This study investigated the association between SCORE and the 2007 ESH-ESC blood pressure categories and explored achievements of blood pressure goals considering global risk. In 2001–2005, a random sample of inhabitants aged 30–74 years in southwestern Sweden was invited to a survey of cardiovascular risk factors. The study enrolled 2816 participants (participation rate 76%). Blood pressure was categorized according to the 2007 ESH-ESC guidelines. Global risk of 10-year CVD death was estimated using the Swedish SCORE chart also accounting for additional risk from diabetes (SCORE-DM). SCORE-DM increased in both sexes from optimal blood pressure to manifest hypertension but did not differ between the normal blood pressure categories. However, SCORE-DM became significantly higher among those with temporarily high blood pressure (men 3.3 SD (1.7), women 1.1 (1.8)) and hypertension (3.6 (2.0), 2.0 (2.0)), compared to optimal blood pressure (1.6 (2.9), 0.6 (1.9)). In the presence of both hypertension and diabetes, high-risk subjects dominated (men 76%, women 61%), and correspondingly a major proportion of patients with known hypertension were at high risk at a blood pressure
Population studies in Sweden and many other countries show that hypertension is a common condition [
Recent studies in Skaraborg, Sweden, show a prevalence of manifest hypertension at 20% among both men and women aged 30–75 [
The aim was to study the association between SCORE and blood pressure levels according to current European expert guidelines in this Swedish population [
The Vara-Skövde Cohort (VSC) was collected 2001–2005 as a random sample of subjects aged 30–74 years residing in these two small municipalities in southwestern Sweden. Of a total 2816 subjects 1400 were men and 1416 women and the participation rate 76% as described in detail before [
The participants provided detailed information on medical history and ongoing medication and filled in a validated questionnaire regarding life styles. A standard blood pressure (right A. Brachialis) to the nearest 2 mm Hg was measured twice in a supine position, with one minute in between. The arm was placed in heart level by the support of a special pillow, and the cuff was automatically adjusted to the circumferences of the upper arm using a special device [
Untreated subjects with a blood pressure of at least at 140/90 mm Hg were seen again at a second visit within 2 weeks, and if still
A diagnosis of hypertension was considered when three consecutive high readings with two-week intervals (≥140 systolic and/or ≥90 mm Hg diastolic) were registered [
The score chart of Sweden was used to estimate the 10-year risk of cardiovascular death, accounting for risks based on sex, age, systolic blood pressure, total serum cholesterol, and on current smoking [
SPSS Base System for Windows 19.0 was used for data analyses. All proportions of the study population were age-standardized by five-year age groups using the whole Skövde-Vara population 30–75 years as standard, while means were adjusted for differences in age using general linear model (GLM). GLM was used to compare means between groups in continuous variables, and results were given as differences with 95% confidence intervals (95% CI). Logistic regression was used to estimate associations between categorical variables, and results were presented as odds ratio (OR) with 95% confidence intervals (CI). Confounding was accounted for by multivariate analyses and by stratification. All tests were 2 sided, and statistical significance was assumed if
The distribution of blood pressure categories according to the 2007 European guidel
Study characteristics of men and women participating in the Vara-Skövde population survey 2001–2005.
Men | Women | |||
---|---|---|---|---|
|
|
|||
|
(SD) |
|
(SD) | |
Age (years) | 47.8 | (11.8) | 47.8 | (11.7) |
Systolic blood pressure (mm Hg) | 124 | (14.2) | 119 | (14.2) |
Diastolic blood pressure (mm Hg) | 72 | (9.5) | 69 | (9.6) |
Serum cholesterol (mmol L−1) | 5.3 | (1.0) | 5.2 | (1.0) |
SCOREa | 1.6 | (1.6) | 0.5 | (1.6) |
SCORE-DMb | 1.9 | (2.5) | 0.8 | (2.5) |
| ||||
|
(%) |
|
(%) | |
| ||||
Daily smoking | 216 | (15) | 289 | (20) |
Known diabetesc | 51 | (5) | 42 | (4) |
SCORE-HIGHd | 179 | (13) | 19 | (1) |
SCORE-DM-HIGHe | 200 | (14) | 52 | (4) |
a SCORE: risk score according to the original model, with missing values for 6 men and 4 women.
bSCORE-DM: risk score considering diabetes, with missing values for 7 men and 6 women.
cSelf-reported doctors diagnosis of diabetes (type 1 or type 2).
dSCORE-HIGH: 10-year risk of cardiovascular death ≥5 percent, with missing values for 6 men and 4 women.
eSCORE-DM-HIGH: 10-year risk of cardiovascular death ≥5 percent considering diabetes, with missing values for 5 men and 3 women.
The figure illustrates the distribution (%) of blood pressure (BP) categories according to the 2007 ESH-ESC guidelines in men and women, respectively. The 2007 ESH-ESC blood pressure categories; normal optimal BP <120/80 mm Hg, normal BP <130/85 mm Hg, normal high BP <140/90 mm Hg. Hypertension was defined as known documented diagnosis for high blood pressure, or by three consecutive BP reading
Table
Comparison of common cardiovascular disease risk factors between categories of hypertension in men and women using aware controlled hypertension as reference. The Vara-Skövde Cohort 2001–2005 within the Skaraborg Project.
Normal blood pressure |
Unstable blood pressure | Hypertension | |||
---|---|---|---|---|---|
Men | Optimal ( |
Normal ( |
High ( |
( |
( |
| |||||
Age | |||||
Mean (SD) | 42.8 (8.5) | 45.0 (10.0) | 51.9 (12.3) | 55.4 (11.1) | 60.5 (10.5) |
Diff (CI) | 2.2 (1.0; 3.5) | 9.2 (7.5; 10.9) | 12.7 (10.2; 15.1) | 17.7 (16.1; 19.3) | |
Systolic BP (mm Hg) | |||||
Mean (SD) | 110.9 (8.9) |
123.4 (8.5) | 132.9 (8.5) | 144.2 (8.6) | 144.9 (9.4) |
Diff (CI) | 12.5 (11.4; 13.6) | 22.0 (20.5; 23.4) | 33.2 (31.1; 35.4) | 34.0 (32.4; 35.5) | |
Diastolic BP (mm Hg) | |||||
Mean (SD) | 66.0 (8.3) | 71.4 (8.0) | 76.9 (8.0) | 83.7 (8.0) | 81.8 (8.8) |
Diff (CI) | 5.8 (4.8; 6.9) | 11.4 (10.0; 12.8) | 18.2 (16.1; 20.2) | 16.3 (14.8; 17.8) | |
Total chol (mmol/L) | |||||
Mean (SD) | 5.3 (1.1) | 5.4 (1.0) | 5.4 (1.0) | 5.7 (1.0) | 5.2 (1.1) |
Diff (CI) | 0.1 (−0.1; 0.2) | −0.2 (0.0; 0.3) | 0.4 (0.1; 0.6) | −0.1 (−0.3; 0.1) | |
SCORE | |||||
Mean (SD) | 1.4 (1.9) | 1.2 (1.9) | 1.2 (1.9) | 2.8 (1.9) | 2.7 (2.1) |
Diff (CI) | −0.1 (−0.3; 0.1) | −0.1 (−0.4; 0.2) | 1.5 (1.0; 2.0) | 1.4 (1.0; 1.7) | |
SCORE-DM | |||||
Mean (SD) | 1.6 (2.9) | 1.4 (2.8) | 1.2 (2.8) | 3.3 (1.7) | 3.6 (2.0) |
Diff (CI) | −0.2 (−0.5; 0.2) | −0.3 (−0.8; 0.2) | 1.7 (1.0; 2.4) | 2.0 (1.5; 2.6) | |
Smoking | |||||
|
87 (16) | 59 (14) | 30 (17) | 15 (22) | 25 (12) |
OR (CI) | 1.0 (0.7; 1.4) | 1.1 (0.7; 1.7) | 1.5 (0.8; 2.9) | 0.7 (0.4; 1.3) | |
Diabetes | |||||
|
15 (3) | 12 (3) | 10 (6) | 7 (10) | 45 (22) |
OR (CI) | 1.0 (0.5; 2.2) | 1.2 (0.5; 2.9) | 2.0 (0.7; 5.3) | 3.9 (1.9; 8.0) | |
CVD | |||||
|
7 (1) | 5 (1) | 11 (6) | 1 (1) | 36 (17) |
OR (CI) | 0.7 (0.2; 2.2) | 1.4 (0.5; 4.1) | 0.2 (0.0; 2.1) | 2.6 (1.0; 6.5) | |
SCORE-HIGH | |||||
|
12 (2) | 19 (5) | 28 (16) | 25 (37) | 95 (46) |
OR (CI) | 1.3 (0.5; 3.9) | 1.3 (0.5; 3.7) | 10.2 (3.2; 33.2) | 4.9 (1.9; 12.2) | |
SCORE-HIGH-DM | |||||
|
15 (3) | 20 (5) | 33 (18) | 28 (41) | 104 (50) |
OR (CI) | 1.0 (0.3; 2.6) | 1.3 (0.5; 3.5) | 10.1 (3.3; 30.5) | 4.7 (2.0; 11.2) | |
| |||||
Women | Optimal |
Normal |
High |
|
|
| |||||
Age | |||||
Mean (SD) | 42.2 (7.9) | 48.7 (10.7) | 55.4 (11.9) | 58.2 (9.5) | 61.1 (10.3) |
Diff (CI) | 6.5 (5.1; 7.8) | 13.2 (11.4; 15.0) | 16.0 (13.6; 18.4) | 18.9 (17.5; 20.3) | |
Systolic BP (mm Hg) | |||||
Mean (SD) | 108.1 (9.6) |
122.8 (8.7) | 132.6 (8.9) | 143.9 (8.9) | 145.4 (9.9) |
Diff (CI) | 14.6 (13.3; 15.9) | 24.5 (22.7; 26.3) | 35.8 (33.4; 38.2) | 37.2 (35.6; 38.9) | |
Diastolic BP (mm Hg) | |||||
Mean (SD) | 63.1 (8.6) | 71.9 (7.8) | 75.0 (8.0) | 81.1 (8.0) | 79.3 (8.9) |
Diff (CI) | 8.9 (7.7; 10.1) | 12.0 (10.3; 13.6) | 18.0 (15.8; 20.2) | 16.2 (14.8; 17.7) | |
Total chol (mmol/L) | |||||
Mean (SD) | 5.2 (1.1) | 5.3 (1.0) | 5.4 (1.0) | 5.5 (1.0) | 5.1 (1.1) |
Diff (CI) | 0.2 (0.0; 0.3) | 0.2 (0.0; 0.4) | 0.3 (0.0; 0.6) | 0.0 (−0.2; 0.1) | |
SCORE | |||||
Mean (SD) | 0.4 (0.8) | 0.3 (0.7) | 0.4 (0.8) | 0.9 (0.8) | 1.1 (0.8) |
Diff (CI) | −0.1 (−0.2; 0.0) | −0.1 (−0.2; 0.1) | 0.4 (0.2; 0.6) | 0.6 (0.5; 0.8) | |
SCORE-DM | |||||
Mean (SD) | 0.6 (1.9) | 0.3 (1.7) | 0.4 (1.8) | 1.1 (1.8) | 2.0 (2.0) |
Diff (CI) | −0.3 (−0.6; 0.0) | −0.2 (−0.5; 0.2) | 0.5 (0.0; 0.9) | 1.3 (1.0; 1.7) | |
Smoking | |||||
|
162 (20) | 50 (22) | 26 (23) | 12 (20) | 39 (19) |
OR (CI) | 1.2 (0.8; 1.7) | 1.3 (0.8; 2.2) | 1.2 (0.6; 2.3) | 1.1 (0.7; 1.8) | |
Diabetes | |||||
|
11 (1) | 5 (2) | 6 (5) | 5 (8) | 42 (20) |
OR (CI) | 1.2 (0.4; 3.5) | 2.2 (0.7; 6.5) | 3.3 (1.0; 10.6) | 8.2 (3.5; 19.0) | |
CVD | |||||
|
6 (1) | 6 (3) | 2 (2) | 1 (2) | 12 (6) |
OR (CI) | 1.1 (0.3; 3.7) | 0.3 (0.0; 1.5) | 0.3 (0.0; 2.4) | 0.6 (0.2; 2.0) | |
SCORE-HIGH | |||||
|
1 (0) | 0 (0) | 2 (2) | 2 (3) | 14 (7) |
OR (CI) | 0.0 (0.0; —) | 1.4 (0.4; 8.6) | 3.0 (0.8; 16.9) | 3.9 (1.8; 24.3) | |
SCORE-HIGH-DM | |||||
|
3 (0) | 0 (0) | 5 (4) | 5 (8) | 39 (19) |
OR (CI) | 0.0 (0.0; —) | 1.8 (0.4; 8.6) | 3.6 (0.8; 16.9) | 6.6 (1.8; 24.3) |
Characteristics of high and low risk subjects, based on SCORE-DM-HIGH, are shown in Figure
Global risk according to SCORE characterized by SCORE variables in men and women of the Vara-Skövde Cohort in the Skaraborg Project 2001–2005.
Mort ≥ 5% | DM | HT | Age | (SD) | SBP | (SD) | Chol | (SD) | Smoke | (%) | |
---|---|---|---|---|---|---|---|---|---|---|---|
Men ( |
|||||||||||
1067 | − | − | − | 43.7 | (8.5) | 120.0 | (13.7) | 5.4 | (1.1) | 157 | (15) |
24 | − | + | − | 44.4 | (8.6) | 125.4 | (13.8) | 5.1 | (1.0) | 7 | (29) |
93 | − | − | + | 53.2 | (8.2) | 139.4 | (13.3) | 5.3 | (1.0) | 6 | (7) |
11 | − | + | + | 47.8 | (11.8) | 132.8 | (13.8) | 4.7 | (1.0) | 0 | (0) |
75 | + | − | − | 68.2 | (4.6) | 118.0 | (15.0) | 5.8 | (1.1) | 23 | (31) |
20 | + | + | − | 66.7 | (5.7) | 119.8 | (14.1) | 5.0 | (1.0) | 4 | (20) |
70 | + | − | + | 68.3 | (4.9) | 141.7 | (14.4) | 5.2 | (1.1) | 11 | (16) |
34 | + | + | + | 68.2 | (5.8) | 134.1 | (14.3) | 5.1 | (1.0) | 8 | (24) |
| |||||||||||
Women ( |
|||||||||||
1176 | − | − | − | 45.2 | (10.1) | 115.9 | (12.9) | 5.2 | (1.0) | 240 | (20) |
18 | − | + | − | 47.8 | (11.7) | 121.0 | (14.4) | 5.2 | (1.0) | 3 | (17) |
151 | − | − | + | 59.7 | (10.4) | 136.4 | (14.0) | 5.2 | (1.0) | 28 | (19) |
16 | − | + | + | 57.1 | (10.1) | 134.2 | (14.3) | 4.5 | (1.0) | 1 | (6) |
4 | + | − | − | 66.6 | (4.4) | 120.8 | (14.4) | 6.8 | (1.0) | 4 | (100) |
8 | + | + | − | 69.0 | (4.2) | 111.4 | (14.5) | 4.8 | (1.0) | 3 | (38) |
13 | + | − | + | 68.4 | (9.3) | 155.2 | (14.2) | 5.4 | (1.0) | 3 | (17) |
25 | + | + | + | 68.6 | (3.8) | 131.4 | (14.7) | 4.8 | (1.0) | 4 | (16) |
Venn diagrams in men (a) and women (b), showing the overlap between categories of hypertension, diabetes, and high risk score, respectively, accounting for diabetes.
Men
Women
Traditional CVD risk factors increased in both men and women the higher the blood pressure category. The accumulation of risk factors among subjects with manifest hypertension and unstable blood pressure was confirmed by the global risk score that significantly separated hypertension and unstable blood pressure from all the normal blood pressure categories according the 2007 European guidelines. This pattern was even more pronounced when risk score also accounted for diabetes. Most subjects with manifest hypertension had an estimated 10-year CVD mortality risk <5% and should thus not by routine be prescribed pharmacological treatment.
Blood pressure levels that are recommended for therapy by expert guidelines are according to this study accurately decided based on SCORE. However, global risk estimation by SCORE did not identify all subjects with a diagnosis of hypertension and/or diabetes as being at a high risk. Many study subjects with hypertension, especially women, did not reach a SCORE that indicates the need of drug treatment. Instead this study showed that a substantial proportion of men having high SCORE had neither hypertension nor diabetes. The high SCORE risk was mainly attributed to old age if hypertension or diabetes were not present (Table
A major strength of this study was the high participation rate, which gives the results a high trustworthiness. It is still likely that individuals with chronic diseases or health problems prior to the study would be more reluctant to participate than healthy people, as often seen in other surveys [
Originally SCORE did not consider risk from diabetes, but a modified algorithm has been proposed by multiplying the score value by two in men and by four in women, which we accordingly did [
We have found that a large proportion of patients with hypertension had a low risk according to SCORE. This contradicts previous reports suggesting that SCORE overestimates cardiovascular risk [
The present findings imply that cardiovascular risk estimation using SCORE is parallel with risk increase according to 2007 ESH-ESC blood pressure categories and general expert treatment guidelines. Our findings may have strong implications on blood pressure evaluation in clinical practice and emphasize the need of nonpharmacological interventions among subjects with high normal blood pressure and low risk hypertension [