Impacts of the New 2017 ACC/AHA Hypertension Guideline on the Prevalence of Brachial Hypertension and Its Concordance with Central Hypertension

Impacts of the New 2017 ACC/AHA Hypertension Guideline on the Prevalence of Brachial Hypertension... Abstract OBJECTIVES The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline lowers the blood pressure (BP) thresholds for defining brachial hypertension. We therefore aimed to investigate how the new guideline influences the prevalence of brachial hypertension and whether it improves the identification of central hypertension in an Asian national representative population. METHODS A total of 2,742 adults older than 19 years participated in the 2013–2016 National Nutrition and Health Survey in Taiwan. Central and brachial BPs were simultaneously measured twice and averaged using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device). Brachial hypertension was defined by brachial systolic/diastolic BP ≥ 130 or 80 mm Hg or using antihypertensive medication, and central hypertension was defined by central systolic/diastolic BP ≥ 130 or 90 mm Hg or using antihypertensive medication. RESULTS The national weighted prevalence rates of brachial hypertension according to the 2017 AHA/ACC guideline were 48.7% in men and 30.7% in women. The prevalence of brachial hypertension increased by 18.8% in men and 9.4% in women, when compared with the prevalence defined by the conventional thresholds of brachial systolic/diastolic BP ≥ 140 or 90 mm Hg. In comparison with the conventional criteria, the new hypertension criteria had a higher sensitivity (93.0% vs. 77.4%) and a lower specificity (86.7% vs. 99.6%) for detecting central hypertension. CONCLUSIONS Adoption of the 2017 AHA/ACC BP thresholds substantially increases the prevalence of brachial hypertension, especially in men, and identifies over 90% of those with central hypertension at the expense of lesser specificity. blood pressure, hypertension; measurement; prevalence The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline recommends lower levels of both systolic and diastolic blood pressure (BP) for defining hypertension,1 and implementation of the new guideline is expected to increase the prevalence of hypertension and use of antihypertensive medication, and reduce cardiovascular disease events in the United States.2 Vascular aging progressively increases systolic BP and lowers diastolic BP, and is the major pathophysiology for the development of hypertension in the elderly population.3 Apparently, lowering systolic BP threshold has a much greater impact on the diagnosis of hypertension than lowering diastolic BP threshold in an elderly population. Central systolic BP is usually lower than brachial systolic BP, and the former is a better indicator of vascular aging than the latter. As vascular aging is a major risk factor of cardiovascular disease events independent of conventional risk factors, central BP might be better than brachial BP in prediction of cardiovascular outcomes.4 It has been shown that using cuff brachial BP to diagnose hypertension may substantially underestimate the prevalence of hypertension,5 because of the limited accuracy of brachial cuff BP.6 Instead, hypertension defined by central BP thresholds of ≥130/90 mm Hg may have a greater discriminatory power for long-term events.7 Using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device),8 we have shown that a substantial proportion of subjects with the central hypertension could not be identified using a conventional brachial BP approach in a national representative population in Taiwan.9 Taiwan is one of the fastest-aging societies in the world,10 and vascular aging would substantially increase the burden of hypertension control at present and in the near future.3 In this study, we therefore estimated the prevalence of brachial hypertension according to the 2017 ACC/AHA guideline and examined the concordance between the brachial hypertension and central hypertension in the same national representative population.9 MATERIAL AND METHODS The sampling and enrollment of the national representative population for the 2013–2016 National Nutrition and Health Survey in Taiwan (NAHSIT) has previously been reported.9 In brief, NAHSIT 2013–2016 was aimed to investigate the nutrition status and the association between nutrition/diet and disease in residents in Taiwan. All residents in the National Household Registry in Taiwan were candidates, excluding those who lived in military institutes, medical institutes, schools, occupation/sport training centers, dormitories, and prisons. Enrolled subjects in the NAHSIT were selected using a multistage stratified sampling scheme. Informed consent was obtained from each participant before the household interview. All subjects who had received the household interview were invited for a health checkup, including fasting blood, biochemical, and urine sample testing, and central and brachial BP measurements. A total of 2,742 residents aged more than 19 years attended the health checkup. BP measurement and definitions of brachial and central hypertension All participants were asked to refrain from exercise, smoking, and drinking tea or coffee before BP measurement. BP measurement was carried out between 8 am and 12 noon while subjects had been seated and relaxed for 5 minutes with back and arms supported, legs uncrossed, and feet flat on the floor in a quiet room at each survey site for the health checkup.11 Central and brachial BPs were measured simultaneously in the right arm with an appropriately sized cuff at heart level, using an oscillometric central BP monitor (WatchBP Office Central; Microlife AG, Widnau, Switzerland).12 The central BP monitor measured brachial systolic and diastolic BP, performed pulse volume plethysmography at cuff pressure of 60 mm Hg to provide an ensemble average brachial pressure waveform, calibrated the ensemble average waveform to the brachial systolic and diastolic BPs, analyzed the calibrated waveform, and finally calculated central systolic BP and pulse pressure (PP) according to separate regression equations constructed from components of the analyzed waveform.12,13 Measurement accuracy of the stand-alone oscillometric central BP monitor with reference to the simultaneously measured invasive central BP in 85 subjects has been previously reported.12 The mean differences of central systolic BP, PP, and diastolic BP with reference to the invasively measured central BPs were −0.6 ± 5.5, −0.4 ± 7.0, and −0.2 ± 6.5 mm Hg, respectively, without obvious systematic bias.12 The central BP monitor displayed readings of brachial systolic and diastolic BPs, central systolic BP and PP, and heart rate, each of which was an average from 2 consecutive measurements separated by an interval of 60 second. Central diastolic BP was calculated as the difference between central systolic BP and PP.12 Normal brachial BP was defined as brachial systolic BP < 120 mm Hg and diastolic BP < 80 mm Hg in subjects without using antihypertensive medication.1 Elevated brachial BP was defined as brachial systolic BP 120–129 mm Hg and diastolic BP < 80 mm Hg in subjects without using antihypertensive medication.1 Brachial hypertension was defined as brachial systolic BP ≥ 130 mm Hg or diastolic BP ≥ 80 mm Hg or using antihypertensive medication.1 In subjects with brachial hypertension, isolated brachial systolic hypertension was defined as brachial systolic BP ≥ 130 mm Hg and diastolic BP < 80 mm Hg; isolated brachial diastolic hypertension was defined as brachial systolic BP < 130 mm Hg and diastolic BP ≥ 80 mm Hg; combined brachial systolic/diastolic hypertension was defined as brachial systolic BP ≥ 130 mm Hg and diastolic BP ≥ 80 mm Hg. Central hypertension was defined as central systolic BP ≥ 130 mm Hg or diastolic BP ≥ 90 mm Hg or using antihypertensive medication.7,9 Other definitions Diabetes was defined as fasting glucose ≥126 mg/dl or using antidiabetic medication. Dyslipidemia was defined as total cholesterol ≥200 mg/dl or low-density lipoprotein cholesterol ≥130 mg/dl or using lipid lowering medication. All subjects were asked about the tobacco exposure status using the questionnaire of “Do you have a habit of smoking?” and a “Yes” answer was categorized as current smoking. Physical activity was measured using the international physical activity questionnaire. Physical inactivity was defined as no activity is reported or some activity is reported but not enough to meet a moderate or high activity category.14 10-year coronary heart disease risk score The 10-year coronary heart disease risk score for everyone was calculated using a simple point system (18 total points) for the clinical model developed from 3,430 Taiwanese participants followed up for a median 15.9 years.9,15 The performance of the clinical model, incorporating age (0–8 points), gender (0–2 points), body mass index (0–4 points), systolic BP (0–3 points), and smoking status (1 point), was not inferior to the cholesterol-based model and Framingham model in the external validation dataset.15 Statistical methods Means (±SD) and proportions were used to describe the characteristics of the national representative population. The analysis of variance method with Scheffe’s multiple comparison and chi-square test were used to examine the difference in intervals and proportions between BP categories, respectively. National weighted prevalence rates of central and brachial hypertension were estimated accounting for sampling scheme in the sampled population using SAS-callable SUDDAN. We also estimated the standardized prevalence rates of central and brachial hypertension using the World Health Organization (WHO) 2000 world standardized population.16,17 The sensitivity, specificity, false-positive rate, and false-negative rate were calculated with central hypertension as the true disease, and conventional brachial hypertension (≥140/90 mm Hg) and 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) guideline were used as screening tools. The concordance rate and kappa index were also calculated. Comparisons between subjects with concordant central and brachial nonhypertension, isolated central hypertension, isolated brachial hypertension, and concordant central and brachial hypertension were performed with multiple comparison test or chi-square test where appropriate. We further used the multivariable logistic regression with stepwise selection from candidates of all significant variables in univariate analyses to identify the independent determinants of isolated central hypertension among subjects without brachial hypertension, and of isolated brachial hypertension among subjects with brachial hypertension. All statistical tests were set at a type I error of 5% and 2 tails. P values of <0.05 were considered statistically significant. RESULTS The national representative sample of 2,742 adults older than 19 years were categorized as normal BP, elevated brachial BP and brachial hypertension according to 2017 ACC/AHA hypertension guideline and the characteristics of the 3 BP categories are shown in Table 1. As expected, subjects with elevated brachial BP or brachial hypertension were older, had higher brachial and central systolic and diastolic BP and PP, body mass index, waist circumference, fasting blood levels of triglycerides, low-density lipoprotein cholesterol, total cholesterol, and glucose, had lower high-density lipoprotein cholesterol, and had higher prevalence of diabetes and dyslipidemia, in comparison to subjects with normal brachial BP. No significant difference in the prevalence of smoking was observed among the 3 BP categories. In subjects with brachial hypertension, 74.4% would also be defined as brachial hypertension according to the conventional brachial BP thresholds of ≥140/90 mm Hg. The crude prevalence of central hypertension was 0.60% in the normal brachial BP category, 25.7% in the elevated brachial BP category, and 85.6% in the brachial hypertension category. Table 1. Characteristics of the national representative population according to the 2017 ACC/AHA hypertension guideline Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 2017 ACC/AHA normal brachial BP: brachial SBP < 120 mm Hg and DBP < 80 mm Hg and without using antihypertensive medication. 2017 ACC/AHA elevated brachial BP: brachial SBP 120–129 or DBP < 80 mm Hg in subjects without using antihypertensive medication. Diabetes: fasting glucose ≥126 mg/dl or using diabetic medicines. Dyslipidemia: total cholesterol ≥200 mg/dl or LDL cholesterol ≥130 mg/dl or using lipids lowering drugs. Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; DBP = diastolic BP; HDL = high-density lipoprotein; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic BP. a2017 ACC/AHA brachial hypertension: brachial SBP ≥ 130 or DBP ≥ 80 mm Hg or using antihypertensive medication. bConventional brachial hypertension: brachial SBP ≥ 140 or DBP ≥ 90 mm Hg or using antihypertensive medication. cCentral hypertension: central SBP ≥ 130 or DBP ≥ 90 mm Hg or using antihypertensive medication. View Large Table 1. Characteristics of the national representative population according to the 2017 ACC/AHA hypertension guideline Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 2017 ACC/AHA normal brachial BP: brachial SBP < 120 mm Hg and DBP < 80 mm Hg and without using antihypertensive medication. 2017 ACC/AHA elevated brachial BP: brachial SBP 120–129 or DBP < 80 mm Hg in subjects without using antihypertensive medication. Diabetes: fasting glucose ≥126 mg/dl or using diabetic medicines. Dyslipidemia: total cholesterol ≥200 mg/dl or LDL cholesterol ≥130 mg/dl or using lipids lowering drugs. Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; DBP = diastolic BP; HDL = high-density lipoprotein; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic BP. a2017 ACC/AHA brachial hypertension: brachial SBP ≥ 130 or DBP ≥ 80 mm Hg or using antihypertensive medication. bConventional brachial hypertension: brachial SBP ≥ 140 or DBP ≥ 90 mm Hg or using antihypertensive medication. cCentral hypertension: central SBP ≥ 130 or DBP ≥ 90 mm Hg or using antihypertensive medication. View Large Prevalence of brachial hypertension according to the 2017 ACC/AHA guideline The WHO-age standardized prevalence of brachial hypertension was 34.5% (43.5% for men and 26.0% for women) (Table 2). The national weighted prevalence of brachial hypertension was 39.1% (48.7% for men and 30.4% for women) (Table 2). The national weighted prevalence of central hypertension and brachial hypertension according to the conventional criteria and the 2017 ACC/AHA hypertension guideline stratified by sex and age groups are shown in Supplementary Table 1. Adoption of the 2017 ACC/AHA guideline would therefore increase the national weighted prevalence of brachial hypertension by 18.8% in men and 9.1% in women, when compared with the corresponding figures of 29.9% in men and 21.3% in women, respectively, defined by the conventional BP thresholds of brachial systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg.9 The increase in the prevalence of brachial hypertension resulting from the lowering of BP thresholds by the 2017 ACC/AHA guideline was particularly remarkable in men aged less than 55 years (Figure 1). Table 2. Prevalence rates of brachial hypertension according to the 2017 ACC/AHA hypertension guideline adjusted for national weights or WHO standardized population National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; WHO = World Health Organization. View Large Table 2. Prevalence rates of brachial hypertension according to the 2017 ACC/AHA hypertension guideline adjusted for national weights or WHO standardized population National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; WHO = World Health Organization. View Large Figure 1. View largeDownload slide Increments (delta, white bars) of the prevalence of brachial hypertension by the 2017 American College of Cardiology/American Heart Association (AHA/ACC) hypertension guideline (black lines) with reference to the prevalence defined by the conventional blood pressure thresholds (grey bars) in men and women, and in different age groups. Figure 1. View largeDownload slide Increments (delta, white bars) of the prevalence of brachial hypertension by the 2017 American College of Cardiology/American Heart Association (AHA/ACC) hypertension guideline (black lines) with reference to the prevalence defined by the conventional blood pressure thresholds (grey bars) in men and women, and in different age groups. In men, the increase in the prevalence of brachial hypertension by the 2017 ACC/AHA hypertension guideline was attributed to a high diastolic BP only (≥80 mm Hg, 47%), a high systolic BP only (≥130 mm Hg, 24%), or both (29%) (Supplementary Figure 1). In contrast, the corresponding figures in women were 33%, 44%, and 23%, respectively (Supplementary Figure 1). Characteristics of the subjects who were initially categorized as nonhypertension according to the conventional BP thresholds but were recategorized as brachial hypertension according to the 2017 ACC/AHA hypertension guideline are shown in Supplementary Table 2. Multivariable stepwise logistic regression analysis revealed that older age, a higher brachial systolic BP, waist circumference and triglyceride level, a history of diabetes and dyslipidemia, and a lower brachial PP, and total cholesterol level were independent correlates of the recategorized brachial hypertension (Supplementary Table 3). Identification of central hypertension by brachial hypertension The performance of brachial hypertension defined by the conventional BP thresholds or the 2017 AHA/ACC guideline in identifying central hypertension is shown in Table 3. Lowering of the BP thresholds increased sensitivity and false-positive rate but decreased specificity and false-negative rate. Overall, the new hypertension criteria had a lower concordance rate (88.8% vs. 92.4%) and a lower kappa index (0.758 vs. 0.815) for detecting central hypertension. Table 3. Identification of central hypertension by brachial hypertension according to the conventional brachial blood pressure thresholds or 2017 AHA/ACC hypertension guideline Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Sensitivity: P (brachial hypertension | central hypertension). Specificity: P (nonbrachial hypertension | noncentral hypertension). False-positive rate: P (brachial hypertension | noncentral hypertension). False-negative rate: P (nonbrachial hypertension | central hypertension). Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; CI = confidence interval. View Large Table 3. Identification of central hypertension by brachial hypertension according to the conventional brachial blood pressure thresholds or 2017 AHA/ACC hypertension guideline Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Sensitivity: P (brachial hypertension | central hypertension). Specificity: P (nonbrachial hypertension | noncentral hypertension). False-positive rate: P (brachial hypertension | noncentral hypertension). False-negative rate: P (nonbrachial hypertension | central hypertension). Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; CI = confidence interval. View Large Isolated central hypertension and isolated brachial hypertension According to the 2017 ACC/AHA hypertension guideline and the central hypertension criteria, all subjects could be classified as concordant nonhypertension (nonbrachial hypertension and noncentral hypertension, n = 1,360, 49.6%), isolated central hypertension (n = 76, 2.8%), isolated brachial hypertension (n = 188, 6.9%), and concordant hypertension (brachial hypertension and central hypertension, n = 1,118, 40.8%) (Table 4). The national weighted prevalence rates of concordant nonhypertension, isolated central hypertension, isolated brachial hypertension, and concordant hypertension were 58.6%, 2.3%, 8.9%, and 30.2%, respectively. Table 4. Characteristics of the subjects with isolated central hypertension or isolated brachial hypertension in comparison to those with concordant nonhypertension or hypertension Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Brachial hypertension: brachial blood pressure ≥130/80 mm Hg or using antihypertensive medication (2017 ACC/AHA hypertension guideline). Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Brachial ISH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure <80 mm Hg. Brachial IDH: brachial systolic blood pressure <130 mm Hg and diastolic blood pressure ≥80 mm Hg. Brachial SDH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg. Abbreviations: DBP = diastolic blood pressure; HDL = high-density lipoprotein; IDH = isolated diastolic hypertension; ISH = isolated systolic hypertension; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic blood pressure; SDH = combined systolic/diastolic hypertension. aP value less than 0.05 for comparing with those without brachial or central hypertension (concordant nonhypertension). bP value less than 0.05 for comparison with those with isolated central hypertension. cP value less than 0.05 for comparison with those with isolated brachial hypertension. View Large Table 4. Characteristics of the subjects with isolated central hypertension or isolated brachial hypertension in comparison to those with concordant nonhypertension or hypertension Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Brachial hypertension: brachial blood pressure ≥130/80 mm Hg or using antihypertensive medication (2017 ACC/AHA hypertension guideline). Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Brachial ISH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure <80 mm Hg. Brachial IDH: brachial systolic blood pressure <130 mm Hg and diastolic blood pressure ≥80 mm Hg. Brachial SDH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg. Abbreviations: DBP = diastolic blood pressure; HDL = high-density lipoprotein; IDH = isolated diastolic hypertension; ISH = isolated systolic hypertension; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic blood pressure; SDH = combined systolic/diastolic hypertension. aP value less than 0.05 for comparing with those without brachial or central hypertension (concordant nonhypertension). bP value less than 0.05 for comparison with those with isolated central hypertension. cP value less than 0.05 for comparison with those with isolated brachial hypertension. View Large The prevalence of isolated brachial hypertension was remarkably higher than isolated central hypertension in the young and middle adults, especially in men (Figure 2). In men, the prevalence of isolated brachial hypertension remained higher than that of isolated central hypertension in the elderly women (Figure 2). In contrast, elderly women had a higher prevalence of isolated central hypertension than isolated brachial hypertension (Figure 2). Figure 2. View largeDownload slide National weighted prevalence of isolated central hypertension and isolated brachial hypertension (≥130/80 mm Hg), by age groups. Figure 2. View largeDownload slide National weighted prevalence of isolated central hypertension and isolated brachial hypertension (≥130/80 mm Hg), by age groups. In subjects with isolated brachial hypertension, the prevalence of isolated brachial diastolic hypertension, combined brachial systolic/diastolic hypertension, and isolated brachial systolic hypertension was 70.2%, 22.3%, and 7.5%, respectively (Table 4). In contrast, in subjects with both brachial and central hypertension (concordant hypertension), the dominant phenotype was combined brachial systolic/diastolic hypertension (86.40%), followed by isolated brachial systolic hypertension (12.3%), then by isolated brachial diastolic hypertension (1.3%) (Table 4). Subjects with isolated central hypertension were older and characterized with a significantly higher central and brachial systolic BP, diastolic BP and PP, a greater body mass index and waist circumference, a higher prevalence of diabetes, and a lower high-density lipoprotein cholesterol level, in comparison with subjects without brachial or central hypertension (concordant nonhypertension) (Table 4). In subjects without brachial hypertension (concordant nonhypertension + isolated central hypertension), multivariable stepwise logistic regression analysis revealed that only central systolic BP (mm Hg) (odds ratio 21.472, 95% confidence intervals 5.621–82.019, P < 0.0001) was significantly independently associated with isolated central hypertension. On the other hand, subjects with isolated brachial hypertension were younger, predominantly men, and characterized with a significantly lower brachial and central systolic BP, diastolic BP and PP, lower body mass index, waist circumference, glucose level, a lower prevalence of diabetes and use of antidiabetic medication, a higher level of triglyceride, and a higher prevalence of smoking, in comparison with subjects with concordant nonhypertension. In subjects with brachial hypertension (concordant hypertension + isolated brachial hypertension), multivariable stepwise logistic regression analysis revealed that younger age (odds ratio 0.943, 95% confidence intervals 0.928–0.959, P < 0.0001), male sex (vs. female) (1.977, 1.248–3.132, P = 0.0037), higher brachial diastolic BP (mm Hg) (1.121, 1.090–1.152, P < 0.0001), lower central systolic BP (mm Hg) (0.846, 0.822–0.870, P < 0.0001), and lower body mass index (kg/m2) (0.902, 0.848–0.958, P = 0.0008) were independently associated with isolated brachial hypertension. Subjects with either isolated central hypertension or isolated brachial hypertension had a significantly higher estimated 10-year coronary heart disease risk score than those without brachial or central hypertension (concordant nonhypertension). On the other hand, subjects with concordant hypertension had the highest brachial systolic BP and PP, central systolic BP, waist circumference, fasting glucose, and estimated 10-year coronary heart disease risk score, when compared with the other groups. DISCUSSION Main findings Almost half of men and one-third of women in Taiwan would be categorized as having brachial hypertension by the 2017 ACC/AHA guideline. The increased prevalence of brachial hypertension was mainly attributed to the high prevalence of isolated diastolic hypertension in the young and middle-aged adults (19–64.9 years), especially in men. The new brachial hypertension criteria were very sensitive in identifying central hypertension, at the expense of lesser specificity. The resultant “false positive” was a group of subjects with brachial hypertension but without central hypertension, namely, the isolated brachial hypertension. Isolated brachial hypertension was characterized by young age, male sex, and isolated diastolic hypertension, implying minimal evidence of the presence of arterial stiffness or vascular aging. Subjects with isolated brachial hypertension had an increased risk of coronary heart disease similar to those with isolated central hypertension, when compared with subjects without brachial or central hypertension (concordant nonhypertension). Moreover, subjects with concordant brachial and central hypertension had a significantly increased estimated 10-year coronary heart disease risk score than those with isolated brachial hypertension. Overall, our results may support the adoption of the 2017 ACC/AHA hypertension guideline for the diagnosis of brachial hypertension, and concomitant measurement of central BP may supplement the new brachial hypertension criteria by helping stratify the high-risk subjects from those with brachial hypertension and identify the remaining central hypertension in those without brachial hypertension. Increase in hypertension prevalence by the 2017 ACC/AHA hypertension guideline The ACC/AHA hypertension guideline lowers the brachial systolic and diastolic BP thresholds and therefore unavoidably increases the prevalence of brachial hypertension and its public burden. Among US adults, the crude prevalence of brachial hypertension reached 45.6% by the new criteria (from 31.9% by the conventional criteria).2 Men had a greater increase in the brachial hypertension prevalence than women (17% [31%->48%] and 11% [32%->43%], respectively), and men aged less than 55 years increased more than 50%. In contrast, in Bangladesh, women had a higher prevalence than men (54.5% vs. 41.4%), and the prevalence of brachial hypertension doubly increased (from 25.7%->48.0%) among adults aged ≥35 years18 by the new hypertension criteria and the increase of brachial hypertension prevalence was similar in both genders (22.0% vs. 22.6%).18 In this study, men would have a higher increase of the prevalence of brachial hypertension than women (18.8% vs. 9.1%), and the increase would reach 50% in young men (aged less than 50 years), according to the 2017 ACC/AHA criteria. Therefore, the impact of the 2017 ACC/AHA hypertension guideline on the prevalence of hypertension and burden of hypertension control may vary substantially among populations. The relationship between brachial hypertension and central hypertension: Impact of the 2017 ACC/AHA hypertension guideline Central BP might be a better predictor for cardiovascular outcomes than peripheral BP.4 Conventional cuff brachial BP monitors usually underestimate intra-arterial brachial systolic BP and overestimate intra-arterial diastolic BP.6 Cuff and intra-arterial aortic systolic BP may show a small mean difference but poor agreement.6 Therefore, cuff BP has variable accuracy for measuring either brachial or aortic intra-arterial BP,6 and this may adversely influence the accuracy of hypertension prevalence. With reference to the intra-arterial aortic BP, we have shown that cuff brachial BP substantially underestimated the prevalence of central hypertension, according to the conventional brachial BP thresholds (≥140/90 mm Hg).5 Moreover, in the same national representative population as the present one, 7.35% of adults with central hypertension were not identified by the cuff BP.9 More importantly, those with the isolated central hypertension had a significantly higher risk of coronary heart disease than those with concordance nonhypertension.9 In this study, adoption of the 2017 ACC/AHA hypertension guideline would identify more subjects with true central hypertension but at the same time misclassify a substantial number of false-positive central hypertension so the concordance between brachial hypertension and central hypertension would not improve, as compared with the conventional hypertension criteria. Isolated brachial hypertension and sex difference In this study, a significant subgroup of subjects with isolated brachial hypertension (national weighted prevalence, 8.9%) was identified, based on the 2017 ACC/AHA hypertension guideline and the central hypertension criteria.7 Subjects with the isolated brachial hypertension were predominantly young men with isolated diastolic hypertension. Male gender, middle age, overweight or obesity, smoking, and hypercholesterolemia were found to be relevant risk factors of isolated diastolic hypertension in adults.19,20 An 11-year follow-up study revealed that subjects with isolated diastolic hypertension defined with home BP measurements had an increased risk of cardiovascular events (hazard ratio 1.95, 95% confidence intervals 1.06–3.57) similar to those with isolated systolic hypertension (2.05; 1.42–3.05), when compared with normotensive subjects.20 Our study also found that subjects with isolated brachial hypertension had a significantly higher coronary artery disease risk than those with concordant nonhypertension and the risk was equivalent to those with isolated central hypertension. Those with isolated brachial hypertension may be early treated by antihypertensive medication and may have the adverse drug effects. However, those subjects may also have benefits for early hypertension identification and early treatment for slower progression of hypertension. Subjects with isolated brachial hypertension were predominantly young men with a high brachial diastolic BP and a low central systolic BP. They also had a low central PP, even significantly lower than that of subjects with concordant nonhypertension (Table 4). A high central PP usually indicates the presence of significant arterial stiffness and vascular aging.21 Conversely, a low central PP may indicate that those young men with isolated brachial hypertension have increased peripheral resistance in the presence of very compliant large arteries or absence of vascular aging, similar to those with the isolated diastolic hypertension defined by office or out-of-office measurements.22 In women, the increase of the prevalence of brachial hypertension by the 2017 ACC/AHA criteria was mainly attributed to a high brachial systolic BP (≥130 mm Hg). Moreover, subjects with isolated central hypertension were mainly women and were characterized with a high central PP, a hall mark of vascular aging.21 In a 9.4-year follow-up study in >4,000 community-dwelling men and women of 20–100 years of age, men and women had different longitudinal rate at which BP changed over time.23 In men, at ages >40 years the rates of change in systolic BP and PP increase plateaued and then declined so that systolic BP also declined at older ages, whereas PP plateaued.23 In women, systolic BP, diastolic BP, and mean BP increased at constant rates across all ages, producing an increasing rate of increase in PP.23 Therefore, increased aortic stiffness is implicated in the age-associated increase in systolic BP and PP but a dissociation of arterial stiffness, PP, and systolic BP trajectories in men but not in women was observed.23 In this study, we observed that diastolic BP and systolic BP contributed differently to the increase of the prevalence of brachial hypertension in men (47% due to isolated diastolic BP ≥ 80 mm Hg, Supplementary Figure 1) and women (44% due to isolated systolic BP ≥ 130 mm Hg, Supplementary Figure 1). Moreover, the prevalence of isolated central hypertension was higher than that of isolated brachial hypertension in elderly women but not in men across the age range (Figure 2). Therefore, our results may support that sex and age modulate the BP trajectories.23 Limitations of the present study This study was carried out in a speedy aging Chinese population. Therefore, the estimated impact of the 2017 ACC/AHA hypertension guideline on the prevalence of brachial hypertension may not apply to other populations. Our study used a type II device to measure central BP and identify the subgroups of isolated brachial hypertension and isolated central hypertension. Use of a type II central BP monitor purporting to measure invasive central BP may not be appropriate to investigate the difference between the central and brachial BP.8 Our results may not be replicated in other population-based study when using a type I device which purports to give an estimate of central BP relative to measured brachial BP (i.e., relatively accurate pressure difference between central and peripheral sites).8 We did not have the information about the kinds of antihypertensive medication, therefore, we could not evaluate the influence of specific antihypertensive drugs on central and peripheral BPs. In addition, we could not evaluate the association between unfit and hypertension, because we did not evaluate the physical function among our participants. Adoption of the 2017 AHA/ACC BP thresholds substantially increases the prevalence of brachial hypertension, especially in men, and identifies more than 90% of those with central hypertension at the expense of lesser specificity. Measurement of central BP using a type II device may have add-on values in risk stratification in those with brachial hypertension, and screening central hypertension in those without brachial hypertension. DISCLOSURE Microlife Co., Ltd., and National Yang-Ming University have signed a contract for transfer of the noninvasive central blood pressure technique. The contract of technology transfer includes research funding for conducting studies validating this technique. ACKNOWLEDGMENT We thank the team of National Nutrition and Health Survey in Taiwan at Academic Sinica, Taipei, Taiwan. This study was funded by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan (grants DOH102-HP-1703, MOHW103-HPA-H-114-124710, MOHW104-HPA-H-114- 134704, MOHW105-HPA-H-114-144709), and National Heath Research Institutes in Taiwan (grants PH-105-PP-19 and PH-106-PP-17). REFERENCES 1. Whelton PK , Carey RM , Aronow WS , Casey DE Jr , Collins KJ , Dennison Himmelfarb C , DePalma SM , Gidding S , Jamerson KA , Jones DW , MacLaughlin EJ , Muntner P , Ovbiagele B , Smith SC Jr , Spencer CC , Stafford RS , Taler SJ , Thomas RJ , Williams KA Sr , Williamson JD , Wright JT Jr . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American college of cardiology/American heart association task force on clinical practice guidelines . J Am Coll Cardiol 2018 ; 71 : e127 – e248 . Google Scholar Crossref Search ADS PubMed 2. 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Constructing a point-based prediction model for the risk of coronary artery disease in a Chinese community: a report from a cohort study in Taiwan . Int J Cardiol 2012 ; 157 : 263 – 268 . Google Scholar Crossref Search ADS PubMed 16. Mills KT , Bundy JD , Kelly TN , Reed JE , Kearney PM , Reynolds K , Chen J , He J . Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries . Circulation 2016 ; 134 : 441 – 450 . Google Scholar Crossref Search ADS PubMed 17. Inskip H , Beral V , Fraser P , Haskey J . Methods for age-adjustment of rates . Stat Med 1983 ; 2 : 455 – 466 . Google Scholar Crossref Search ADS PubMed 18. Kibria GMA , Swasey K , Choudhury A , Burrowes V , Stafford KA , Uddin SMI , Mirbolouk M , Sharmeen A , Kc A , Mitra DK . The new 2017 acc/aha guideline for classification of hypertension: changes in prevalence of hypertension among adults in Bangladesh . J Hum Hypertens 2018 ; 32 : 608 – 616 . 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Curr Hypertens Rep 2014 ; 16 : 489 . Google Scholar Crossref Search ADS PubMed 23. Scuteri A , Morrell CH , Orrù M , Strait JB , Tarasov KV , Ferreli LA , Loi F , Pilia MG , Delitala A , Spurgeon H , Najjar SS , AlGhatrif M , Lakatta EG . Longitudinal perspective on the conundrum of central arterial stiffness, blood pressure, and aging . Hypertension 2014 ; 64 : 1219 – 1227 . Google Scholar Crossref Search ADS PubMed © American Journal of Hypertension, Ltd 2019. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Hypertension Oxford University Press

Impacts of the New 2017 ACC/AHA Hypertension Guideline on the Prevalence of Brachial Hypertension and Its Concordance with Central Hypertension

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Oxford University Press
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© American Journal of Hypertension, Ltd 2019. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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0895-7061
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1941-7225
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10.1093/ajh/hpz008
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Abstract

Abstract OBJECTIVES The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline lowers the blood pressure (BP) thresholds for defining brachial hypertension. We therefore aimed to investigate how the new guideline influences the prevalence of brachial hypertension and whether it improves the identification of central hypertension in an Asian national representative population. METHODS A total of 2,742 adults older than 19 years participated in the 2013–2016 National Nutrition and Health Survey in Taiwan. Central and brachial BPs were simultaneously measured twice and averaged using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device). Brachial hypertension was defined by brachial systolic/diastolic BP ≥ 130 or 80 mm Hg or using antihypertensive medication, and central hypertension was defined by central systolic/diastolic BP ≥ 130 or 90 mm Hg or using antihypertensive medication. RESULTS The national weighted prevalence rates of brachial hypertension according to the 2017 AHA/ACC guideline were 48.7% in men and 30.7% in women. The prevalence of brachial hypertension increased by 18.8% in men and 9.4% in women, when compared with the prevalence defined by the conventional thresholds of brachial systolic/diastolic BP ≥ 140 or 90 mm Hg. In comparison with the conventional criteria, the new hypertension criteria had a higher sensitivity (93.0% vs. 77.4%) and a lower specificity (86.7% vs. 99.6%) for detecting central hypertension. CONCLUSIONS Adoption of the 2017 AHA/ACC BP thresholds substantially increases the prevalence of brachial hypertension, especially in men, and identifies over 90% of those with central hypertension at the expense of lesser specificity. blood pressure, hypertension; measurement; prevalence The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline recommends lower levels of both systolic and diastolic blood pressure (BP) for defining hypertension,1 and implementation of the new guideline is expected to increase the prevalence of hypertension and use of antihypertensive medication, and reduce cardiovascular disease events in the United States.2 Vascular aging progressively increases systolic BP and lowers diastolic BP, and is the major pathophysiology for the development of hypertension in the elderly population.3 Apparently, lowering systolic BP threshold has a much greater impact on the diagnosis of hypertension than lowering diastolic BP threshold in an elderly population. Central systolic BP is usually lower than brachial systolic BP, and the former is a better indicator of vascular aging than the latter. As vascular aging is a major risk factor of cardiovascular disease events independent of conventional risk factors, central BP might be better than brachial BP in prediction of cardiovascular outcomes.4 It has been shown that using cuff brachial BP to diagnose hypertension may substantially underestimate the prevalence of hypertension,5 because of the limited accuracy of brachial cuff BP.6 Instead, hypertension defined by central BP thresholds of ≥130/90 mm Hg may have a greater discriminatory power for long-term events.7 Using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device),8 we have shown that a substantial proportion of subjects with the central hypertension could not be identified using a conventional brachial BP approach in a national representative population in Taiwan.9 Taiwan is one of the fastest-aging societies in the world,10 and vascular aging would substantially increase the burden of hypertension control at present and in the near future.3 In this study, we therefore estimated the prevalence of brachial hypertension according to the 2017 ACC/AHA guideline and examined the concordance between the brachial hypertension and central hypertension in the same national representative population.9 MATERIAL AND METHODS The sampling and enrollment of the national representative population for the 2013–2016 National Nutrition and Health Survey in Taiwan (NAHSIT) has previously been reported.9 In brief, NAHSIT 2013–2016 was aimed to investigate the nutrition status and the association between nutrition/diet and disease in residents in Taiwan. All residents in the National Household Registry in Taiwan were candidates, excluding those who lived in military institutes, medical institutes, schools, occupation/sport training centers, dormitories, and prisons. Enrolled subjects in the NAHSIT were selected using a multistage stratified sampling scheme. Informed consent was obtained from each participant before the household interview. All subjects who had received the household interview were invited for a health checkup, including fasting blood, biochemical, and urine sample testing, and central and brachial BP measurements. A total of 2,742 residents aged more than 19 years attended the health checkup. BP measurement and definitions of brachial and central hypertension All participants were asked to refrain from exercise, smoking, and drinking tea or coffee before BP measurement. BP measurement was carried out between 8 am and 12 noon while subjects had been seated and relaxed for 5 minutes with back and arms supported, legs uncrossed, and feet flat on the floor in a quiet room at each survey site for the health checkup.11 Central and brachial BPs were measured simultaneously in the right arm with an appropriately sized cuff at heart level, using an oscillometric central BP monitor (WatchBP Office Central; Microlife AG, Widnau, Switzerland).12 The central BP monitor measured brachial systolic and diastolic BP, performed pulse volume plethysmography at cuff pressure of 60 mm Hg to provide an ensemble average brachial pressure waveform, calibrated the ensemble average waveform to the brachial systolic and diastolic BPs, analyzed the calibrated waveform, and finally calculated central systolic BP and pulse pressure (PP) according to separate regression equations constructed from components of the analyzed waveform.12,13 Measurement accuracy of the stand-alone oscillometric central BP monitor with reference to the simultaneously measured invasive central BP in 85 subjects has been previously reported.12 The mean differences of central systolic BP, PP, and diastolic BP with reference to the invasively measured central BPs were −0.6 ± 5.5, −0.4 ± 7.0, and −0.2 ± 6.5 mm Hg, respectively, without obvious systematic bias.12 The central BP monitor displayed readings of brachial systolic and diastolic BPs, central systolic BP and PP, and heart rate, each of which was an average from 2 consecutive measurements separated by an interval of 60 second. Central diastolic BP was calculated as the difference between central systolic BP and PP.12 Normal brachial BP was defined as brachial systolic BP < 120 mm Hg and diastolic BP < 80 mm Hg in subjects without using antihypertensive medication.1 Elevated brachial BP was defined as brachial systolic BP 120–129 mm Hg and diastolic BP < 80 mm Hg in subjects without using antihypertensive medication.1 Brachial hypertension was defined as brachial systolic BP ≥ 130 mm Hg or diastolic BP ≥ 80 mm Hg or using antihypertensive medication.1 In subjects with brachial hypertension, isolated brachial systolic hypertension was defined as brachial systolic BP ≥ 130 mm Hg and diastolic BP < 80 mm Hg; isolated brachial diastolic hypertension was defined as brachial systolic BP < 130 mm Hg and diastolic BP ≥ 80 mm Hg; combined brachial systolic/diastolic hypertension was defined as brachial systolic BP ≥ 130 mm Hg and diastolic BP ≥ 80 mm Hg. Central hypertension was defined as central systolic BP ≥ 130 mm Hg or diastolic BP ≥ 90 mm Hg or using antihypertensive medication.7,9 Other definitions Diabetes was defined as fasting glucose ≥126 mg/dl or using antidiabetic medication. Dyslipidemia was defined as total cholesterol ≥200 mg/dl or low-density lipoprotein cholesterol ≥130 mg/dl or using lipid lowering medication. All subjects were asked about the tobacco exposure status using the questionnaire of “Do you have a habit of smoking?” and a “Yes” answer was categorized as current smoking. Physical activity was measured using the international physical activity questionnaire. Physical inactivity was defined as no activity is reported or some activity is reported but not enough to meet a moderate or high activity category.14 10-year coronary heart disease risk score The 10-year coronary heart disease risk score for everyone was calculated using a simple point system (18 total points) for the clinical model developed from 3,430 Taiwanese participants followed up for a median 15.9 years.9,15 The performance of the clinical model, incorporating age (0–8 points), gender (0–2 points), body mass index (0–4 points), systolic BP (0–3 points), and smoking status (1 point), was not inferior to the cholesterol-based model and Framingham model in the external validation dataset.15 Statistical methods Means (±SD) and proportions were used to describe the characteristics of the national representative population. The analysis of variance method with Scheffe’s multiple comparison and chi-square test were used to examine the difference in intervals and proportions between BP categories, respectively. National weighted prevalence rates of central and brachial hypertension were estimated accounting for sampling scheme in the sampled population using SAS-callable SUDDAN. We also estimated the standardized prevalence rates of central and brachial hypertension using the World Health Organization (WHO) 2000 world standardized population.16,17 The sensitivity, specificity, false-positive rate, and false-negative rate were calculated with central hypertension as the true disease, and conventional brachial hypertension (≥140/90 mm Hg) and 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) guideline were used as screening tools. The concordance rate and kappa index were also calculated. Comparisons between subjects with concordant central and brachial nonhypertension, isolated central hypertension, isolated brachial hypertension, and concordant central and brachial hypertension were performed with multiple comparison test or chi-square test where appropriate. We further used the multivariable logistic regression with stepwise selection from candidates of all significant variables in univariate analyses to identify the independent determinants of isolated central hypertension among subjects without brachial hypertension, and of isolated brachial hypertension among subjects with brachial hypertension. All statistical tests were set at a type I error of 5% and 2 tails. P values of <0.05 were considered statistically significant. RESULTS The national representative sample of 2,742 adults older than 19 years were categorized as normal BP, elevated brachial BP and brachial hypertension according to 2017 ACC/AHA hypertension guideline and the characteristics of the 3 BP categories are shown in Table 1. As expected, subjects with elevated brachial BP or brachial hypertension were older, had higher brachial and central systolic and diastolic BP and PP, body mass index, waist circumference, fasting blood levels of triglycerides, low-density lipoprotein cholesterol, total cholesterol, and glucose, had lower high-density lipoprotein cholesterol, and had higher prevalence of diabetes and dyslipidemia, in comparison to subjects with normal brachial BP. No significant difference in the prevalence of smoking was observed among the 3 BP categories. In subjects with brachial hypertension, 74.4% would also be defined as brachial hypertension according to the conventional brachial BP thresholds of ≥140/90 mm Hg. The crude prevalence of central hypertension was 0.60% in the normal brachial BP category, 25.7% in the elevated brachial BP category, and 85.6% in the brachial hypertension category. Table 1. Characteristics of the national representative population according to the 2017 ACC/AHA hypertension guideline Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 2017 ACC/AHA normal brachial BP: brachial SBP < 120 mm Hg and DBP < 80 mm Hg and without using antihypertensive medication. 2017 ACC/AHA elevated brachial BP: brachial SBP 120–129 or DBP < 80 mm Hg in subjects without using antihypertensive medication. Diabetes: fasting glucose ≥126 mg/dl or using diabetic medicines. Dyslipidemia: total cholesterol ≥200 mg/dl or LDL cholesterol ≥130 mg/dl or using lipids lowering drugs. Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; DBP = diastolic BP; HDL = high-density lipoprotein; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic BP. a2017 ACC/AHA brachial hypertension: brachial SBP ≥ 130 or DBP ≥ 80 mm Hg or using antihypertensive medication. bConventional brachial hypertension: brachial SBP ≥ 140 or DBP ≥ 90 mm Hg or using antihypertensive medication. cCentral hypertension: central SBP ≥ 130 or DBP ≥ 90 mm Hg or using antihypertensive medication. View Large Table 1. Characteristics of the national representative population according to the 2017 ACC/AHA hypertension guideline Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 Normal brachial BP (n = 1,167, 42.56%) Elevated brachial BP (n = 269, 9.81%) Brachial hypertensiona (n = 1306, 47.63%) P value Age, years 45.4 ± 16.2 55.2 ± 17.7 62.2 ± 14.8 <0.0001 Male, % 37.36 56.51 57.12 <0.0001 Brachial SBP, mm Hg 106.2 ± 8.6 123.9 ± 2.8 135.6 ± 16.5 <0.0001 Brachial DBP, mm Hg 66.0 ± 6.5 72.0 ± 5.3 79.8 ± 10.9 <0.0001 Brachial PP, mm Hg 40.2 ± 7.2 51.9 ± 5.4 55.7 ± 14.0 <0.0001 Central SBP, mm Hg 110.6 ± 8.2 125.8 ± 6.7 135.8 ± 16.4 <0.0001 Central DBP, mm Hg 64.2 ± 5.7 69.1 ± 5.0 75.2 ± 9.4 <0.0001 Central PP, mm Hg 46.3 ± 8.2 57.2 ± 8.9 60.6 ± 16.4 <0.0001 Body mass index, kg/m2 22.5 ± 3.2 24.6 ± 3.8 25.9 ± 4.0 <0.0001 Waist circumference, cm 78.8 ± 9.3 85.5 ± 10.1 89.8 ± 10.4 <0.0001 Triglycerides, mg/dl 99.5 ± 60.5 120.3 ± 73.7 139.8 ± 97.1 <0.0001 HDL cholesterol, mg/dl 56.9 ± 15.3 54.3 ± 14.2 50.5 ± 15.0 <0.0001 LDL cholesterol, mg/dl 114.0 ± 31.6 121.2 ± 35.1 119.4 ± 33.6 <0.0001 Total cholesterol, mg/dl 184.7 ± 34.6 193.4 ± 38.5 190.2 ± 36.9 <0.0001 Fasting glucose, mg/dl 98.4 ± 20.4 105.7 ± 24.4 114.2 ± 34.4 <0.0001 Crude prevalence of conventional brachial hypertensionb 0% 0% 74.4% <0.0001 Crude prevalence of central hypertensionc 0.60% 25.7% 85.6% <0.0001 Antihypertensive medication, % 0 0 54.5 <0.0001 Smoking, % 14.4 17.1 13.8 0.3685 Diabetes, % 5.7 11.9 24.3 <0.0001 Antidiabetic medication, % 3.26 4.83 16.69 <0.0001 Dyslipidemia, % 34.79 46.10 49.0 <0.0001 Lipids lowering medication, % 1.80 2.97 10.64 <0.0001 Physical inactivity, % 33.50 26.77 28.79 0.0142 2017 ACC/AHA normal brachial BP: brachial SBP < 120 mm Hg and DBP < 80 mm Hg and without using antihypertensive medication. 2017 ACC/AHA elevated brachial BP: brachial SBP 120–129 or DBP < 80 mm Hg in subjects without using antihypertensive medication. Diabetes: fasting glucose ≥126 mg/dl or using diabetic medicines. Dyslipidemia: total cholesterol ≥200 mg/dl or LDL cholesterol ≥130 mg/dl or using lipids lowering drugs. Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; DBP = diastolic BP; HDL = high-density lipoprotein; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic BP. a2017 ACC/AHA brachial hypertension: brachial SBP ≥ 130 or DBP ≥ 80 mm Hg or using antihypertensive medication. bConventional brachial hypertension: brachial SBP ≥ 140 or DBP ≥ 90 mm Hg or using antihypertensive medication. cCentral hypertension: central SBP ≥ 130 or DBP ≥ 90 mm Hg or using antihypertensive medication. View Large Prevalence of brachial hypertension according to the 2017 ACC/AHA guideline The WHO-age standardized prevalence of brachial hypertension was 34.5% (43.5% for men and 26.0% for women) (Table 2). The national weighted prevalence of brachial hypertension was 39.1% (48.7% for men and 30.4% for women) (Table 2). The national weighted prevalence of central hypertension and brachial hypertension according to the conventional criteria and the 2017 ACC/AHA hypertension guideline stratified by sex and age groups are shown in Supplementary Table 1. Adoption of the 2017 ACC/AHA guideline would therefore increase the national weighted prevalence of brachial hypertension by 18.8% in men and 9.1% in women, when compared with the corresponding figures of 29.9% in men and 21.3% in women, respectively, defined by the conventional BP thresholds of brachial systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg.9 The increase in the prevalence of brachial hypertension resulting from the lowering of BP thresholds by the 2017 ACC/AHA guideline was particularly remarkable in men aged less than 55 years (Figure 1). Table 2. Prevalence rates of brachial hypertension according to the 2017 ACC/AHA hypertension guideline adjusted for national weights or WHO standardized population National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; WHO = World Health Organization. View Large Table 2. Prevalence rates of brachial hypertension according to the 2017 ACC/AHA hypertension guideline adjusted for national weights or WHO standardized population National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% National weighted rates (≥19 years old) WHO standardized rates (≥20 years old) Total Men Women Total Men Women Normal BP 51.2% 39.0% 62.4% 56.1% 43.1% 68.0% Elevated BP 9.7% 12.3% 7.3% 9.4% 13.4% 6.0% Hypertension  Stage I 13.7% 18.8% 9.1% 13.7% 18.3% 9.0%  Stage II 25.4% 29.9% 21.3% 20.8% 25.2% 17.0%  Stage I + II 39.1% 48.7% 30.4% 34.5% 43.5% 26.0% Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; BP = blood pressure; WHO = World Health Organization. View Large Figure 1. View largeDownload slide Increments (delta, white bars) of the prevalence of brachial hypertension by the 2017 American College of Cardiology/American Heart Association (AHA/ACC) hypertension guideline (black lines) with reference to the prevalence defined by the conventional blood pressure thresholds (grey bars) in men and women, and in different age groups. Figure 1. View largeDownload slide Increments (delta, white bars) of the prevalence of brachial hypertension by the 2017 American College of Cardiology/American Heart Association (AHA/ACC) hypertension guideline (black lines) with reference to the prevalence defined by the conventional blood pressure thresholds (grey bars) in men and women, and in different age groups. In men, the increase in the prevalence of brachial hypertension by the 2017 ACC/AHA hypertension guideline was attributed to a high diastolic BP only (≥80 mm Hg, 47%), a high systolic BP only (≥130 mm Hg, 24%), or both (29%) (Supplementary Figure 1). In contrast, the corresponding figures in women were 33%, 44%, and 23%, respectively (Supplementary Figure 1). Characteristics of the subjects who were initially categorized as nonhypertension according to the conventional BP thresholds but were recategorized as brachial hypertension according to the 2017 ACC/AHA hypertension guideline are shown in Supplementary Table 2. Multivariable stepwise logistic regression analysis revealed that older age, a higher brachial systolic BP, waist circumference and triglyceride level, a history of diabetes and dyslipidemia, and a lower brachial PP, and total cholesterol level were independent correlates of the recategorized brachial hypertension (Supplementary Table 3). Identification of central hypertension by brachial hypertension The performance of brachial hypertension defined by the conventional BP thresholds or the 2017 AHA/ACC guideline in identifying central hypertension is shown in Table 3. Lowering of the BP thresholds increased sensitivity and false-positive rate but decreased specificity and false-negative rate. Overall, the new hypertension criteria had a lower concordance rate (88.8% vs. 92.4%) and a lower kappa index (0.758 vs. 0.815) for detecting central hypertension. Table 3. Identification of central hypertension by brachial hypertension according to the conventional brachial blood pressure thresholds or 2017 AHA/ACC hypertension guideline Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Sensitivity: P (brachial hypertension | central hypertension). Specificity: P (nonbrachial hypertension | noncentral hypertension). False-positive rate: P (brachial hypertension | noncentral hypertension). False-negative rate: P (nonbrachial hypertension | central hypertension). Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; CI = confidence interval. View Large Table 3. Identification of central hypertension by brachial hypertension according to the conventional brachial blood pressure thresholds or 2017 AHA/ACC hypertension guideline Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Conventional brachial hypertension (≥140/90 mm Hg) 2017 AHA/ACC brachial hypertension (≥130/80 mm Hg) Sensitivity, % 77.4 93.0 Specificity, % 99.6 86.7 False-positive rate, % 0.4 13.2 False-negative rate, % 22.6 7.0 Concordance, % 92.4 88.8 Kappa (95% CI) 0.815 (0.8149–0.8153) 0.758 (0.7574–0.7578) Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Sensitivity: P (brachial hypertension | central hypertension). Specificity: P (nonbrachial hypertension | noncentral hypertension). False-positive rate: P (brachial hypertension | noncentral hypertension). False-negative rate: P (nonbrachial hypertension | central hypertension). Abbreviations: ACC/AHA = American College of Cardiology/American Heart Association; CI = confidence interval. View Large Isolated central hypertension and isolated brachial hypertension According to the 2017 ACC/AHA hypertension guideline and the central hypertension criteria, all subjects could be classified as concordant nonhypertension (nonbrachial hypertension and noncentral hypertension, n = 1,360, 49.6%), isolated central hypertension (n = 76, 2.8%), isolated brachial hypertension (n = 188, 6.9%), and concordant hypertension (brachial hypertension and central hypertension, n = 1,118, 40.8%) (Table 4). The national weighted prevalence rates of concordant nonhypertension, isolated central hypertension, isolated brachial hypertension, and concordant hypertension were 58.6%, 2.3%, 8.9%, and 30.2%, respectively. Table 4. Characteristics of the subjects with isolated central hypertension or isolated brachial hypertension in comparison to those with concordant nonhypertension or hypertension Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Brachial hypertension: brachial blood pressure ≥130/80 mm Hg or using antihypertensive medication (2017 ACC/AHA hypertension guideline). Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Brachial ISH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure <80 mm Hg. Brachial IDH: brachial systolic blood pressure <130 mm Hg and diastolic blood pressure ≥80 mm Hg. Brachial SDH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg. Abbreviations: DBP = diastolic blood pressure; HDL = high-density lipoprotein; IDH = isolated diastolic hypertension; ISH = isolated systolic hypertension; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic blood pressure; SDH = combined systolic/diastolic hypertension. aP value less than 0.05 for comparing with those without brachial or central hypertension (concordant nonhypertension). bP value less than 0.05 for comparison with those with isolated central hypertension. cP value less than 0.05 for comparison with those with isolated brachial hypertension. View Large Table 4. Characteristics of the subjects with isolated central hypertension or isolated brachial hypertension in comparison to those with concordant nonhypertension or hypertension Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Characteristics Concordant nonhypertension (n = 1,360, 49.6%) Isolated central hypertension (n = 76, 2.8%) Isolated brachial hypertension (n = 188, 6.9%) Concordant hypertension (n = 1,118, 40.8%) Age, years 46.8 ± 16.6 55.4 ± 20.1a 49.4 ± 14.5b 64.3 ± 13.7a,b,c Men, n (%) 40.51 48.68 70.06a,b 53.94a,c Brachial SBP, mm Hg 108.7 ± 10.1 124.8 ± 3.2a 124.9 ± 6.8a 137.4 ± 17.0a,b,c Brachial DBP, mm Hg 66.9 ± 6.7 71.7 ± 4.9a 83.1 ± 4.4a,b 79.3 ± 11.5a,b,c Brachial PP, mm Hg 41.8 ± 8.0 53.1 ± 5.5a 41.8 ± 7.3b 58.1 ± 13.5a,b,c Central SBP, mm Hg 112.3 ± 8.9 133.1 ± 4.0a,c 122.0 ± 5.5a,b 138.1 ± 16.5a,b,c Central DBP, mm Hg 65.0 ± 5.9 67.8 ± 4.9a,c 78.1 ± 4.4a,b 74.7 ± 9.9a,b,c Central PP, mm Hg 47.4 ± 8.5 65.3 ± 6.2a,c 43.9 ± 6.7a,b 63.5 ± 15.8a,c Brachial ISH, % 0 0 7.5 12.3 Brachial IDH, % 0 0 70.2 1.3 Brachial SDH, % 0 0 22.3 86.4 Body mass index, kg/m2 22.8 ± 3.3 25.2 ± 4.5 24.7 ± 3.9a 26.1 ± 4.0a,c Waist circumference, cm 79.8±9.6 85.6±11.7a 86.3±10.0a 90.4±10.4a,b,c Triglycerides, mg/dl 102.1 ± 63.1 125.4 ± 70.0 155.5 ± 140.9a 137.1 ± 87.2a,c HDL cholesterol, mg/dl 56.7 ± 15.2 51.4 ± 12.7a 50.2 ± 16.2a 50.6 ± 14.8a LDL cholesterol, mg/dl 115.1 ± 32.2 119.0 ± 35.0 125.2 ± 34.5a 118.4 ± 33.3 Total cholesterol, mg/dl 186.2 ± 35.4 188.9 ± 37.2 196.7 ± 34.4a 189.1 ± 37.2 Glucose, mg/dl 99.3 ± 21.0 107.8 ± 26.6 104.4 ± 21.3 115.9 ± 35.8a,c Smoking, % 15.0 13.16 22.34a 12.34c Diabetes, % 6.40 14.47a 10.64a 26.57a,c Antidiabetic medication, % 3.46 5.26 5.32 18.60a,b,c Lipids lowering medication, % 1.99 2.63 4.26a 11.72a,b,c Dyslipidemia, % 36.54 43.42 47.34a 49.28a Physical inactivity, % 32.65 27.66 25.00 28.98a Estimated 10-year coronary heart disease risk score, 0–18 points15 5.20 ± 3.38 7.93 ± 2.98a 7.56 ± 2.80a 10.5 ± 2.5a,b,c Brachial hypertension: brachial blood pressure ≥130/80 mm Hg or using antihypertensive medication (2017 ACC/AHA hypertension guideline). Central hypertension: central blood pressure ≥130/90 mm Hg or using antihypertensive medication. Brachial ISH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure <80 mm Hg. Brachial IDH: brachial systolic blood pressure <130 mm Hg and diastolic blood pressure ≥80 mm Hg. Brachial SDH: brachial systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg. Abbreviations: DBP = diastolic blood pressure; HDL = high-density lipoprotein; IDH = isolated diastolic hypertension; ISH = isolated systolic hypertension; LDL = low-density lipoprotein; PP = pulse pressure; SBP = systolic blood pressure; SDH = combined systolic/diastolic hypertension. aP value less than 0.05 for comparing with those without brachial or central hypertension (concordant nonhypertension). bP value less than 0.05 for comparison with those with isolated central hypertension. cP value less than 0.05 for comparison with those with isolated brachial hypertension. View Large The prevalence of isolated brachial hypertension was remarkably higher than isolated central hypertension in the young and middle adults, especially in men (Figure 2). In men, the prevalence of isolated brachial hypertension remained higher than that of isolated central hypertension in the elderly women (Figure 2). In contrast, elderly women had a higher prevalence of isolated central hypertension than isolated brachial hypertension (Figure 2). Figure 2. View largeDownload slide National weighted prevalence of isolated central hypertension and isolated brachial hypertension (≥130/80 mm Hg), by age groups. Figure 2. View largeDownload slide National weighted prevalence of isolated central hypertension and isolated brachial hypertension (≥130/80 mm Hg), by age groups. In subjects with isolated brachial hypertension, the prevalence of isolated brachial diastolic hypertension, combined brachial systolic/diastolic hypertension, and isolated brachial systolic hypertension was 70.2%, 22.3%, and 7.5%, respectively (Table 4). In contrast, in subjects with both brachial and central hypertension (concordant hypertension), the dominant phenotype was combined brachial systolic/diastolic hypertension (86.40%), followed by isolated brachial systolic hypertension (12.3%), then by isolated brachial diastolic hypertension (1.3%) (Table 4). Subjects with isolated central hypertension were older and characterized with a significantly higher central and brachial systolic BP, diastolic BP and PP, a greater body mass index and waist circumference, a higher prevalence of diabetes, and a lower high-density lipoprotein cholesterol level, in comparison with subjects without brachial or central hypertension (concordant nonhypertension) (Table 4). In subjects without brachial hypertension (concordant nonhypertension + isolated central hypertension), multivariable stepwise logistic regression analysis revealed that only central systolic BP (mm Hg) (odds ratio 21.472, 95% confidence intervals 5.621–82.019, P < 0.0001) was significantly independently associated with isolated central hypertension. On the other hand, subjects with isolated brachial hypertension were younger, predominantly men, and characterized with a significantly lower brachial and central systolic BP, diastolic BP and PP, lower body mass index, waist circumference, glucose level, a lower prevalence of diabetes and use of antidiabetic medication, a higher level of triglyceride, and a higher prevalence of smoking, in comparison with subjects with concordant nonhypertension. In subjects with brachial hypertension (concordant hypertension + isolated brachial hypertension), multivariable stepwise logistic regression analysis revealed that younger age (odds ratio 0.943, 95% confidence intervals 0.928–0.959, P < 0.0001), male sex (vs. female) (1.977, 1.248–3.132, P = 0.0037), higher brachial diastolic BP (mm Hg) (1.121, 1.090–1.152, P < 0.0001), lower central systolic BP (mm Hg) (0.846, 0.822–0.870, P < 0.0001), and lower body mass index (kg/m2) (0.902, 0.848–0.958, P = 0.0008) were independently associated with isolated brachial hypertension. Subjects with either isolated central hypertension or isolated brachial hypertension had a significantly higher estimated 10-year coronary heart disease risk score than those without brachial or central hypertension (concordant nonhypertension). On the other hand, subjects with concordant hypertension had the highest brachial systolic BP and PP, central systolic BP, waist circumference, fasting glucose, and estimated 10-year coronary heart disease risk score, when compared with the other groups. DISCUSSION Main findings Almost half of men and one-third of women in Taiwan would be categorized as having brachial hypertension by the 2017 ACC/AHA guideline. The increased prevalence of brachial hypertension was mainly attributed to the high prevalence of isolated diastolic hypertension in the young and middle-aged adults (19–64.9 years), especially in men. The new brachial hypertension criteria were very sensitive in identifying central hypertension, at the expense of lesser specificity. The resultant “false positive” was a group of subjects with brachial hypertension but without central hypertension, namely, the isolated brachial hypertension. Isolated brachial hypertension was characterized by young age, male sex, and isolated diastolic hypertension, implying minimal evidence of the presence of arterial stiffness or vascular aging. Subjects with isolated brachial hypertension had an increased risk of coronary heart disease similar to those with isolated central hypertension, when compared with subjects without brachial or central hypertension (concordant nonhypertension). Moreover, subjects with concordant brachial and central hypertension had a significantly increased estimated 10-year coronary heart disease risk score than those with isolated brachial hypertension. Overall, our results may support the adoption of the 2017 ACC/AHA hypertension guideline for the diagnosis of brachial hypertension, and concomitant measurement of central BP may supplement the new brachial hypertension criteria by helping stratify the high-risk subjects from those with brachial hypertension and identify the remaining central hypertension in those without brachial hypertension. Increase in hypertension prevalence by the 2017 ACC/AHA hypertension guideline The ACC/AHA hypertension guideline lowers the brachial systolic and diastolic BP thresholds and therefore unavoidably increases the prevalence of brachial hypertension and its public burden. Among US adults, the crude prevalence of brachial hypertension reached 45.6% by the new criteria (from 31.9% by the conventional criteria).2 Men had a greater increase in the brachial hypertension prevalence than women (17% [31%->48%] and 11% [32%->43%], respectively), and men aged less than 55 years increased more than 50%. In contrast, in Bangladesh, women had a higher prevalence than men (54.5% vs. 41.4%), and the prevalence of brachial hypertension doubly increased (from 25.7%->48.0%) among adults aged ≥35 years18 by the new hypertension criteria and the increase of brachial hypertension prevalence was similar in both genders (22.0% vs. 22.6%).18 In this study, men would have a higher increase of the prevalence of brachial hypertension than women (18.8% vs. 9.1%), and the increase would reach 50% in young men (aged less than 50 years), according to the 2017 ACC/AHA criteria. Therefore, the impact of the 2017 ACC/AHA hypertension guideline on the prevalence of hypertension and burden of hypertension control may vary substantially among populations. The relationship between brachial hypertension and central hypertension: Impact of the 2017 ACC/AHA hypertension guideline Central BP might be a better predictor for cardiovascular outcomes than peripheral BP.4 Conventional cuff brachial BP monitors usually underestimate intra-arterial brachial systolic BP and overestimate intra-arterial diastolic BP.6 Cuff and intra-arterial aortic systolic BP may show a small mean difference but poor agreement.6 Therefore, cuff BP has variable accuracy for measuring either brachial or aortic intra-arterial BP,6 and this may adversely influence the accuracy of hypertension prevalence. With reference to the intra-arterial aortic BP, we have shown that cuff brachial BP substantially underestimated the prevalence of central hypertension, according to the conventional brachial BP thresholds (≥140/90 mm Hg).5 Moreover, in the same national representative population as the present one, 7.35% of adults with central hypertension were not identified by the cuff BP.9 More importantly, those with the isolated central hypertension had a significantly higher risk of coronary heart disease than those with concordance nonhypertension.9 In this study, adoption of the 2017 ACC/AHA hypertension guideline would identify more subjects with true central hypertension but at the same time misclassify a substantial number of false-positive central hypertension so the concordance between brachial hypertension and central hypertension would not improve, as compared with the conventional hypertension criteria. Isolated brachial hypertension and sex difference In this study, a significant subgroup of subjects with isolated brachial hypertension (national weighted prevalence, 8.9%) was identified, based on the 2017 ACC/AHA hypertension guideline and the central hypertension criteria.7 Subjects with the isolated brachial hypertension were predominantly young men with isolated diastolic hypertension. Male gender, middle age, overweight or obesity, smoking, and hypercholesterolemia were found to be relevant risk factors of isolated diastolic hypertension in adults.19,20 An 11-year follow-up study revealed that subjects with isolated diastolic hypertension defined with home BP measurements had an increased risk of cardiovascular events (hazard ratio 1.95, 95% confidence intervals 1.06–3.57) similar to those with isolated systolic hypertension (2.05; 1.42–3.05), when compared with normotensive subjects.20 Our study also found that subjects with isolated brachial hypertension had a significantly higher coronary artery disease risk than those with concordant nonhypertension and the risk was equivalent to those with isolated central hypertension. Those with isolated brachial hypertension may be early treated by antihypertensive medication and may have the adverse drug effects. However, those subjects may also have benefits for early hypertension identification and early treatment for slower progression of hypertension. Subjects with isolated brachial hypertension were predominantly young men with a high brachial diastolic BP and a low central systolic BP. They also had a low central PP, even significantly lower than that of subjects with concordant nonhypertension (Table 4). A high central PP usually indicates the presence of significant arterial stiffness and vascular aging.21 Conversely, a low central PP may indicate that those young men with isolated brachial hypertension have increased peripheral resistance in the presence of very compliant large arteries or absence of vascular aging, similar to those with the isolated diastolic hypertension defined by office or out-of-office measurements.22 In women, the increase of the prevalence of brachial hypertension by the 2017 ACC/AHA criteria was mainly attributed to a high brachial systolic BP (≥130 mm Hg). Moreover, subjects with isolated central hypertension were mainly women and were characterized with a high central PP, a hall mark of vascular aging.21 In a 9.4-year follow-up study in >4,000 community-dwelling men and women of 20–100 years of age, men and women had different longitudinal rate at which BP changed over time.23 In men, at ages >40 years the rates of change in systolic BP and PP increase plateaued and then declined so that systolic BP also declined at older ages, whereas PP plateaued.23 In women, systolic BP, diastolic BP, and mean BP increased at constant rates across all ages, producing an increasing rate of increase in PP.23 Therefore, increased aortic stiffness is implicated in the age-associated increase in systolic BP and PP but a dissociation of arterial stiffness, PP, and systolic BP trajectories in men but not in women was observed.23 In this study, we observed that diastolic BP and systolic BP contributed differently to the increase of the prevalence of brachial hypertension in men (47% due to isolated diastolic BP ≥ 80 mm Hg, Supplementary Figure 1) and women (44% due to isolated systolic BP ≥ 130 mm Hg, Supplementary Figure 1). Moreover, the prevalence of isolated central hypertension was higher than that of isolated brachial hypertension in elderly women but not in men across the age range (Figure 2). Therefore, our results may support that sex and age modulate the BP trajectories.23 Limitations of the present study This study was carried out in a speedy aging Chinese population. Therefore, the estimated impact of the 2017 ACC/AHA hypertension guideline on the prevalence of brachial hypertension may not apply to other populations. Our study used a type II device to measure central BP and identify the subgroups of isolated brachial hypertension and isolated central hypertension. Use of a type II central BP monitor purporting to measure invasive central BP may not be appropriate to investigate the difference between the central and brachial BP.8 Our results may not be replicated in other population-based study when using a type I device which purports to give an estimate of central BP relative to measured brachial BP (i.e., relatively accurate pressure difference between central and peripheral sites).8 We did not have the information about the kinds of antihypertensive medication, therefore, we could not evaluate the influence of specific antihypertensive drugs on central and peripheral BPs. In addition, we could not evaluate the association between unfit and hypertension, because we did not evaluate the physical function among our participants. Adoption of the 2017 AHA/ACC BP thresholds substantially increases the prevalence of brachial hypertension, especially in men, and identifies more than 90% of those with central hypertension at the expense of lesser specificity. Measurement of central BP using a type II device may have add-on values in risk stratification in those with brachial hypertension, and screening central hypertension in those without brachial hypertension. DISCLOSURE Microlife Co., Ltd., and National Yang-Ming University have signed a contract for transfer of the noninvasive central blood pressure technique. The contract of technology transfer includes research funding for conducting studies validating this technique. ACKNOWLEDGMENT We thank the team of National Nutrition and Health Survey in Taiwan at Academic Sinica, Taipei, Taiwan. This study was funded by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan (grants DOH102-HP-1703, MOHW103-HPA-H-114-124710, MOHW104-HPA-H-114- 134704, MOHW105-HPA-H-114-144709), and National Heath Research Institutes in Taiwan (grants PH-105-PP-19 and PH-106-PP-17). REFERENCES 1. Whelton PK , Carey RM , Aronow WS , Casey DE Jr , Collins KJ , Dennison Himmelfarb C , DePalma SM , Gidding S , Jamerson KA , Jones DW , MacLaughlin EJ , Muntner P , Ovbiagele B , Smith SC Jr , Spencer CC , Stafford RS , Taler SJ , Thomas RJ , Williams KA Sr , Williamson JD , Wright JT Jr . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American college of cardiology/American heart association task force on clinical practice guidelines . J Am Coll Cardiol 2018 ; 71 : e127 – e248 . Google Scholar Crossref Search ADS PubMed 2. 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Measurement accuracy of a stand-alone oscillometric central blood pressure monitor: a validation report for Microlife WatchBP Office Central . Am J Hypertens 2013 ; 26 : 42 – 50 . Google Scholar Crossref Search ADS PubMed 13. Sung SH , Cheng HM , Chuang SY , Shih YT , Wang KL , Chen YH , Lin SJ , Yu WC , Chen CH . Measurement of central systolic blood pressure by pulse volume plethysmography with a noninvasive blood pressure monitor . Am J Hypertens 2012 ; 25 : 542 – 548 . Google Scholar Crossref Search ADS PubMed 14. Craig CL , Marshall AL , Sjöström M , Bauman AE , Booth ML , Ainsworth BE , Pratt M , Ekelund U , Yngve A , Sallis JF , Oja P . International physical activity questionnaire: 12-country reliability and validity . Med Sci Sports Exerc 2003 ; 35 : 1381 – 1395 . Google Scholar Crossref Search ADS PubMed 15. Chien KL , Hsu HC , Su TC , Chang WT , Chen PC , Sung FC , Lin HJ , Chen MF , Lee YT . 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Google Scholar Crossref Search ADS PubMed 19. Liu F , Adi D , Xie X , Li XM , Fu ZY , Shan CF , Huang Y , Chen BD , Gai MT , Gao XM , Ma YT , Yang YN . Prevalence of isolated diastolic hypertension and associated risk factors among different ethnicity groups in Xinjiang, China . PLoS One 2015 ; 10 : e0145325 . Google Scholar Crossref Search ADS PubMed 20. Niiranen TJ , Rissanen H , Johansson JK , Jula AM . Overall cardiovascular prognosis of isolated systolic hypertension, isolated diastolic hypertension and pulse pressure defined with home measurements: the Finn-home study . J Hypertens 2014 ; 32 : 518 – 524 . Google Scholar Crossref Search ADS PubMed 21. Nilsson PM . Hemodynamic aging as the consequence of structural changes associated with early vascular aging (EVA) . Aging Dis 2014 ; 5 : 109 – 113 . Google Scholar PubMed 22. Li Y , Wei FF , Wang S , Cheng YB , Wang JG . Cardiovascular risks associated with diastolic blood pressure and isolated diastolic hypertension . Curr Hypertens Rep 2014 ; 16 : 489 . Google Scholar Crossref Search ADS PubMed 23. Scuteri A , Morrell CH , Orrù M , Strait JB , Tarasov KV , Ferreli LA , Loi F , Pilia MG , Delitala A , Spurgeon H , Najjar SS , AlGhatrif M , Lakatta EG . Longitudinal perspective on the conundrum of central arterial stiffness, blood pressure, and aging . Hypertension 2014 ; 64 : 1219 – 1227 . Google Scholar Crossref Search ADS PubMed © American Journal of Hypertension, Ltd 2019. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

American Journal of HypertensionOxford University Press

Published: Mar 16, 2019

References

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