Framingham risk score as a pragmatic tool to detect masked daytime hypertension
A Pavlovic, X Trudel, C Blanchette, A MilotAbstract
Background/Introduction
Masked hypertension (MH), defined by normal clinic blood pressure (CBP) with elevated out-of-office BP, is associated with cardiovascular risk comparable to sustained hypertension but remains underdiagnosed. Universal ambulatory BP monitoring (ABPM) is impractical, and current guidelines provide limited guidance on whom to screen. Pragmatic strategies using existing cardiovascular risk tools are needed.
Purpose
To assess whether higher global cardiovascular risk, estimated by the Framingham 10-year cardiovascular disease (CVD) risk score, is associated with a higher prevalence of masked daytime hypertension (MDH), and whether cardiovascular risk stratification improves detection beyond CBP alone.
Methods
We conducted a prospective cohort study in a subsample of 1,713 white-collar workers from Québec, contributing 3,197 observations over three data collection phases (2000–2009). CBP was measured under standardized conditions, and daytime ambulatory BP was assessed using oscillometric ABPM. MDH was defined as CBP <140/90 mmHg with daytime ambulatory BP ≥135/85 mmHg[AM1] . Participants were categorized by Framingham 10-year CVD risk (low <10%, intermediate 10–20%, high >20%). Prevalence ratios (PRs) were estimated using unadjusted and adjusted models. Analyses were stratified by clinic BP (<130/80 vs. 130–139/80–89 mmHg).
Results
Overall MDH prevalence was 19.3%. MDH prevalence increased stepwise across Framingham risk categories: 16% in low-risk, 37% in intermediate-risk, and 46% in high-risk participants. Compared with low risk, adjusted PRs were 1.70 (95% CI 1.36–2.11) for intermediate risk and 1.98 (95% CI 1.35–2.91) for high risk (p-trend <0.001).Among participants with clinic BP <130/80 mmHg, MDH prevalence increased from 5.0% (low risk) to 9.0% (intermediate) and 13.3% (high), with PRs of 1.78 (95% CI 0.99–3.20) and 2.65 (95% CI 0.71–9.90), respectively. When CBP was high-normal (130–139/80–89 mmHg), MDH prevalence increased significantly across Framingham risk strata, with prevalence ratios of 1.33 (95% CI 1.15–1.54) in the intermediate-risk group and 1.41 (95% CI 1.07–1.86) in the high-risk group. Longer working hours (≥41 hours per week), was associated with a significantly higher prevalence of MDH, but this association was not observed in the high Framingham risk group.
Conclusion
Higher Framingham CVD risk is associated with MDH, particularly among individuals with high-normal CBP (130–139/80–89 mmHg). Leveraging established cardiovascular risk scores may offer a pragmatic and scalable strategy to order ABPM and improve detection of this high-risk but underrecognized condition.MDH prevalence by Framingham risk & clinic BPCohort characteristics by Framingham risk