Major adverse cardiovascular events are closely associated with 24-hour blood pressure (BP). We determined outcome-driven thresholds for 24-hour mean arterial pressure (MAP), a BP index estimated by oscillometric devices. We assessed the association of major adverse cardiovascular events with 24-hour MAP, systolic BP (SBP), and diastolic BP (DBP) in a population-based cohort (n=11 596). Statistics included multivariable Cox regression and the generalized R2 statistic to test model fit. Baseline office and 24-hour MAP averaged 97.4 and 90.4 mm Hg. Over 13.6 years (median), 2034 major adverse cardiovascular events occurred. Twenty-four-hour MAP levels of <90 (normotension, n=6183), 90 to <92 (elevated MAP, n=909), 92 to <96 (stage-1 hypertension, n=1544), and ≥96 (stage-2 hypertension, n=2960) mm Hg yielded equivalent 10-year major adverse cardiovascular events risks as office MAP categorized using 2017 American thresholds for office SBP and DBP. Compared with 24-hour MAP normotension, hazard ratios were 0.96 (95% CI, 0.80-1.16), 1.32 (1.15-1.51), and 1.77 (1.59-1.97), for elevated and stage-1 and stage-2 hypertensive MAP. On top of 24-hour MAP, higher 24-hour SBP increased, whereas higher 24-hour DBP attenuated risk (P<0.001). Considering the 24-hour measurements, R2 statistics were similar for SBP (1.34) and MAP (1.28), lower for DBP than for MAP (0.47), and reduced to null, if the base model included SBP and DBP; if the ambulatory BP indexes were dichotomized according to the 2017 American guideline and the proposed 92 mm Hg for MAP, the R2 values were 0.71, 0.89, 0.32, and 0.10, respectively. In conclusion, the clinical application of 24-hour MAP thresholds in conjunction with SBP and DBP refines risk estimates.

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

Alzheimer's Disease Resource Center for Minority Aging Research University of Texas Rio Grande Valley Brownsville

Asociación Española Primera de Socorros Mutuos Montevideo Uruguay

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

Centre for Molecular and Vascular Biology KU Leuven Department of Cardiovascular Sciences University of Leuven Belgium

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

Conway Institute University College Dublin Ireland

Department of Cardiology Shanghai General Hospital Shanghai Jiao Tong University School of Medicine China

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

Department of Hypertension Medical University of Gdańsk Poland

Department of Medicine University of Padova Italy

Division of Cardiology Department of Internal Medicine University Hospitals Leuven Belgium

Faculty of Medicine Charles University Pilsen Czech Republic

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

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

Laboratory of Neurosciences Faculty of Medicine University of Zulia Maracaibo Venezuela

Research Institute Alliance for the Promotion of Preventive Medicine Mechelen Belgium

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

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

Stroke and Hypertension Unit Blanchardstown Dublin Ireland

Tohoku Institute for Management of Blood Pressure

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