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Blood Pressure Elevation and Cardiovascular Risk: The Crucial Link Between Hypertension, Coronary Artery Disease, and Stroke in Japan

Posted on by Jim Peterson
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Hypertension, commonly known as high blood pressure, is a significant public health concern affecting approximately 1.13 billion people worldwide1. It is a leading risk factor for cardiovascular diseases (CVD), primarily coronary artery disease (CAD) and stroke2. While numerous clinical trials and observational studies have established the link between hypertension and these life-threatening conditions, real-world evidence (RWE) is essential for further understanding the full impact of blood pressure elevation on CAD and stroke in the general population. RWE, derived from sources such as electronic health records, insurance claims data, and patient registries, offers valuable insights into the effectiveness, safety, and cost-effectiveness of healthcare interventions and patient outcomes3.

This article examines the latest RWE on the association between blood pressure elevation and the development of CAD and stroke. We will explore how the real-world data complements the findings from clinical trials, addressing the challenges faced in managing hypertension and its associated complications. Additionally, this article will discuss the implications of RWE for policymakers, healthcare professionals, and patients alike, highlighting the importance of comprehensive and accurate data in the development of effective strategies for the prevention and management of hypertension-related complications.

Japanese Research

A recent study by Yamada et al. investigated the relationship between blood pressure (BP) and the incidence of coronary artery disease (CAD) or stroke, considering glucose levels in the Japanese population. The study analyzed data from a nationwide claims-based database of 805,992 adults with no prior cardiovascular disease. The results showed a linear relationship between systolic blood pressure (SBP) and diastolic blood pressure (DBP) and CAD or stroke morbidity, regardless of the presence or severity of abnormal glucose levels.

The hazard ratios (HRs) for CAD and stroke progressively increased with higher SBP and DBP quintiles in normoglycemic, borderline hyperglycemic, and diabetic subjects. The findings indicate that BP elevation and worsening glucose status have an additive effect on CAD morbidity, but not on stroke risk. One of the study’s strengths is its large sample size and accurate definitions of CAD and stroke events, which were based on detailed data regarding medications and procedures, allowing for precise identification of patients with incident CAD and CVD during the follow-up period4.

The large-scale real-world study conducted in Japan confirms that the risks of CAD and stroke progressively increase with SBP/DBP levels lower than the current diagnostic threshold for hypertension, irrespective of glucose status. This finding supports the recommendation for early lifestyle modifications, particularly salt reduction, for the prevention of cardiovascular diseases in individuals with a BP of 120/80 mmHg or higher. With the increasing trend of myocardial infarction in Japan due to the westernization of lifestyles, strict control of BP and blood glucose through early intervention is crucial for preventing and reducing cardiovascular diseases, including CAD and stroke, in Japanese and Asian populations.

Previous Research

Previous research has indeed supported the association between elevated blood pressure levels and the risk of cardiovascular diseases such as CAD and stroke. The 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines1 and the 2017 American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines.2 both emphasize the importance of managing blood pressure levels to reduce cardiovascular risk.

A meta-analysis of 61 prospective observational studies, including 958,074 adults, demonstrated that mortality rates for CAD and stroke increased exponentially with elevated systolic and diastolic blood pressure levels, with no threshold down to at least 115/75 mmHg2. Furthermore, the EPOCH-JAPAN study, a meta-analysis of 10 cohort studies involving approximately 70,000 individuals in Japan, found that the association between systolic/diastolic blood pressure levels and cardiovascular disease mortality was almost logarithmically linear, with the lowest risk among individuals with BP levels <120/80 mmHg in both middle-aged and elderly age groups2.

These findings, along with the results from the study by Yamada et al.4, highlight the importance of early interventions and lifestyle modifications to prevent and manage cardiovascular diseases associated with elevated blood pressure levels.

Glossary of Terms

  • Blood Pressure (BP): The force exerted by circulating blood on the walls of blood vessels; measured in millimeters of mercury (mmHg) and expressed as two values, systolic pressure over diastolic pressure.

  • Cardiovascular Disease (CVD): A class of diseases that involve the heart and blood vessels, including coronary artery disease, heart failure, and stroke.

  • Coronary Artery Disease (CAD): A condition where the blood vessels that supply blood and oxygen to the heart become narrow or blocked, often due to a buildup of fatty deposits called plaque.

  • Diastolic Blood Pressure (DBP): The pressure in the arteries when the heart is at rest between beats; the lower number in a blood pressure reading.

  • Glucose: A simple sugar that serves as the main source of energy for the body; its levels in the blood are regulated by hormones, such as insulin.

  • Hazard Ratio (HR): A measure of how often a particular event happens in one group compared to another, over time; used in survival analysis to compare the risk of an outcome between different groups.

  • Hypertension: A medical condition characterized by persistently elevated blood pressure, typically defined as systolic blood pressure of 130 mmHg or higher, or diastolic blood pressure of 80 mmHg or higher.

  • Normoglycemia: A normal level of glucose in the blood.

  • Systolic Blood Pressure (SBP): The pressure in the arteries when the heart beats and pumps blood; the higher number in a blood pressure reading.

  • Stroke: A sudden interruption of blood flow to the brain, either due to a blocked blood vessel (ischemic stroke) or a ruptured blood vessel (hemorrhagic stroke), leading to the death of brain cells and potential long-term neurological damage.

Footnotes

  1. World Health Organization. Hypertension. https://www.who.int/news-room/fact-sheets/detail/hypertension

  2. Rapsomaniki, E., Timmis, A., George, J., Pujades-Rodriguez, M., Shah, A. D., Denaxas, S., … & Hemingway, H. (2014). Blood pressure and incidence of twelve cardiovascular diseases: Lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet, 383(9932), 1899-1911. https://www.sciencedirect.com/science/article/pii/S0140673613622747 

  3. Sherman, R. E., Anderson, S. A., Dal Pan, G. J., Gray, G. W., Gross, T., Hunter, N. L., … & Woodcock, J. (2016). Real-world evidence—what is it and what can it tell us? New England Journal of Medicine, 375(23), 2293-2297. https://www.nejm.org/doi/full/10.1056/NEJMsb1609216

  4. Yamada, T., Higashiyama, A., Yoshida, D., Nishida, Y., Misumi, T., & Noda, M. (2022). Real-world evidence of the association between blood pressure elevation and coronary artery disease and stroke in Japan. Hypertens Res 46, 1073–1074. https://doi.org/10.1038/s41440-022-01156-z

  5. Williams, B., Mancia, G., Spiering, W., Agabiti Rosei, E., Azizi, M., Burnier, M., … & Kjeldsen, S. E. (2018). 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal, 39(33), 3021-3104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 

  6. Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … & Wright, J. T. (2018). 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. Journal of the American College of Cardiology, 71(19), e127-e248.https://www.sciencedirect.com/science/article/pii/S0735109717415191

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