
INTRODUCTION
Cardiovascular disease (CVD) has become the leading cause of death among Chinese adults,
with a heart disease mortality (per 100,000 person) of 319.1 in men and 268.5 in women and
stroke mortality of 310.5 in men and 242.3 in women (1). Hypertension is the most important
modifiable risk factor for CVD and all-cause mortality worldwide (2,3). Data from a national
blood pressure (BP) survey in China indicated that the prevalence of hypertension in the adult
Chinese population aged 35–74 years was 27.2% in 2000–2001 (4). In addition, an estimated
7.6% of Chinese adults had isolated systolic hypertension (ISH), 7.4% had combined systolic
and diastolic hypertension (SDH), 4.4% had isolated diastolic hypertension (IDH), and 7.7%
were taking antihypertensive medication (5).
In recent years the common paradigm of hypertension research has shifted from diastolic (DBP)
to systolic BP (SBP) as the most important determinant of CVD risk (6–8). Researchers have
investigated the singular and combined effects of elevations in SBP and DBP, with a growing
awareness that hypertension subtypes may reflect unique biological processes, perhaps with
distinct clinical implications (9–11). SDH arises from a combination of increased arterial
stiffness along with a rise in arteriolar resistance; ISH reflects increased arterial stiffness alone
and is most common in the elderly, while IDH is a consequence of an increase in only arteriolar
resistance and is more frequent in young and middle-aged persons (10–12). A clear
understanding of how each of these pathophysiologic mechanisms influences CVD risk is
crucial for establishing appropriate treatment recommendations and guidelines. While several
studies have been conducted in Western populations examining this association, very few have
been conducted in Asian populations, and none in a nationally representative cohort of Chinese
adults (12–14).
The purpose of this study was to quantify the risk of CVD, coronary heart disease (CHD), and
stroke incidence and mortality associated with hypertension subtype in a prospective,
nationally representative Chinese cohort. In addition, gender and age-specific effects of
hypertension subtype on CVD risk were examined.
METHODS
Study Population
In 1991, the third China National Hypertension Survey was carried out in all 27 provinces and
3 municipalities of mainland China using a multi-stage random cluster sampling design to
select a nationally representative sample of the Chinese population aged 15 years or older
(15). In 1999–2000, investigators from each province were invited to participate in the Chinese
National Hypertension Epidemiology Follow-up study. Of the 30 provinces or autonomous
regions, 13 were not included in the follow-up study because study participants’ contact
information was not available (Figure 1). However, the sampling process was conducted
independently within each province in the1991 China National Hypertension Survey and the
17 provinces that were included in the follow-up study were evenly distributed in different
geographic regions representing various economic developing statuses in China. Participants
from included provinces did not differ with respect to baseline characteristics compared to
those from excluded provinces. Overall, 83,533 men and 86,338 women aged 40 years or older
at their baseline examination were eligible to participate in the follow-up study. From this
population, a total of 158,666 study participants (93.4%) (or their proxies) were identified and

Kelly et al. Page 3
agreed to be interviewed as part of the follow-up study. In this report, study participants with
missing BP values (n=283), and prevalent CVD (n=4,412), CHD (n=2,253) or stroke (n=2,303)
were excluded from related analyses, respectively. Figure 2 shows the sample size of
participants and exclusion reasons in our study.
Baseline Examination
Baseline data were collected at a single clinic visit by specially trained physicians and nurses
using standardized methods with stringent levels of quality control (15). Data on demographic
characteristics, medical history (including physician’s diagnosis of hypertension and other
CVD as well as use of antihypertensive medication), and lifestyle risk factors were obtained
using a standard questionnaire administered by trained staff. Work-related physical activity
was assessed because leisure-time physical activity was uncommon. Cigarette smokers were
defined as having smoked at least 1 cigarette per day for 1 year or more. Alcohol consumption
was defined as drinking alcohol at least 12 times during the last year. Body weight and height
were measured in light indoor clothing without shoes according to a standardized protocol.
Body mass index (BMI) was calculated as weight in kilograms divided by height in square
meters. Three BP measurements were obtained by a trained observer using a standard mercury
sphygmomanometer according to a standard protocol after the study participant had been seated
quietly for 5 minutes (16). The first and fifth Korotkoff sounds were recorded as SBP and DBP,
respectively. Participants were instructed not to eat, drink alcohol, coffee, or tea, smoke, or
exercise for at least 30 minutes prior to their blood pressure measurement. The mean of 3 BP
measures was used in all analyses. There was no evidence of digit preference on BP readings.
Follow-up Data Collection

The follow-up examination, which was conducted between 1999 and 2000, included tracking
study participants or their proxies to a current address, performing in-depth interviews to
ascertain disease status and vital information, and obtaining hospital records and death
certificates. If a study participant reported a hospitalization or emergency room overnight-stay
due to a study outcome including acute myocardial infarction or stroke during the in-person
interview, the participant’s hospital records, including medical history, physical examination
findings, laboratory test results, and discharge diagnosis, were abstracted by trained staff using
a standard form. In addition, photocopies of selected sections of the participant’s inpatient
record, discharge summary, electrocardiogram, and pathology reports were obtained. All
deaths reported during the in-person interview were verified by obtaining death certificates
from the local public health department or police department. If death occurred during a
hospitalization, the participant’s hospital records and autopsy results were also abstracted by
trained staff using a standard form. An end-point assessment committee within each province
reviewed all data abstraction forms to ensure the completeness of medical information.
A study-wide end point assessment committee, consisting of cardiologists, neurologists, and

clinical epidemiologist at the Chinese Academy of Medical Sciences in Beijing, China,
reviewed all hospital records and death certificates and determined the final diagnosis of event
or underlying cause of death using pre-established criteria (17). Two committee members
independently verified the diagnosis and discrepancies were adjudicated by discussion
involving additional committee members. All members of the local and study-wide end point
assessment committees were blinded to the study participant’s baseline risk factor information.
Causes of death were coded according to the International Classification of Diseases, Ninth
Revision (ICD-9).
For this analysis, CVD was defined as a confirmed diagnosis of acute myocardial infarction
or stroke during the follow-up period or mortality with a cardiovascular event (ICD-9 390.0–
398.9, 401.0–429.9, and 430.0–438.9) listed as an underlying cause of death. CHD was defined

Kelly et al. Page 4
as a confirmed diagnosis of acute myocardial infarction during the follow-up period or CHD
listed as an underlying cause of death (ICD-9 410.0–414.9). Finally, stroke was defined as a
confirmed diagnosis of stroke during the follow-up period or stroke listed as an underlying
cause of death (ICD-9 430.0–438.9).
This study was approved by the Tulane University Health Sciences Center Institutional Review
Board and the Cardiovascular Institute and Fu Wai Hospital Ethics Committee. Written
informed consent was obtained from all study participants who agreed to participate in the
follow-up study.
Statistical Analysis
Hypertension subtype was determined by average baseline SBP and DBP and use of
antihypertensive medications. Treated hypertensives, defined as receiving antihypertensive
medication within the past two weeks were further categorized into one of two groups,
SBP<140 and DBP<90 mm Hg or SBP≥140 and/or DBP≥90 mm Hg. Untreated hypertensive
participants were grouped according to SBP and DBP as follows: SDH (SBP≥140 mm Hg and
DBP≥90 mm Hg), ISH (SBP≥140 mm Hg and DBP<90 mm Hg), or IDH (SBP<140 mm Hg
and DBP≥90 mm Hg). Participants with a SBP<140 mm Hg and DBP< 90 mm Hg were
classified into the normotensive group.
Baseline characteristics were compared between each hypertension subtype and the
normotensive group using X2 tests for categorical variables and ANOVA for continuous
variables. Person-years of follow-up were calculated from the date of baseline examination
until the date of cardiovascular event, death, or follow-up interview for each study participant.
Age-standardized incidence and mortality were calculated using the 5-year age-specific
incidence and mortality and the age distribution of the Chinese population from year 2000
census data.
To examine the association between hypertension subtype and CVD incidence and mortality,
Cox proportional hazards regression models were used to adjust for baseline age, sex,
education, cigarette smoking, alcohol consumption, physical inactivity, BMI, geographic
region (north vs. south), urbanization (rural vs. urban) and diabetes as a time-dependent
covariate. The onset time and diagnosis of diabetes were self-reported. Multivariable-adjusted
relative risks were calculated using normotensives as the reference category. Sub-group
analyses by gender and age (<60 years or ≥ 60 years) were conducted. The proportional hazards
assumption was visually assessed using plots of the Schoenfeld residuals versus time for each
covariate modeled. Methods to estimate variances that take into account sample clustering, by
province, were used in Cox proportional hazards models (18). Statistical analyses were
conducted using SAS statistical software (version 9.1; SAS Institute Inc, Cary, NC).
Statement of Responsibility—The authors had full access to the data and take
responsibility for its integrity. All authors have read and agree to the manuscript as written.
RESULTS
Baseline characteristics of the study participants by normotensive status and hypertension
subtype are presented in Table 1. Overall, SDH was the most common hypertension subtype
(10.8%), followed by ISH (10.5%) and IDH (3.6%). Only 2.8% of study participants were
taking antihypertensive medication, with a SBP<140 and DBP<90 mm Hg attained in 24.0%
of those treated. The average age of study participants ranged from 52.9 years among those
with IDH to 64.6 years among those with ISH. Compared to the normotensive group, all
hypertension subtypes had a higher mean BMI, SBP, and DBP. Moreover, hypertensive
participants were more likely to be physically inactive, diabetic, and living in urban regions

Kelly et al. Page 5
compared to normotensive participants. With the exception of those with ISH, hypertensive
participants were also more likely to be living in north China. High school education, cigarette
smoking and alcohol consumption varied between groups with the highest percentage among
those with IDH.
During an average follow-up of 8.3 years there were a total of 11,543 cardiovascular events
(8,745 fatal), including 1,907 CHD events (1,300 fatal) and 7,151 strokes (4,249 fatal). The
treated hypertensives with a SBP≥140 and/or DBP≥90 mmHg had the highest relative risk
(RR) of all cardiovascular events compared to normotensive participants (Table 2). The treated
hypertensives with a SBP<140 and/or DBP<90 mmHg were also at an increased risk of CVD,
CHD, and stroke incidence and mortality compared to normotensive participants. Among
untreated hypertensives, those with SDH had the highest RR of all cardiovascular events. Both
ISH and IDH conferred similar increased risks of CVD, CHD and stroke incidence and
mortality compared to the normotensive group.
The association between hypertension subtype and CVD incidence and mortality was
consistent between genders (Table 3). Similarly, the multivariable-adjusted RRs (95% CI) of
stroke incidence in men and women were 3.68 (3.41–3.98) and 3.84 (3.49–4.21) for SDH, 2.09
(1.91–2.30) and 2.33 (2.11–2.57) for ISH, 1.70 (1.46–1.98) and 2.21 (1.78–2.74) for IDH, 2.20
(1.55–3.13) and 2.76 (1.94–3.93) for treated hypertensives with a SBP<140 and DBP<90
mmHg, and 4.17 (3.56–4.87) and 4.87 (4.16–5.70) for treated hypertensive with a SBP≥140
and/or DBP≥90 mmHg, respectively. The multivariable-adjusted RRs (95% CI) of stroke
mortality in men and women were 4.18 (3.77–4.62) and 4.21 (3.71–4.77) for SDH, 2.13 (1.89–
2.39) and 2.40 (2.11–2.72) for ISH, 1.72 (1.36–2.17) and 2.29 (1.66–3.15) for IDH, 2.32 (1.57–
3.42) and 2.22 (1.38–3.57) for treated hypertensives with a SBP<140 and DBP<90 mmHg,
and 4.23 (3.54–5.06) and 4.40 (3.61–5.37) for treated hypertensives with a SBP≥140 and/or
DBP≥90 mmHg, respectively. Due to the small number of CHD events and deaths in women,
the multivariable-adjusted RR estimates by gender were unstable (data not shown). Subgroup
analyses by age showed that participants 60 years and older had an attenuated RR of incidence
(Figure 3) and mortality (Figure 4) of CVD and stroke associated with SDH, ISH, and treated-
hypertension with a SBP≥140 and/or DBP≥90 mmHg compared to those <60 years of age.
DISCUSSION
While elevated BP has long been established as an important risk factor for CVD, the risk
conferred by hypertension subtype has not been well examined. Our analysis indicates that
among untreated hypertensives, participants with SDH were at the highest risk for any
cardiovascular event while both ISH and IDH increased the risk of CVD compared to their
normotensive counterparts. We found that treated hypertensives, including those with a
SBP<140 and DBP<90 mmHg, were at an increased risk of CVD compared to normotensives,
while treated participants with a SBP≥140 and/or DBP≥90 mmHg had the highest risk among
all hypertensive subtypes studied. An increased risk of CVD associated with hypertension
subtype was observed in both genders and age groups. The present results emphasize the
importance of hypertension subtype in predicting CVD risk and highlight the need for a public
health response focusing on primary prevention of hypertension in the general Chinese
population.
The current study is the only prospective cohort in which the association between hypertension
subtype and CVD risk in a large, population-based, nationally representative sample of the
general Chinese population has been examined. The study population included middle-aged
and older persons of both genders, and stringent quality control procedures were used to assess
BP, other co-variables, and all clinical outcomes. While a very high follow-up rate of 93.4%
was achieved, those that were lost to follow-up were more likely to have SDH, ISH, and treated

Kelly et al. Page 6
hypertension at the baseline examination compared to those retained in the study, which may
have resulted in a slight underestimate of the rate and relative risk of CVD in this population.
Certain other limitations should also be acknowledged. BP measurements and information on
the use of antihypertensive medication were collected only at the baseline examination, and,
therefore, the impact of changes in these measurements on CVD risk cannot be assessed. In
addition, because the original survey was not conducted with the current follow-up study in
mind, important covariables including serum lipids, glucose, diet, and leisure-time physical
activity were not obtained and information on lifestyle risk factors and medical history was
self-reported. Lack of or under-adjustment for these variables might have resulted in a slight
over-estimate of the relative risk of CVD. Furthermore, study outcomes were identified by
self-reported events retrospectively and only one underlying cause of death was recorded for
each participant, which might underascertain events. Finally, no information on stroke subtype
was available, and although associations between BP and both ischemic and hemorrhagic
strokes have been observed, the precise effects of hypertension subtype on differing stroke
types may vary due to the distinct etiologies of these conditions (14,19,20).
In general, we observed lower CHD and higher stroke rates for any given BP level compared
to studies conducted in western populations (21,22). A lower serum lipid level in the Chinese
population may help explain the lower rates of CHD (23). Similarly, population differences in
CVD risk factors may explain the higher stroke rates. For example, hemorrhagic strokes are
more common in the Chinese population compared to Western populations (24,25). Low serum
cholesterol level and cigarette smoking are important risk factors for hemorrhagic stroke.
ISH has been associated with a higher risk of CVD compared to SDH in some large, prospective
studies (26–28). In contrast, our results and findings from other studies suggest that SDH
confers a higher CVD risk compared to ISH (12,14). Discrepancies may be due to heterogeneity
between the study populations regarding age, and other CVD risk factors.
The current study also showed that IDH was a significant predictor of CVD in the general
Chinese population. Some studies have indicated no relationship between IDH and CVD risk
(25–27) but others have reported results similar to our findings (14). A recent study by Fang
et al examining the effects of hypertension subtype in a Chinese cohort reported a 2.2-fold
increased risk of stroke incidence associated with IDH, which was similar to our observation
(14). Again, population heterogeneity may have contributed to these discrepant findings in the
relationship between IDH and CVD risk.
An important finding of this study is that treated hypertensives, including those with a SBP<140
and DBP<90 mmHg, were at an increased risk of all cardiovascular events compared to
participants with a normal BP. To date, many clinical trials have shown that anti-hypertension
treatment results in a reduction of cardiovascular events, but few studies have compared treated
hypertensives to normotensives in a prospective cohort (14,29–33). A recent study by Almgren
et al indicated that treated hypertensive men had an elevated risk of CHD and stroke compared
to men with normal BP, which is confirmed by the findings of this study (33). The high risk
of CVD conferred by inadequate treatment of hypertension underlines the need for more
aggressive anti-hypertension treatment in this population. The potential benefits of BP-
lowering treatment are reflected in the lower risks experienced by treated participants with a
SBP<140 and DBP<90 mm Hg. Despite adequate treatment of BP based on current guidelines,
these participants still experienced higher rates of cardiovascular events compared to
participants with normal BP. As a matter of fact, mean BP levels in this group were significantly
higher than those in normotensive participants. These findings illustrate that BP treatment to
the “controlled” range based on the current guideline still translates into higher CVD-related
morbidity and mortality. Future studies are warranted to examine the benefit of lowering BP
to normal level, i.e., SBP<120 and DBP<80 mm Hg on CVD risk. Our results also underscore

Kelly et al. Page 7
the need for an increased focus on primary prevention of hypertension to reduce the societal
burden of CVD in the Chinese population.
Increased risks of CVD incidence and mortality associated with all hypertension subtypes were
observed among men and women and among those ≥60 years and <60 years. The relationships
between each subtype and CVD risk were consistent across genders. While similar patterns of
association were seen between age groups, the risk of CVD conferred by hypertension subtype
was attenuated among participants ≥60 years compared to participants <60 years. These results
are similar to findings reported elsewhere (14,34,35), and, overall, they highlight the
importance of hypertension prevention and treatment in both genders and all age groups.
In conclusion, our study identified a significantly increased risk of CVD associated with both
isolated systolic and diastolic and combined systolic and diastolic elevations in BP. Most
importantly, this analysis indicated that treated hypertensives are at a significantly increased
risk of CVD, including those with a SBP<140 and DBP<90 mm Hg. Therefore, while more
aggressive secondary prevention efforts may help decrease CVD risk among those already
affected with inadequately treated or untreated hypertension, the primary prevention of
hypertension may be most effective and should be considered the first choice for curbing the
rising CVD epidemic in this population. A national program emphasizing lifestyle modification
for the primary prevention of hypertension should be established in China.
Clinical Summary
We examined the relationship between hypertension subtype and cardiovascular disease
(CVD) incidence and mortality in a prospective cohort study of 169,871 Chinese men and
women aged 40 years and older. Hypertension subtypes were defined as combined systolic and
diastolic hypertension [SDH: systolic blood pressure (SBP)≥140 and diastolic BP (DBP) ≥90
mm Hg], isolated systolic hypertension (ISH: SBP≥140 and DBP<90 mm Hg), isolated
diastolic hypertension (IDH: SBP<140 and DBP≥90 mm Hg), and two categories of treated
hypertension (SBP<140 and DBP<90 mm Hg or SBP≥140 and/or DBP≥90 mm Hg). All
hypertension subtypes were associated with an increased risk of CVD compared to participants
with normal BP. Compared to normotensives, SDH was associated with 2.73- and 2.53-fold
increased risk of CVD incidence and mortality; ISH was associated with 1.78- and 1.68-fold
increased risk of CVD incidence and mortality, IDH was associated with 1.59- and 1.45-fold
increased risk of CVD incidence and mortality, treated hypertension with SBP<140 and
DBP<90 mm Hg was associated with 2.01- and 1.61-fold increased risk of CVD incidence and
mortality, and treated hypertension with SBP≥140 and/or DBP≥90 mm Hg was associated with
3.37- and 2.88-fold increased risk of CVD incidence and mortality, respectively, after
adjustment for important covariables. These findings suggest that more aggressive
antihypertensive treatment efforts may help decrease CVD risk among those already affected
with inadequately treated or untreated hypertension while the primary prevention of
hypertension may be most effective and should be considered the first choice for curbing the
rising CVD epidemic in the Chinese population.
Acknowledgments
Funding Sources
This study was supported by a national Grant-in-Aid (9750612N) from the American Heart Association, Dallas, TX,
and partially supported by a grant (R01 HL68057) from the National Heart, Lung, and Blood Institute of the National
Institutes of Health, Bethesda, MD, and by a grant (1999-272) from the Chinese Ministry of Health, Beijing, China
and by the Chinese Academy of Medical Sciences, Beijing, China.

Kelly et al. Page 8
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Kelly et al. Page 10
Figure 1.
Map of China with participating provinces highlighted.

Figure 2.
Flow chart of participant recruitment and derivation of the population used in the final analysis.


Figure 3.
Relative risk (95% confidence interval) of cardiovascular disease, coronary heart disease, and
stroke incidence among those aged <60 and ≥ 60 years, after adjustment for baseline age, sex,
education, cigarette smoking, alcohol consumption, physical inactivity, body-mass index,
geographic region, urbanization and time-dependent history of diabetes.


Figure 4.
Relative risk (95% confidence interval) of cardiovascular disease, coronary heart disease, and
stroke mortality among those aged <60 and ≥60 years, after adjustment for baseline age, sex,
education, cigarette smoking, alcohol consumption, physical inactivity, body-mass index,
geographic region, urbanization and time-dependent history of diabetes.

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 1
Baseline characteristics of study participants by hypertension subtype
Untreated Hypertensives Treated Hypertensives

Characteristics Normotensives
SDH* ISH* IDH* <140/90 ≥140/90
Kelly et al.
No. of participants 122612 18310 17849 6140 1121 3545

Age, mean (SD), y 54.1 (10.1) 59.2 (10.4)§ 64.6 (10.6)§ 52.9 (9.3)§ 58.0 (9.5)§ 60.5 (10.0)§
Men, No. (%) 60538 (49.4) 9326 (50.9)§ 7333 (41.1)§ 4002 (65.2)§ 510 (45.5)‡ 1664 (46.9)†
≥High school education, No. (%) 26839 (24.3) 4352 (25.1)† 2614 (16.0)§ 2053 (35.3)§ 332 (32.1)§ 765 (22.9)
Cigarette smokers, No. (%) 42784 (38.5) 6434 (37.0)‡ 5628 (34.2)§ 2465 (42.3)§ 317 (30.7)§ 1098 (32.8)§
Alcohol consumption, No. (%) 21819 (19.6) 3810 (21.9)§ 2776 (16.9)§ 1645 (28.2)§ 155 (15.0)‡ 504 (15.1)§
Physical inactivity, No. (%) 37553 (33.5) 7515 (42.9)§ 7414 (44.8)§ 2196 (37.3)§ 697 (67.4)§ 2034 (60.8)§
BMI, mean (SD), kg/m2 22.1 (3.4) 24.3 (4.1)§ 22.8 (4.0)§ 24.1 (3.6)§ 24.8 (3.8)§ 25.0 (4.0)§
Diabetes, No. (%) 1597 (1.4) 548 (3.3)§ 422 (2.6)§ 153 (2.7)§ 53 (5.2)§ 176 (5.5)§
Systolic BP, mean (SD), mmHg 116.0 (12.4) 163.0 (19.5)§ 152.9 (13.4)§ 130.3 (6.8)§ 126.0 (9.4)§ 163.0 (21.8)§
Diastolic BP, mean (SD), mmHg 72.7 (8.5) 98.4 (8.5)§ 79.7 (7.4)§ 92.4 (3.5)§ 77.6 (7.9)§ 92.7 (12.4)§
North, No. (%) 70973 (57.9) 13516 (73.8)§ 10450 (58.6) 4749 (77.4)§ 693 (61.8)† 2185 (61.6)§
Urban, No. (%) 67829 (55.3) 12224 (66.8)§ 10752 (60.2)§ 4386 (71.4)§ 912 (81.4)§ 2755 (77.7)§
*
SDH=Combined systolic and diastolic hypertension; ISH=Isolated systolic hypertension; IDH=Isolated diastolic hypertension.
†
P<0.05,
‡
P<0.001,

§
P<0.0001 for x2 test or ANOVA, compared with normotensive group.
Page 16
Table 2
Relative risk of cardiovascular disease by hypertension subtype

Normotensives
SDH* ISH* IDH* <140/90 ≥140/90
Kelly et al.
CVD Incidence
Person-years of follow-up 896060 113095 113426 43620 6872 19889
No. of events 5404 2720 2389 400 92 538
Age-standardized rate, per 100,000 590.7 1718.7 1023.7 996.7 1085.7 1931.3
person-yrs
Age and sex adjusted RR (95% CI) 1.00 2.68 (2.56–2.81) 1.76 (1.67–1.85) 1.53 (1.38–1.69) 1.88 (1.53–2.31) 3.16 (2.88–3.46)
Multivariable adjusted RR† (95% 1.00 2.73 (2.60–2.86) 1.78 (1.69–1.87) 1.59 (1.43–1.76) 2.01 (1.64–2.48) 3.37 (3.07–3.69)
CI)
CVD Mortality
No. of events 3882 2134 1938 235 75 481
person-yrs
Multivariable adjusted RR (95% 1.00 2.53 (2.39–2.68) 1.68 (1.58–1.78) 1.45 (1.27–1.65) 1.61 (1.28–2.03) 2.88 (2.60–3.19)
CI)
CHD Incidence
No. of events 920 405 382 83 24 93
Age-standardized rate, per 100,000 97.9 243 165.7 202.5 266.9 253.2

person-yrs
Age and sex adjusted RR(95% CI) 1.00 1.98 (1.76–2.23) 1.67 (1.47–1.89) 1.56 (1.24–1.95) 2.79 (1.86–4.20) 2.98 (2.40–3.71)
Multivariable adjusted RR(95% 1.00 1.93 (1.71–2.18) 1.62 (1.43–1.84) 1.55 (1.23–1.94) 2.20 (1.46–3.32) 2.44 (1.95–3.06)
CI)
CHD Mortality
No. of events 571 305 293 47 15 69
person-yrs
Age and sex adjusted RR(95% CI) 1.00 2.03 (1.76–2.33) 1.62 (1.40–1.87) 1.44 (1.07–1.95) 2.86 (1.71–4.79) 3.45 (2.67–4.47)
Page 17

Normotensives
SDH* ISH* IDH* <140/90 ≥140/90
Kelly et al.
Multivariable adjusted RR(95% 1.00 1.85 (1.60–2.14) 1.55 (1.34–1.79) 1.47 (1.09–1.99) 2.06 (1.23–3.47) 2.61 (2.00–3.40)
CI)
Stroke Incidence
No. of events 2861 2090 1466 274 64 396
person-yrs
CI)
Stroke Mortality
No. of events 1473 1351 950 120 45 310
person-yrs
CI)
*
†
Adjusted for baseline age, sex, education, cigarette smoking, alcohol consumption, physical inactivity, BMI, geographic region (north vs. south), urbanization (rural vs. urban) and diabetes as a time-
dependent covariate.

Page 18
Table 3
Relative risk of cardiovascular disease by hypertension subtype and gender
Normotensives SDH* ISH* IDH* <140/90 ≥140/90

Kelly et al.
Men
CVD Incidence
No. of events 3182 1567 1143 260 45 266
Age-standardized rate, per 668.8 1895.6 1172.5 10271 1100.6 2011.8
100,000 person-yrs
Age and sex adjusted RR 95% CI) 1.0 2.67 (2.51–2.85) 1.74 (1.62–1.86) 1.43 (1.26–1.62) 1.65 (1.22–2.21) 3.07 (2.70–3.49)
Multivariable adjusted RR† (95% 1.0 2.72 (2.56–2.90) 1.76 (1.64–1.89) 1.49 (1.31–1.69) 1.79 (1.33–2.40) 3.30 (2.90–3.76)
CI)
CVD Mortality
No. of events 2297 1242 930 148 43 264
Age-standardized rate, per 474.1 1227.9 741.8 577.9 695.4 1456.9
100,000 person-yrs
CI)
Women
CVD Incidence

No. of events 2222 1153 1246 140 47 272
100,000 person-yrs
CI)
CVD Mortality
No. of events 1585 892 1008 87 32 217
100,000 person-yrs
Page 19
Normotensives SDH* ISH* IDH* <140/90 ≥140/90

Kelly et al.
CI)
*
†
Adjusted for baseline age, sex, education, cigarette smoking, alcohol consumption, physical inactivity, BMI, geographic region (north vs. south), urbanization (rural vs. urban) and diabetes as a time-
dependent covariate.

Page 20

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Circulation. 2008 October 7; 118(15): 1558–1566. doi:10.1161/CIRCULATIONAHA.107.723593.

Hypertension Subtype and Risk of Cardiovascular Disease in

New Orleans, LA, USA

Circulation. Author manuscript; available in PMC 2009 October 7.

participants and exclusion reasons in our study.

Follow-up Data Collection

A study-wide end point assessment committee, consisting of cardiologists, neurologists, and

Circulation. Author manuscript; available in PMC 2009 October 7.

cause of death (ICD-9 430.0–438.9).

Circulation. Author manuscript; available in PMC 2009 October 7.

those with IDH.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Version 4.0. [October 1997].

Circulation. Author manuscript; available in PMC 2009 October 7.

24. Rosamund W, Flegal K, Friday G, Furie K, Go A, Greenlund K, Haase N, Ho M, Howard V, Kissela

the elderly: meta-analysis of outcome trials. Lancet 2000;355:865–72. [PubMed: 10752701]

Pacifica region. J Hypert 2003;21:707–16.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Circulation. Author manuscript; available in PMC 2009 October 7.

Untreated Hypertensives Treated Hypertensives

No. of participants 122612 18310 17849 6140 1121 3545

Circulation. Author manuscript; available in PMC 2009 October 7.

Untreated Hypertensives Treated Hypertensives

Circulation. Author manuscript; available in PMC 2009 October 7.

Untreated Hypertensives Treated Hypertensives

Circulation. Author manuscript; available in PMC 2009 October 7.

Untreated Hypertensives Treated Hypertensives

Normotensives SDH* ISH* IDH* <140/90 ≥140/90

Circulation. Author manuscript; available in PMC 2009 October 7.

Untreated Hypertensives Treated Hypertensives

Normotensives SDH* ISH* IDH* <140/90 ≥140/90

Circulation. Author manuscript; available in PMC 2009 October 7.

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