Identifying Individuals at Risk for Cardiovascular Events Across the Spectrum of Blood Pressure Levels

Background We determined the proportion of atherosclerotic cardiovascular disease (ASCVD) events that occur across the spectrum of systolic blood pressure (SBP) and assessed whether multivariable risk assessment can identify persons who experience ASCVD events at all levels of SBP, including those with goal levels. Methods and Results Participants aged 45 to 64 years from the Framingham Offspring and Atherosclerosis Risk in Communities studies were stratified based on treated and untreated SBP levels (<120, 120 to 129, 130 to 139, 140 to 149, 150 to 159, ≥160 mm Hg). We determined the number of excess ASCVD events in each SBP stratum by calculating the difference between observed and expected events (ASCVD event rate in untreated SBP <120 mm Hg was used as the reference). We categorized participants into 10‐year ASCVD risk groups using the Pooled Cohort risk equations. There were 18 898 participants (78% white; 22% black) who were followed for 10 years. We estimated 427 excess ASCVD events, of which 56% (109 of 197) and 50% (115 of 230), respectively, occurred among untreated and treated participants with elevated SBP who were not recommended for antihypertensive therapy. Among untreated participants, 10‐year ASCVD risk ≥7.5% identified 64% of those who experienced an ASCVD at 10 years and 30% of those who did not. Multivariable risk assessment was less useful in baseline‐treated participants. Conclusions Half of excess ASCVD events occurred in persons with elevated SBP who were not currently recommended for antihypertensive therapy. Multivariable risk assessment may help identify those likely to benefit from further risk‐reducing therapies. These findings support consideration of multivariable risk in guiding prevention across the spectrum of SBP.