Social determinants of health, blood pressure classification, and incident stroke in community-dwelling adults: a prospective cohort study

Abstract Objective To determine whether the association of blood pressure (BP) categories, defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline, with stroke differ among Chinese adults with low or high burden of unfavorable social determinants of health (SDOH). Design and Methods: Analyses were conducted in the prospective sub-cohort of the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project, started in 1, July 2017 and followed stroke events until 31, June 2023. Participants were divided into groups with low and high burden of unfavorable SDOH, which consisted of educational attainment, economic stability, health care access, social support, and neighborhood relationship. Within each group, participants were categorized as having normal BP (systolic BP [SBP] <120 mm Hg and diastolic BP [DBP] <80 mm Hg), elevated BP (SBP 120-129 mm Hg and DBP <80 mm Hg), stage 1 hypertension (SBP 130-139 mm Hg or DBP 80-89 mm Hg), and stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90mm Hg). The association between BP categories and stroke risk were examined within each SDOH group, separately, using multivariable-adjusted Cox proportional hazards models. Results Of the 96,686 adults included in this study (mean [SD] age, 53.8 [10.1] years; 59,080 [61.1%] women), 64,823 (67.0%) were categorized as having high burden of unfavorable SDOH. Over a median follow-up of 5.0 years, 4,673 (4.8%) incident stroke events occurred. In the group of low burden of SDOH, hazard ratios (95% CI) for stroke events for elevated BP, stage 1 hypertension, and stage 2 hypertension vs normal BP were 1.09 (0.86-1.37), 1.14 (0.94-1.37), and 1.59 (1.33-1.90), respectively. In the group of high burden of SDOH, hazard ratios for stroke events for elevated BP, stage 1 hypertension, and stage 2 hypertension vs normal BP were 1.20 (1.04-1.38), 1.45 (1.29-1.62), and 1.71 (1.53-1.91), respectively. Results were similar after excluding those taking antihypertensive medications. Conclusion Lower BP categories were closely associated with increased risk of stroke in the context of high burden of SDOH. Early counseling and surveillance of high BP should be emphasized within socioeconomically disadvantaged populations.