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Research ArticleOriginal Research

Quantifying Risk of Adverse Clinical Events With One Set of Vital Signs Among Primary Care Patients with Hypertension

William M Tierney, Margaret Brunt, Joseph Kesterson, Xiao-Hua Zhou, Gil L’Italien and Pablo Lapuerta
The Annals of Family Medicine May 2004, 2 (3) 209-217; DOI: https://doi.org/10.1370/afm.76
William M Tierney
MD
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Margaret Brunt
MD
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Joseph Kesterson
MS
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Xiao-Hua Zhou
PhD
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Gil L’Italien
PhD
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Pablo Lapuerta
MD
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    Table 1.

    Dichotomous Univariable Predictors of Adverse Vascular Events

    Coefficients for Univariable Proportional Hazards Regression
    VariableNo.(%)MICVAMI or CVAIHDHFCRIDeath
    MI = myocardial infarction, CVA = stroke (cerebrovascular accident), IHD = ischemic heart disease, HF = heart failure, CRI = chronic renal insufficiency.
    * P ≤.001.
    † P ≤.05.
    ‡ P ≤.01.
    Patient Characteristics
    Female sex4028(69)−0.368*−0.138†−0.202*−0.224†0.005−0.458*−0.319‡
    Black race3659(63)−0.362*−0.032−0.113†−0.413*−0.4080.278†0.031
    Smoker1344(23)0.599*0.383*0.439*0.1000.340*0.1920.535*
    Vascular events prior to index visit
    Ischemic heart disease2,209(38)1.402*0.632*0.832*—0.615*0.483*0.635*
    Renal failure1,255(22)0.823*0.773*0.773*0.547*0.640*—1.036
    Heart failure895(15)1.231*0.790*0.941*0.742*—0.979*1.307*
    Myocardial infarction814(14)2.009*0.868*1.241*—0.924*0.600*1.034*
    Stroke563(10)0.720*2.472*2.141*0.486‡0.608*0.162*0.827*
    Myocardial infarction or stroke1,198(21)1.733*1.693*1.777*—0.853*0.513*1.094*
    Active drug therapy at index visit
    Diuretics2,493(43)0.405*0.785*0.314*0.1920.292*0.530*0.417*
    Aspirin1,306(22)1.254*1.174*1.217*0.560*0.794*0.568*0.713*
    Calcium channel blockers1,867(32)0.698*0.495*0.530*0.1240.526*0.548*0.256‡
    Ace inhibitors1,706(29)0.538*0.441*0.475*0.265†0.508*0.558*0.499*
    Nitrates839(14)1.729*0.785*1.083*—0.819*0.842*0.020
    Beta blockers711(12)0.726*0.381*0.494*0.1660.338*0.313†−0.149
    Insulin581(10)0.729*0.502*0.587*0.801*1.020*1.739*0.710*
    Oral antidiabetic drugs565(10)0.541*0.454*0.488*0.394‡0.515*0.884*0.195
    Statin antilipemic drug216(4)0.908*0.600*0.622*0.623†0.476‡0.657‡0.613‡
    Alpha blockers147(2)0.3050.422‡0.2980.3660.569‡0.944*0.380
    Warfarin127(2)1.483*0.796*1.040*1.050‡0.939*0.724†1.108*
    Previous diagnoses recorded on or before index visit
    Diabetes mellitus1,933(33)0.899*0.648*0.713*0.625*0.788*1.346*0.861*
    Obesity1,508(26)0.0900.0290.0580.0320.258‡0.385*0.010
    Alcohol abuse741(13)0.263†0.328*0.286*0.1770.0650.413‡0.545*
    Chronic obstructive lung disease573(10)0.885*0.724*0.796*0.573*0.783*0.3371.058*
    Renal insufficiency369(6)1.042*1.060*1.050*0.514†0.778*3.075*1.496*
    Hypothyroidism368(6)0.566*0.397*0.418*0.0500.298†0.2960.187
    Peripheral arterial disease257(4)0.998*0.768*0.811*0.960*0.703*1.084*1.211*
    • View popup
    Table 2.

    Continuous Univariable Predictors of Adverse Vascular Events

    Coefficients for Univariable Proportional Hazards Regression
    VariableMean(SD)MICVAMI or CVAIHDHFCRIDeath
    MI = myocardial infarction, CVA = stroke (cerebrovascular accident), IHD = ischemic heart disease, HF = heart failure, CRI = chronic renal insufficiency.
    * P ≤.001.
    † P ≤.05.
    ‡ P ≤ 0.01.
    Patient characteristics at index visit
    Index age (y)57(14)0.023*0.044*0.038*0.021*0.030*0.028*0.053*
    Time treated for hypertension (y)5.6(5.6)0.038*0.057*0.051*0.023†0.041*0.034*0.053*
    Vital signs from the index visit
    Systolic blood pressure (mmHg)143(22)0.0010.007*0.006*0.005†0.009*0.010*0.002
    Diastolic blood pressure (mmHg)84(13)−0.011‡−0.006†−0.008*−0.005−0.001−0 .003−0.020*
    Heart rate (beats/min)81(10)−0.0030.00043−0.000860.0000550.012‡0.0110.016‡
    Mean blood pressure (mmHg)104(14)−0.0050.0030.0020.0020.007‡0.007−0.010‡
    Systolic blood pressure × heart rate11,557(2,343)−0.0000010.000048*0.000034‡0.0000360.000095*0.000087*0.000039
    Pulse pressure (mmHg)59(18)0.007‡0.013*0.012*0.010*0.013*0.016*0.012*
    Pulse pressure × heart rate4,770(1,594)0.000006†0.00012*0.00011*0.00011*0.00016*0.00016*0.00013*
    Height (in)65(3)0.027†−0.009−0.0030.0140.0050.0260.017
    Weight (lb)192(52)−0.003‡−0.006*−0.005*−0.0010.000530.001−0.006*
    Body mass index32(8)−0.020‡−0.035*−0.032*−0.0070.0050.003−0.037*
    Laboratory test results available at index visit
    Hemoglobin (g/dL) (n = 5,248)13.4(1.6)−0.040−0.046†−0.047‡0.002−0.074‡−0.138*-0.168*
    Creatinine (mg/dL) (n = 5,487)1.1(0.6)0.289*0.245*0.252*0.235*0.258*3.540*0.382*
    Cholesterol (mg/dL) (n = 5,248)210(47)0.003‡0.002*0.002*0.003‡0.002‡0.001−5.8 3 10−4
    Albumin (g/dL) (n = 5,157)4.1(0.4)−0.571*−0.411*−0.446*−0.388‡−0.693*−1.087*−1.066*
    Uric acid (mg/dL) (n = 5,172)5.9(1.7)0.100*0.075*0.074*0.075‡0.093*0.207*0.126*
    Glucose (mg/dL) (n = 5,475)126(63)0.003*0.002*0.002*0.003*0.003*0.005*0.003*
    Potassium (mEq/L) (n = 5,267)4.1(0.4)0.361*0.349*0.335*0.1230.1630.054*0.404*
    • View popup
    Table 3.

    Multivariable Models With Vital Signs Predicting Adverse Vascular Events

    Outcome Predicted (Subjects)Vital SignPValueRisk Ratio (95% CI)Other Significant Multivariable Predictors*
    CI = 95% confidence interval.
    * From information available on or before index visit. See text for definitions. Variables are listed in decreasing order of predictive power. Those variables underlined were negatively correlated with risk of the outcome event.
    Myocardial infarction (all patients)NonePrevious myocardial infarction, smoker, nitrates, warfarin, diabetes, time treated for hypertension, renal insufficiency, aspirin
    First myocardial infarction (patients with no previous infarction)Systolic blood pressure.0161.010 (1.002–1.018)Calcium channel blocker, diabetes, uric acid, African American
    Stroke (all patients)Systolic blood pressure.0011.007 (1.003–1.011)Prior stroke, age, weight, aspirin, calcium channel blocker, chronic obstructive pulmonary disease, uric acid, diabetes, renal insufficiency, glucose, previous myocardial infarction or stroke, creatinine clearance (calculated)
    First stroke (patients with no previous stroke)Diastolic blood pressure.0051.013 (1.004–1.023)Age, weight, aspirin, chronic obstructive pulmonary disease, diabetes, heart failure, uric acid, creatinine, creatinine clearance (calculated), glucose, renal insufficiency
    Myocardial infarction or stroke (all patients)Systolic blood pressure.00151.006 (1.002–1.009)Previous stroke, previous stroke or myocardial infarction, age, aspirin, renal insufficiency, diabetes, smoker, weight, time treated for hypertension, nitrates, chronic obstructive pulmonary disease, glucose
    First myocardial infarction or stroke (patients with no previous myocardial infarction or stroke)Systolic blood pressure.0051.007 (1.002–1.012)Age, smoker, chronic obstructive pulmonary disease, diabetes, uric acid, body mass index, renal insufficiency, glucose, warfarin
    Ischemic heart disease (patients with no previous ischemic heart disease)Systolic blood pressure.0051.009 (1.003–1.015)Insulin, heart failure, age, oral hypoglycemic drug, African American, peripheral arterial disease
    Heart failure (patients with no prior heart failure)Mean blood pressure.0011.012 (1.005–1.020)Age, albumin, insulin, uric acid, chronic obstructive pulmonary disease, previous myocardial infarction, oral hypoglycemic drug, cholesterol, obesity, calcium channel blocker
    Chronic renal Insufficiency (patients with no prior chronic renal insufficiency)Systolic blood pressure<.0011.013 (1.006 – 1.021)Creatinine, insulin, albumin, oral hypoglycemic drug, heart failure, glucose, acute renal failure, alcoholism, calcium channel blocker, hemoglobin, peripheral arterial disease
    All-cause mortalityHeart rate.0031.016 (1.005–1.026)Age, albumin, heart failure, alcoholism glucose, peripheral arterial disease, renal insufficiency, creatinine, smoker, time treated for hypertension, previous stroke or myocardial infarction, statin antilipemic drug, chronic obstructive pulmonary disease
    • View popup
    Table 4.

    Model Performance in the Validation Cohort

    Outcome Predicted (Subjects)Number of PatientsPatient With Outcome No. (%)C-Statistic
    * Good predictive model (defined a priori as having a C -statistic > 0.70)39,40
    Myocardial infarction (all patients)2,912198 (6.8)0.76*
    First myocardial infarction (patients with no previous myocardial infarction)2,522112 (4.4)0.62
    Stroke (all patients)2,912514 (18)0.79*
    First stroke (patients with no previous stroke)2,612317 (12)0.67
    Myocardial infarction or stroke (all patients)2,912640 (22)0.78*
    First myocardial infarction or stroke (patients with no previous myocardial infarction or stroke)2,326334 (14)0.65
    First ischemic heart disease (patients with no previous ischemic heart disease)1,811194 (11)0.63
    First heart failure (patients with no previous heart failure)2,481332 (13)0.68
    First chronic renal insufficiency (patients with no previous renal insufficiency)2,281151 (6.6)0.81*
    All-cause mortality (all patients)2,912378 (13)0.78*
    • View popup
    Table 5.

    Marginal Predictive Power of the Significant Vital Sign

    Outcome PredictedPartial Likelihood Ratio StatisticPValue
    First myocardial infarction (patients with no previous myocardial infarction)5.55.0180
    Stroke (all patients)10.32.0013
    First stroke (patients with no previous stroke)7.78.0053
    Myocardial infarction or stroke (all patients)6.28.0120
    First myocardial infarction or stroke (patients with no previous myocardial infarction or stroke)7.66.0065
    First ischemic heart disease (patients with no previous ischemic heart disease)7.76.0053
    First heart failure (patients with no previous heart failure)9.99.0016
    First chronic renal insufficiency (patients with no previous renal insufficiency)13.38.0002
    All-cause mortality (all patients)8.65.0033

Additional Files

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    A blood pressure reading includes two numbers: systolic blood pressure (the first number), which is measured after a heart beat, and diastolic blood pressure (the second number), which is measured between heart beats. A single finding of high systolic blood pressure can be a sign of increased risk of stroke, heart disease, heart attack, or kidney failure.

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Quantifying Risk of Adverse Clinical Events With One Set of Vital Signs Among Primary Care Patients with Hypertension
William M Tierney, Margaret Brunt, Joseph Kesterson, Xiao-Hua Zhou, Gil L’Italien, Pablo Lapuerta
The Annals of Family Medicine May 2004, 2 (3) 209-217; DOI: 10.1370/afm.76

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Quantifying Risk of Adverse Clinical Events With One Set of Vital Signs Among Primary Care Patients with Hypertension
William M Tierney, Margaret Brunt, Joseph Kesterson, Xiao-Hua Zhou, Gil L’Italien, Pablo Lapuerta
The Annals of Family Medicine May 2004, 2 (3) 209-217; DOI: 10.1370/afm.76
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