Participant-level meta-analyses assessed the age-specific relevance of office blood pressure to cardiovascular complications, but this information is lacking for out-of-office blood pressure. At baseline, daytime ambulatory (n=12 624) or home (n=5297) blood pressure were measured in 17 921 participants (51.3% women; mean age, 54.2 years) from 17 population cohorts. Subsequently, mortality and cardiovascular events were recorded. Using multivariable Cox regression, floating absolute risk was computed across 4 age bands (≤60, 61-70, 71-80, and >80 years). Over 236 491 person-years, 3855 people died and 2942 cardiovascular events occurred. From levels as low as 110/65 mm Hg, risk log-linearly increased with higher out-of-office systolic/diastolic blood pressure. From the youngest to the oldest age group, rates expressed per 1000 person-years increased (P<0.001) from 4.4 (95% CI, 4.0-4.7) to 86.3 (76.1-96.5) for all-cause mortality and from 4.1 (3.9-4.6) to 59.8 (51.0-68.7) for cardiovascular events, whereas hazard ratios per 20-mm Hg increment in systolic out-of-office blood pressure decreased (P≤0.0033) from 1.42 (1.19-1.69) to 1.09 (1.05-1.12) and from 1.70 (1.51-1.92) to 1.12 (1.07-1.17), respectively. These age-related trends were similar for out-of-office diastolic pressure and were generally consistent in both sexes and across ethnicities. In conclusion, adverse outcomes were directly associated with out-of-office blood pressure in adults. At young age, the absolute risk associated with out-of-office blood pressure was low, but relative risk high, whereas with advancing age relative risk decreased and absolute risk increased. These observations highlight the need of a lifecourse approach for the management of hypertension.

1st Department of Cardiology Interventional Electrocardiology and Hypertension Jagiellonian University Medical College Kraków Poland

Asociación Española Primera de Socorros Mutuos Montevideo Uruguay

Cardiovascular Research Institute Maastricht

Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluations Shanghai Institute of Hypertension Shanghai Key Laboratory of Hypertension Ruijin Hospital Shanghai Jiaotong University School of Medicine China

Centro de Nefrología and Departamento de Fisiopatología Hospital de Clínicas Universidad de la República Montevideo Uruguay

Conway Institute University College Dublin Ireland

Department of Hygiene and Public Health Teikyo University School of Medicine Tokyo Japan

Department of Hypertension Medical University of Gdańsk Poland

Department of Medicine Hospital Italiano de Buenos Aires University of Buenos Aires Argentina

Department of Medicine Turku University Hospital and University of Turku Finland

Department of Medicine University of Padova Italy

Department of Preventive Medicine and Epidemiology Tohoku Medical Megabank Organization Tohoku University Sendai Japan

Department of Public Health and Caring Sciences Section of Geriatrics Uppsala University Sweden

Department of Public Health Tohoku University Graduate School of Medicine Sendai Japan

Departments of Neuroscience and Human Genetics University of Texas Rio Grande Valley Brownsville TX

Division of Cardiovascular Medicine Department of Clinical Sciences Danderyd Hospital Karolinska Institutet Stockholm Sweden

Faculty of Medicine Charles University Pilsen Czech Republic

Hypertension Center STRIDE 7 National and Kapodistrian University of Athens School of Medicine 3rd Department of Medicine Sotiria Hospital Greece

Institute of Internal and Preventive Medicine Internal and Preventive Medicine Branch of the Institute of Cytology and Genetics Siberian Branch of the Russian Academy of Science Novosibirsk Russian Federation

Laboratorio de Neurociencias and Instituto Cardiovascular Universidad del Zulia Maracaibo Venezuela

National Institute for Health and Welfare Turku Finland

Research Unit Hypertension and Cardiovascular Epidemiology KU Leuven Department of Cardiovascular Sciences University of Leuven Belgium

Steno Diabetes Center Copenhagen Gentofte and Research Centre for Prevention and Health Capital Region of Denmark Denmark

Stroke and Hypertension Unit Blanchardstown Dublin Ireland

Tohoku Institute for Management of Blood Pressure

See more in PubMed

Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–1913. doi: 10.1016/s0140-6736(02)11911-8. PubMed DOI

Asia Pacific Cohort Studies Collaboration. Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens. 2003;21:707–716. doi: 10.1097/01.hjh.0000052492.18130.07. PubMed DOI

Lacey B, Lewington S, Clarke R, et al.; China Kadoorie Biobank collaborative group. Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0.5 million adults in China: a prospective cohort study. Lancet Glob Health. 2018;6:e641–e649. doi: 10.1016/S2214-109X(18)30217-1. PubMed DOI PMC

Hansen TW, Kikuya M, Thijs L, Björklund-Bodegård K, Kuznetsova T, Ohkubo T, Richart T, Torp-Pedersen C, Lind L, Jeppesen J, Ibsen H, Imai Y, Staessen JA; IDACO Investigators. Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations : a meta-analysis of 7030 individuals. J Hypertens. 2007;25:1554–1564. doi: 10.1097/hjh.0b013e3281c49da5. PubMed DOI

Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ, Ruiz-Hurtado G, Segura J, Rodríguez-Artalejo F, Williams B. Relationship between clinic and ambulatory blood-pressure measurements and mortality. N Engl J Med. 2018;378:1509–1520. doi: 10.1056/NEJMoa1712231. PubMed DOI

Niiranen TJ, Hänninen MR, Johansson J, Reunanen A, Jula AM. Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure. Hypertension. 2010;55:1346–1351. doi: 10.1161/HYPERTENSIONAHA.109.149336. PubMed DOI

Whelton PK, Carey RM, Aronow WS, et al. 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. Hypertension. 2018;71(6):e13–e115. doi: 10.1161/HYP.0000000000000065. PubMed DOI

National Institute for Health and Clinical Excellence (NICE). The clinical management of primary hypertension in adults. Clinical Guideline 127. Methods, evidence and recommendations. http://www.nice.org.uk/guidance/CG127 2011. doi: 10.1007/978-3-642-16483-5_3972. DOI

Williams B, Mancia G, Spiering W, et al.; Authors/Task Force Members:. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36:1953–2041. doi: 10.1097/HJH.0000000000001940. PubMed DOI

Thijs L, Hansen TW, Kikuya M, et al.; IDACO Investigators. The International Database of Ambulatory blood pressure in relation to Cardiovascular Outcome (IDACO): protocol and research perspectives. Blood Press Monit. 2007;12:255–262. doi: 10.1097/mbp.0b013e3280f813bc. PubMed DOI

Niiranen TJ, Thijs L, Asayama K, Johansson JK, Ohkubo T, Kikuya M, Boggia J, Hozawa A, Sandoya E, Stergiou GS, Tsuji I, Jula AM, Imai Y, Staessen JA; IDHOCO Investigators. The International Database of HOme blood pressure in relation to Cardiovascular Outcome (IDHOCO): moving from baseline characteristics to research perspectives. Hypertens Res. 2012;35:1072–1079. doi: 10.1038/hr.2012.97. PubMed DOI PMC

World Medical Association. World Medical Association Declaration of Helsinki : ethical principles for medical research invovling human subjects. JAMA. 2013;310:2191–2194. doi: 10.1001/jama.2013.281053. PubMed DOI

Hansen TW, Jeppesen J, Rasmussen F, Ibsen H, Torp-Pedersen C. Ambulatory blood pressure monitoring and mortality: a population-based study. Hypertension. 2005;45:499–504. doi: 10.1161/01.hyp.0000160402.39597.3b. PubMed DOI

Ohkubo T, Hozawa A, Yamaguchi J, Kikuya M, Ohmori K, Michimata M, Matsubara M, Hashimoto J, Hoshi H, Araki T, Tsuji I, Satoh H, Hisamichi S, Imai Y. Prognostic significance of the nocturnal decline in blood pressure in individuals with and without high 24-h blood pressure: the Ohasama study. J Hypertens. 2002;20:2183–2189. doi: 10.1097/00004872-200211000-00017. PubMed DOI

Staessen JA, Bieniaszewski L, O’Brien ET, Imai Y, Fagard R. An epidemiological approach to ambulatory blood pressure monitoring: the Belgian population study. Blood Press Monit. 1996;1:13–26. doi: https://lirias.kuleuven.be/handle/123456789/275980. PubMed

Ingelsson E, Björklund K, Lind L, Ärnlöv J, Sundström J. Diurnal blood pressure pattern and risk of congestive heart failure. JAMA. 2006;295:2859–2866. doi: 10.1111/j.1527-5299.2006.04942.x. PubMed DOI

Schettini C, Bianchi M, Nieto F, Sandoya E, Senra H, Hypertension Working Group. Ambulatory blood pressure. Normality and comparison with other measurements. Hypertension. 1999;34:818–825. doi: 10.1161/01.HYP.35.3.e8. PubMed DOI

Li Y, Wang JG, Gao HF, Nawrot T, Wang GL, Qian YS, Staessen JA, Zhu DL. Are published characteristics of the ambulatory blood pressure generalizable to rural Chinese? The JingNing population study. Blood Press Monit. 2005;10:125–134. doi: 10.1016/j.amjhyper.2005.03.098. PubMed DOI

Kuznetsova T, Malyutina S, Pello E, Thijs L, Nikitin Y, Staessen JA. Ambulatory blood pressure of adults in Novosibirsk, Russia: interim report on a population study. Blood Press Monit. 2000;5:291–296. doi: 10.1016/S0895-7061(01)01501-1. PubMed DOI

Kuznetsova T, Staessen JA, Kawecka-Jaszcz K, Babeanu S, Casiglia E, Filipovský J, Nachev C, Nikitin Y, Peleskã J, O’Brien E. Quality control of the blood pressure phenotype in the European Project on Genes in Hypertension. Blood Press Monit. 2002;7:215–224. doi: 10.1097/00126097-200208000-00003. PubMed DOI

O’Brien E, Murphy J, Tyndall A, Atkins N, Mee F, McCarthy G, Staessen J, Cox J, O’Malley K. Twenty-four-hour ambulatory blood pressure in men and women aged 17 to 80 years: the Allied Irish Bank Study. J Hypertens. 1991;9:355–360. doi: 10.1097/00004872-199104000-00007. PubMed DOI

Maestre GE, Pino-Ramírez G, Molero AE, Silva ER, Zambrano R, Falque L, Gamero MP, Sulbarán TA. The Maracaibo Aging Study: population and methodological issues. Neuroepidemiology. 2002;21:194–201. doi: 10.1159/000059524. PubMed DOI

Niu K, Hozawa A, Awata S, Guo H, Kuriyama S, Seki T, Ohmori-Matsuda K, Nakaya N, Ebihara S, Wang Y, Tsuji I, Nagatomi R. Home blood pressure is associated with depressive symptoms in an elderly population aged 70 years and over : a population-based, cross-sectional analysis. Hypertens Res. 2008;31:409–416. doi: 10.1291/hypres.31.409. PubMed DOI

Stergiou GS, Baibas NM, Kalogeropoulos PG. Cardiovascular risk prediction based on home blood pressure measurement: the Didima Study. J Hypertens. 2007;25:1590–1596. doi: 10.1097/HJH.0b013e3281ab6c69. PubMed DOI

Asayama K, Ohkubo T, Kikuya M, Metoki H, Hoshi H, Hashimoto J, Totsune K, Satoh H, Imai Y. Prediction of stroke by self-measurement of blood pressure at home versus casual screening blood pressure measurement in relation to the Joint National Committee 7 classification: the Ohasama study. Stroke. 2004;35:2356–2361. doi: 10.1161/01.STR.0000141679.42349.9f. PubMed DOI

Li Y, Thijs L, Hansen TW, et al.; on behalf of the International Database on Ambulatory blood pressure monitoring in relation to Cardiovascular Outcomes (IDACO) investigators. Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations. Hypertension. 2010;55:1040–1048. doi: 10.1161/HYPERTENSIONAHA.109.137273. PubMed DOI

Thijs L, Staessen J, Fagard R. Analysis of the diurnal blood pressure curve. High Blood Press Cardiovasc Prev 1992;1:17–28. doi: 10.1111/jch.12003. DOI

Asayama K, Thijs L, Brguljan Hitij J, et al.; International Database of Home Blood Pressure in Relation to Cardiovascular Outcome (IDHOCO) investigators. Risk stratification by self-measured home blood pressure across categories of the conventional blood pressure : a participant-level meta-analysis. PLOS Med. 2014;11:e1001591. doi: 10.1371/journal.pmed.1001591. PubMed DOI PMC

Pitsavos C, Panagiotakos DB, Chrysohoou C, Stefanadis C. Epidemiology of cardiovascular risk factors in Greece: aims, design and baseline characteristics of the ATTICA study. BMC Public Health. 2003;3:32. doi: 10.1186/1471-2458-3-32. PubMed DOI PMC

Easton DF, Peto J, Babiker AGAG. Floating absolute risk: an alternative to relative risk in survival and case-control analysis avoiding an arbitrary reference group. Stat Med. 1991;10:1025–1035. doi: 10.1002/sim.4780100703. PubMed DOI

Hong LS, Lewington S. Lexis Expansion - Age-at-risk adjustment for survival analysis. 2012; https://www.lexjansen.com/phuse/2013/sp/SP09.pdf (accessed 1 September 2018).

Olsen MH, Angell SY, Asma S, et al. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. Lancet. 2016; 388: 2665–2712. doi: 10.1016/S0140-6736(16)31134-5. PubMed DOI

Boggia J, Thijs L, Hansen TW, et al.; International Database on Ambulatory blood pressure in relation to Cardiovascular Outcomes (IDACO) Investigators. Ambulatory blood pressure monitoring in 9357 subjects from 11 populations highlights missed opportunities for cardiovascular prevention in women. Hypertension. 2011;57:397–405. doi: 10.1161/HYPERTENSIONAHA.110.156828. PubMed DOI PMC

Staessen JA, Kuznetsova T, Stolarz K. Hypertension prevalence and stroke mortality across populations. JAMA. 2003;289:2420–2422. doi: 10.1001/jama.289.18.2420. PubMed DOI

Tan CS, Müller-Riemenschneider F, Ng SH, Tan PZ, Chan BP, Tang KF, Ahmad A, Kong KH, Chang HM, Chow KY, Koh GC, Venketasubramanian N; Singapore Stroke Registry. Trends in Stroke Incidence and 28-Day Case Fatality in a Nationwide Stroke Registry of a Multiethnic Asian Population. Stroke. 2015;46:2728–2734. doi: 10.1161/STROKEAHA.115.009797. PubMed DOI

Read SH, Kerssens JJ, McAllister DA, Colhoun HM, Fischbacher CM, Lindsay RS, McCrimmon RJ, McKnight JA, Petrie JR, Sattar N, Wild SH; Scottish Diabetes Research Network Epidemiology Group. Trends in type 2 diabetes incidence and mortality in Scotland between 2004 and 2013. Diabetologia. 2016;59:2106–2113. doi: 10.1007/s00125-016-4054-9. PubMed DOI PMC

Lovibond K, Jowett S, Barton P, Caulfield M, Heneghan C, Hobbs FD, Hodgkinson J, Mant J, Martin U, Williams B, Wonderling D, McManus RJ. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care : a modelling study. Lancet. 2011;378:1219–1230. doi: 10.1016/S0140-6736(11)61184-7. PubMed DOI

Franklin SS, Thijs L, Li Y, et al.; International Database on Ambulatory blood pressure in Relation to Cardiovascular Outcomes Investigators. Masked hypertension in diabetes mellitus : treatment implications for clinical practice. Hypertension. 2013;61:964–971. doi:10.1161/HYPERTENSIONAHA.111.00289. PubMed DOI PMC

Asayama K, Li Y, Franklin SS, Thijs L, O’Brien E, Staessen JA. Cardiovascular risk associated with white-coat hypertension: con side of the argument. Hypertension. 2017;70:676–682. doi:10.1161/HYPERTENSIONAHA.117.08902. PubMed DOI

Bombelli M, Toso E, Peronio M, Fodri D, Volpe M, Brambilla G, Facchetti R, Sega R, Grassi G, Mancia G. The Pamela study: main findings and perspectives. Curr Hypertens Rep. 2013;15:238–243. doi: 10.1007/s11906-013-0348-1. PubMed DOI

Ravenell J, Shimbo D, Booth JN 3rd, Sarpong DF, Agyemang C, Beatty Moody DL, Abdalla M, Spruill TM, Shallcross AJ, Bress AP, Muntner P, Ogedegbe G. Thresholds for Ambulatory Blood Pressure Among African Americans in the Jackson Heart Study. Circulation. 2017;135:2470–2480. doi: 10.1161/CIRCULATIONAHA.116.027051. PubMed DOI PMC

MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease. Part 1, prolonged differences in blood pressure : prospective observational studies corrected for the regression dilution bias. Lancet. 1990;335:765–774. doi: 10.1016/0140-6736(90)90878-9. PubMed DOI

Odili AN, Thijs L, Yang WY, Ogedengbe JO, Nwegbu MM, Jacobs L, Wei FF, Feng YM, Zhang ZY, Kuznetsova T, Nawrot TS, Staessen JA. Office and home blood pressures as determinants of electrocardiographic left ventricular hypertrophy among black Nigerians compared with white Flemish. Am J Hypertens. 2017;30:1083–1092. doi: 10.1093/ajh/hpx114. PubMed DOI PMC

Ambulatory blood pressure monitoring, European guideline targets, and cardiovascular outcomes: an individual patient data meta-analysis

Derivation of an Outcome-Driven Threshold for Aortic Pulse Wave Velocity: An Individual-Participant Meta-Analysis

The International Database of Central Arterial Properties for Risk Stratification: Research Objectives and Baseline Characteristics of Participants

Relative and Absolute Risk to Guide the Management of Pulse Pressure, an Age-Related Cardiovascular Risk Factor

Association of Fatal and Nonfatal Cardiovascular Outcomes With 24-Hour Mean Arterial Pressure