Medicine

OBSERVATIONAL STUDY

Identification of Normal Blood Pressure

in Different Age Group
Jiunn-Diann Lin, Yen-Lin Chen, Chung-Ze Wu, Chang-Hsun Hsieh, Dee Pei,
Yao-Jen Liang, and Jin-Biou Chang

Abstract: The concept of using single criterion of normal blood Abbreviations: BP = blood pressure, CVD = cardiovascular
pressure with systolic blood pressure (SBP) < 140 mmHg and diastolic disease, DBP = diastolic blood pressure, FPG = fasting plasma
blood pressure (DBP) < 90 mmHg for all ages is still disputable. The glucose, JNC = Joint National committee on Detection Evaluation
aim of the study is to identify the cutoff value of normotension in and Treatment of High Blood Pressure, ROC = receiver operating
different age and sex groups. characteristic, MetS = metabolic syndrome, SBP = systolic blood
Totally, 127,922 (63,724 men and 64,198 women) were enrolled pressure, TG = triglyceride.
for the analysis. Finally, four fifths of them were randomly selected
as the study group and the other one fifths as the validation group.
Due the tight relationship with comorbidities from cardiovascular
INTRODUCTION
disease (CVD), metabolic syndrome (MetS) was used as a surrogate
to replace the actual cardiovascular outcomes in the younger I t is well-known that high blood pressure (BP) is the funda-
mental cause for many serious cardiovascular diseases (CVD)
such as cerebral vascular disease and coronary artery disease.1
subjects.
For SBP, MetS predicted by our equation had a sensitivity of 55% Several reports have shown that there is a continuous, graded,
and specificity of 67% in males and 65%, 83% in females, respect- and strong relationships between BP and the risk CVD.2,3
ively. At the same time, they are 61%, 73% in males and 73%, 86% in The definition of normal BP (systolic blood pressure
females for DBP, respectively. These sensitivity, specificity, odds [SBP] < 140 mmHg and diastolic blood pressure
ratio, and area under the receiver operating characteristic curve from [DBP] < 90 mmHg) was first proposed by the 3rd report of Joint
our equations are all better than those derived from the criteria of 140/ National committee on Detection, Evaluation and Treatment of
90 or 130/85 mmHg in both genders. High Blood Pressure in 1984 (JNC III).4 However, some of the
By using the presence of MetS as the surrogate of CVD, the researchers are still skeptical about this criteria. For example,
regression equations between SBP, DBP, and age were built in both Domanski et al5 suggested that the cardiovascular mortality could
genders. These new criteria are proved to have better sensitivity and be avoided by lowering the BP down to 120/80 mmHg in both
specificity for MetS than either 140/90 or 130/85 mmHg. These simple younger and middle-aged group based on data from a 22 years
equations should be used in clinical settings for early prevention of follow-up cohort (Multiple Intervention Trial cohort). Further-
CVD. more, by using logistic splines analytic method, Port et al6 also
suggested that hypertension should be defined according to age-
(Medicine 95(14):e3188) and sex-specific threshold rather than a single value. At the same
time, one of the largest meta-analysis including 61 cohorts,
958,074 subjects, and 56,000 cardiovascular deaths also indicated
a different value of optimal BP which is 115/75 mmHg.7 The
Editor: Miguel Camafort-Babkowski. results of these important studies indicated that the definition of
Received: October 23, 2015; revised: February 26, 2016; accepted: March
3, 2016. normal BP is still under controversial.
From the Division of Endocrinology, Department of Internal Medicine, The clustering of hypertension, dyslipidemia, and obesity
School of Medicine, College of Medicine, Taipei Medical University (J- have been noted early in 2001.8 As they are highly correlated to
DL, C-ZW); Department of Pathology, Cardinal Tien Hospital, School of future occurring of the CVD and diabetes, the World Health
Medicine, Fu-Jen Catholic University, New Taipei (Y-LC); Division of
Endocrinology and Metabolism, Department of Internal Medicine, Tri- Organization has denoted this phenomenon as metabolic syn-
Service General Hospital, National Defense Medical School, Taipei (C- drome (MetS) in 1998.9 Later, a modified and simpler version
HH); Department of Internal Medicine, Cardinal Tien Hospital, School of published by the National Cholesterol Education Program in
Medicine, Fu-Jen Catholic University, New Taipei (DP); Associate Dean of 2002.10 By far, this is the most widely accepted and used
College of Science and Engineering, Director of Graduate Institute of
Applied Science and Engineering, Department and Institute of Life- criteria. It should be stressed that the original purpose to define
Science, Fu-Jen Catholic University, New Taipei (Y-JL); and Department MetS was trying to early detect subjects with high risk for CVD
of Pathology, National Defense Medical Center, Division of Clinical and diabetes. Till now, compiling results derived either in the
Pathology, Tri-Service General Hospital, Taipei, Taiwan ROC (J-BC). cross-sectional or the longitudinal studies all repeatedly vali-
Correspondence: Jin-Biou Chang, Department of Pathology, National
Defense Medical Center, Division of Clinical Pathology, Tri-Service dated its predictability. Noticeably, in most of these pivotal
General Hospital. No 325, Sec 2, Cheng-Kung Road, Nei-Hu, Taipei, studies, actual occurrences of mortality and/or morbidities were
Taiwan ROC (e-mail: jinbiou@gmail.com). often used as the primary endpoints. It is not difficult to
The authors have no funding and conflicts of interest to disclose. postulate that these endpoints are common in the elderly.
Copyright # 2016 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons However, in the younger cohort, these cardiovascular outcomes
Attribution-NonCommercial-NoDerivatives License 4.0, where it is are much less to be found. To have enough number for an
permissible to download, share and reproduce the work in any medium, observational study to become statistically significant would
provided it is properly cited. The work cannot be changed in any way or take a long time which is difficult for many of the researchers.
used commercially.
ISSN: 0025-7974 Unfortunately, the aforementioned definition for normotension
DOI: 10.1097/MD.0000000000003188 derived from older cohort is being applied to all age groups at

Medicine
Volume 95, Number 14, April 2016 www.md-journal.com | 1

Lin et al Medicine
Volume 95, Number 14, April 2016

present, and it is easily to understand that this is just not Laboratory Evaluation
reasonable. Ever since the publication of the notion of MetS, After the 10 hour overnight fast, blood specimens were
there are many longitudinal studies focusing on its predictable collected from each subject for further analysis. Plasma was
CVD.11 – 13 These studies unanimously showed positive results separated from the whole blood within 1 hour and stored at
and were published in some of the best journals. Thus, 70 8C. Fasting plasma glucose (FPG) and plasma lipid con-
MetS could be used as a surrogate to replace the actual centrations were measured later. A glucose oxidase method
cardiovascular outcomes in the younger subjects. Although (YSI 203 glucose analyzer; Scientific Division, Yellow Springs
it is less accurate, by using this method, we could re-evaluate Instruments, Yellow Springs, OH) was used to determine FPG
the more logical cutoff points of normotension in the younger levels. The dry, multilayer analytical slide method in the Fuji
population. Dri-Chem 3000 analyzer (Fuji Photo Film, Minato-Ku, Tokyo,
Other than this, it is also important to note that both SBP Japan), was used to determine total cholesterol and triglyceride
and DBP change as age increases.14 In other words, age plays a (TG). An enzymatic cholesterol assay following dextran sulfate
very important role in the regulation of BP. Therefore, precipitation was used to determine serum high-density lipo-
we hypothesized that the definition for normal SBP and protein cholesterol and low-density lipoprotein cholesterol
DBP should vary rather than using the same value in all levels.
age-groups.
In this cross-sectional study, we enrolled 127,922 subjects. Definition of Metabolic Syndrome
Four fifths of the subjects were used to build an equation from
We used the newest criteria of MetS in 2009 with some
the logistic regression lines of SBP and DBP to have MetS in
revision.15 The WC more than or equal to 90 and 80 cm in
different gender. The levels of BP calculated from these curves
Taiwanese men and women, respectively.16 Other 4 criteria
could detect either CVD or diabetes more precisely and should
were the same: SBP more than or equal to 130 mmHg or DBP
be regarded as the definition of hypertension in its correspond-
more than or equal to 85 mmHg, TG more than or equal to
ing age and sex groups. Finally, these equations are further
150 mg/dL, FPG more than or equal to 100 mg/dL, and HDL
verified and compared with the present standard of normal BP
less than or equal to 40 and 50 mg/dL in men and women or
in the remaining one fifths of the subjects.
taking related medications.
In the present study, the BP was the independent com-
MATERIALS AND METHODS ponent. Thus, subjects with any 2 of remaining 4 MetS com-
ponents were regarded as fulfilling the diagnosis of MetS. Other
Study Population than the National Cholesterol Education Program hypertension
The study subjects of the present study were enrolled form criteria, the JNC VII definition (140/90 mmHg) was also used
the data bank of Meei-Jaw (MJ) Health Screening Centers for the comparison.
between 1999 and 2008. MJ health screening centers are
privately owned chain of outpatient department located Statistical Analysis
throughout the whole Taiwan, which offer routine health check- Subjects in the study group were stratified by the age
ups. Therefore, the database contained subjects everywhere in interval (every 5-year old) in both men and women. From 21 to
Taiwan. All study subjects were anonymous, and informed 65 years old, 9 age groups were obtained. There are 2 parts of
consent was obtained from each participant. The study proposal the analysis. The purpose of the 1st one is to build the equations
was reviewed by the institutional review board of MJ Health which could be used to identify the cutoff values for MetS. In
Screening. Totally, 129,680 subjects were enrolled when under- the study group, whether the participants having MetS or not (0
going routine health checkups. They were between 21 and or 1) was regarded as the dependent variable. At the same time,
65 years old. Since BP was the major variables we SBP or DBP was the independent variable. By using the logistic
evaluated in this study, subjects who taking any medications regression and receiver operation curve, cutoff values for SBP
would influence BP were excluded. Finally, 127,922 (63,724 and DBP were determined in each age group. Subjects with
men and 64,198 women) were eligible for the analysis. Four higher BP than these cutoff values would have a higher chance
fifths of them were randomly selected as the study group and the to have MetS. Then, the cutoff points of each 5-year age group
other one fifths as the validation group. Reporting of this study were plotted against age for SBP and DBP in a scatter graph
conforms to the STROBE statement along with references to the separately (y- and x-axis, respectively). A fitted line was
STROBE statement and the guidelines. determined by regression analysis and, finally, a corresponding
equation was obtained for either SBP or DBP in women and
Anthropometric Measurements and General men separately. In the 2nd part, our purpose was to validate the
Data proposed new criteria derived from the equations. Basically,
The participant’s medical history, including present medi- the ages of the participants were put into the equations which are
cations, was acquired by the study nurses using a questionnaire. sex-specific and then the estimated criteria for normal BP would
Detailed physical examinations were done for each subject. An be obtained accordingly. Afterwards, we compared the JNC VII
auto-anthropometer Nakamura KN-5000A (Nakamura, Tokyo, (140/90 mmHg) and MetS criteria (130/85 mmHg) against ours
Japan) was used to determine body weight and height. Waist for predicting having MetS.15,17 To fulfill this purpose, in the
circumference was measured at the midpoint between the validation group, subjects were divided into normotensive and
inferior border of the last rib and the iliac crest in a horizontal hypertensive according to the 3 different definitions. This is
level. A computerized auto-mercury-sphygmomanometer, regarded as the independent variable. Then, whether having
Citizen CH-5000 (Citizen, Tokyo, Japan) was used to measure MetS is taken as the dependent variable in logistic regression
BP on the right arm of each subject seated, after 5 minutes of model. The area under receiver operating characteristic (ROC)
rest. BP was measured twice at 10-min intervals. The average curve derived from these 3 models are compared. The larger the
value of these 2 records was taken into the analysis. area, the more accuracy the model is for predicting having

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Medicine
Volume 95, Number 14, April 2016 Identifying Normotension

MetS. In other words, it should be a better definition between the 2 groups. However, between subjects with and
for hypertension. without MetS, it could be noted that all the components
All statistical analyses were performed using SPSS 18.0 were significantly different which is not surprizing. As it is
software (SPSS Inc., Chicago, IL). The data are presented as the explained in the method, the cutoff values for proper SBP and
mean  standard deviation unless indicated otherwise. Indepen- DBP were determined by using the logistic regression and ROC
dent t-test was applied to compare the differences between the curve for each 5-year age group. These results are showed in
study and the external validation groups and between subjects Table 2. These cutoff points for SBP and DBP in both males and
with and without MetS. The TG level was not normally dis- females were plotted against the age and are showed in Figure 1.
tributed and therefore log transformation was performed before It could be noted that for both genders the SBP concave down a
analysis. Logistic regression analysis was used to calculate odds little bit between 30 and 40 years old. On the other hand, the
ratios (ORs) for an increased risk of having MetS. curves are quite different for DBP. The line for male is a
sigmoidal curve. Compared to it, the relationship between
age and DBP is a straight line in females. From these lines,
RESULTS equations were built and then were used in the validation groups
The demographic data of the study and validation group for for predicting MetS. The positive predict value, negative predict
males and females is displayed in Table 1. By the grouping value, sensitivity, and specificity of different BP cutoff points
criteria, it could be expected that there were no significant are shown in Table 3. For SBP, MetS predicted by our equation
difference in demographic and major MetS components had a sensitivity of 55% and specificity of 67% in males and

TABLE 1. Demographic Data of the Study and Validation Group

MetS () MetS (þ) P

Study group
Male
n 34840 14617
Age, years 46.3  11.4 47.3  9.4 <0.001
Body mass index, kg/m2 23.6  3.2 23.8  3.0 <0.001
Systolic blood pressure, mmHg 119.9  15.9 122.8  14.1 <0.001
Diastolic blood pressure, mmHg 75.3  10.8 74.3  10.2 <0.001
Fasting plasma glucose, mg/dL 98.4  21.0 94.5  15.6 <0.001
HDL-C, mg/dL 42.4  12.5 43.6  9.3 <0.001
Triglyceride, mg/dL 127.8  73.1 128.0  85.0 <0.001
Female
n 41265 11598
Age, years 45.7  11.7 46.3  9.6 <0.001
Body mass index, kg/m2 22.3  3.4 22.7  3.2 <0.001
Systolic blood pressure, mmHg 115.6  18.3 113.0  14.8 <0.001
Diastolic blood pressure, mmHg 72.1  10.8 67.3  9.8 <0.001
Fasting plasma glucose, mg/dL 95.3  18.7 90.6  13.3 <0.001
HDL-C, mg/dL 50.6  13.3 53.2  11.9 <0.001
Triglyceride, mg/dL 96.3  54.2 94.5  57.1 <0.001
Validation group
Male
n 8042 6225
Age, years 49.0  9.7 50.0  8.8 <0.001
Body mass index, kg/m2 23.5  2.5 26.5  2.8 <0.001
Systolic blood pressure, mmHg 120.5  13.5 125.7  14.2 <0.001
Diastolic blood pressure, mmHg 72.6  9.8 76.4  10.3 <0.001
Fasting plasma glucose, mg/dL 90.7  10.5 99.0  19.3 <0.001
HDL-C, mg/dL 47.0  9.0 38.7  6.7 <0.001
Triglyceride, mg/dL 102.3  46.5 184.4  100.7 <0.001
Female
n 8669 2666
Age, years 47.3  9.5 51.9  8.6 <0.001
Body mass index, kg/m2 21.7  2.4 25.8  3.4 <0.001
Systolic blood pressure, mmHg 110.6  13.6 120.7  15.4 <0.001
Diastolic blood pressure, mmHg 65.9  9.3 71.6  10.0 <0.001
Fasting plasma glucose, mg/dL 87.6  7.7 99.3  21.1 <0.001
HDL-C, mg/dL 55.7  11.4 44.0  7.6 <0.001
Triglyceride, mg/dL 77.6  33.2 149.7  79.1 <0.001

HDL-C ¼ high density lipoprotein cholesterol.

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Lin et al Medicine
Volume 95, Number 14, April 2016

studies focusing on the predictability of MetS. Although these

TABLE 2. Blood Pressure Cutoff Point According to the Age studies used different endpoints (coronary heart disease, myo-
Strata in Study Group cardial infarction, stroke and diabetes, etc.), the results unan-
Age SBP DBP
imously support the values of MetS. Fourth, it is undoubtable
that each component of MetS is independently related to future
Male CVD and diabetes. Thus, the collectively correlations of these
21–25 120.5 78.5 components should be better than the single component.
26–30 119.5 76.5 In the present study, equations for SBP and DBP were built
31–35 114.5 75.5 separately in men and women. By putting the ages into these
36–40 120.5 75.5 equations, the levels of normal SBP and DPB for that age will be
41–45 115.5 78.5 calculated. The results of ROC curve showed that our revised
46–50 119.5 80.5 criteria have unanimously higher predictive power for MetS
51–55 125.5 80.5 than that of the traditional criteria in both genders. In other
56–60 129.5 79.5 words, the tradition generalized criteria of hypertension for all
61–65 143.5 76.5 ages are challenged.
Female Most evidences have shown that SBP increases with age.
21–25 115.5 70.5 However, DBP increases first before 45 years old and then
26–30 113.5 71.5 declines afterwards. The main underlying mechanism of this
31–35 110.5 72.5 age-related changes of BP might be caused by the arterial
36–40 112.5 74.5 stiffness.14,18– 21 In their longitudinal study, Safar et al19 found
41–45 116.5 73.5 that the relationships between SBP, DBP, and ages are linear
46–50 124 78.5 and curvilinear, respectively, in a healthy population. Similar to
51–55 122.55 74.5 the grouping criteria used in Framingham and Safar’s studies,
56–60 132.5 78.5 we divided our subjects into 5-year-old subgroups. Four
61–65 130.5 77.5 equations were made to define the threshold of BP for having
MetS in both genders. Not surprizingly, as age increases, the
DBP ¼ diastolic blood pressure, SBP ¼ systolic blood pressure. cutoffs of SBP rise in both sexes. In the same time, this linear
relationship was only found in the DBP of females. The curve of
DBP in male is an interesting exception which is a sigmoid line
and has the lowest values between 31 and 40 years old
65%, 83% in females, respectively. At the same time, they are (75.5 mmHg) and the highest at 46 and 55 (80.5 mmHg). This
61%, 73% in males and 73%, 86% in females for DBP, finding might be attributed to the interference of some risk
respectively. These sensitivity and specificity are better than factors other than the MetS components, such as smoking or
those derived from the criteria of 140/90 or 130/85 mmHg. low-density lipoprotein cholesterol, which were not analyzed in
Table 4 shows the ORs derived from the logistic regression of the present study. Further well-designed research is needed to
the various criteria of BP predicting MetS. As expected, the ORs elucidate this issue.
estimated by our equations were better than conventional Pathologically, the mechanisms of increased SBP and DBP
normotension criteria in both genders. in hypertensive patients are not the same. The elevation of SBP
Finally, Figure 2 shows the ROC curves of the 3 different is partly caused by the increased cardiac output, reduced large
normotension criteria. The areas under ROC from our equations arteries compliance and the rise of peripheral resistance.22,23
were unanimously the highest one in either SBP or DBP in both However, in the general population, diseases resulting in
genders. All of them reached statistical significance. increase of the cardiac output, such as anemia, hyperthyroidism
aortic regurgitation, and arteriovenous fistula, etc. are relatively
few. In other words, age-related arterial rigidity and resistance
DISCUSSION play the most important role in the ‘‘systolic hypertension.’’18
The present criteria of normal BP was first proposed by As age increases or atherosclerosis advances, the elasticity of
JNC III. It was determined according to several large-scale, aorta decreases which followed by the increased SBP and
prospective, and observational studies by using stroke and reduced DBP. Interestingly, DBP is considered to be the main
coronary heart disease as the primary end points. However, target of treatment for the young people while, in the elderly,
the concept of using 1 criterion for all ages is still disputable. SBP is the goal.18,20 In this study, we believed that our criteria
For instance, it is hard to be agreed that a 20-year-old subject are more sensitive for detecting subjects with risks since it is
would under the same CVD risks compared to a 65-year-old age- and sex-specific.
subject if they all had a BP of 130/80 mmHg. One may argue It is well-recognized that gender differences in BP starts
about the justifiability to use MetS as an endpoint for determin- since adolescence.24 After puberty, females generally have
ing the cutoff values of BP. However, as mentioned earlier in lower BP than males. This difference might be caused by the
the introduction, we have several reasons to rationalize this higher androgen secretion in males. This hypothesis could be
method. First, the traditional definition of normal BP is derived supported by either the human or the animal studies. For
from the older subjects. Caution must be taken when exercise example, in females with polycystic ovary syndrome, the BP
this definition into young adulthoods. Second, it is practically increases.25 On the other hand, in castration male rats which
very difficult to follow a person from young to old age. Before have decreased androgen, the BP parallels with the change of
further longitudinal study by using CVD as the endpoint in the hormone.26 Results of observational studies in human
young adults could be done, our results provide a new concept to beings also suggest the protection role of estrogen against
define ‘‘normal’’ BP. Third, Ford11 had published his milestone hypertension since higher BP is noted after menopause.25
study in Diabetes Care by observing all the major longitudinal However, some reports showed that there was no significant

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Medicine
Volume 95, Number 14, April 2016 Identifying Normotension

FIGURE 1. Equation of the blood pressure according to the cutoff point in different age strata in study group. (A) Male systolic blood
pressure; (B) male diastolic blood pressure; (C) female systolic blood pressure; and (D) female diastolic blood pressure.

TABLE 3. Positive Predict Value, Negative Predict Value, Sensitivity, and Specificity of Different Blood Pressure Cut Point in
Validation Group

PPV, % NPV, % Sensitivity, % Specificity, %

Male
SBP cut point by equation 56 66 55 67
SBP cut point of 130 mmHg 55 61 37 76
SBP cut point of 140 mmHg 60 58 15 92
DBP cut point by equation 64 71 61 73
DBP cut point of 85 mmHg 59 59 20 89
DBP cut point of 80 mmHg 63 58 11 95
Female
SBP cut point by equation 54 89 65 83
SBP cut point of 130 mmHg 47 80 27 91
SBP cut point of 140 mmHg 47 78 10 96
DBP cut point by equation 62 91 73 86
DBP cut point of 85 mmHg 57 78 11 98
DBP cut point of 80 mmHg 53 77 5 99

DBP ¼ diastolic blood pressure, SBP ¼ systolic blood pressure.

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Lin et al Medicine
Volume 95, Number 14, April 2016

TABLE 4. Odds Ratio of Different Blood Pressure Cut Point in Validation Group

Odds Ratio (95% Confidence Interval) P Value

Male
SBP cut point by equation 2.350 (2.197–2.514) <0.001
SBP cut point of 130 mmHg 1.897 (1.766–2.038) <0.001
SBP cut point of 140 mmHg 2.109 (1.895–2.346) <0.001
DBP cut point by equation 4.042 (3.769–4.334) <0.001
DBP cut point of 85 mmHg 2.038 (1.860–2.234) <0.001
DBP cut point of 80 mmHg 2.315 (2.037–2.630) <0.001
Female
SBP cut point by equation 8.720 (7.923–9.598) <0.001
SBP cut point of 130 mmHg 3.605 (3.229–4.025) <0.001
SBP cut point of 140 mmHg 4.745 (3.956–5.690) <0.001
DBP cut point by equation 15.927 (14.367–17.656) <0.001
DBP cut point of 85 mmHg 3.105 (2.626–3.671) <0.001
DBP cut point of 80 mmHg 3.879 (2.986–5.039) <0.001

DBP ¼ diastolic blood pressure, SBP ¼ systolic blood pressure.

FIGURE 2. Receiver operating characteristic curve of different blood pressure criteria in predicting subjects with 2 or more metabolic
syndrome components in validation group. (A) Male systolic blood pressure; (B) male diastolic blood pressure; (C) female systolic blood
pressure; and (D) female diastolic blood pressure.

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Medicine
Volume 95, Number 14, April 2016 Identifying Normotension

reduction of BP after replacement of estrogen in the menopause 8. Vega GL. Results of expert meetings: obesity and cardiovascular
females.27,28 The discrepancy might be explained by the possib- disease. Obesity, the metabolic syndrome, and cardiovascular
ility that the abrupt decline of estrogen in menopause women disease. Am Heart J. 2001;142:1108–1116.
might not be the only component responsible for increase of 9. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of
BP.27,28 For instance, other than the drop of the estrogen, a mild diabetes mellitus and its complications. Part 1: diagnosis and
decrease of androgen secretion was also noted which could classification of diabetes mellitus provisional report of a WHO
modulate BP through the rennin-angiotensin-aldosterone sys- consultation. Diabet Med. 1998;15:539–553.
tem and oxidative stress.29 Because of these aforementioned 10. National Cholesterol Education Program (NCEP) Expert Panel on
reasons, our data highly suggest that the definition of normal BP Detection, Evaluation, and Treatment of High Blood Cholesterol in
should be gender-specific. Adults (Adult Treatment Panel III). Third Report of the National
To our knowledge, this is the 1st study trying to define Cholesterol Education Program (NCEP) Expert Panel on Detection,
normotension criteria in subjects with different age and genders. Evaluation, and Treatment of High Blood Cholesterol in Adults
However, there are still some limitations in our study. First, this (Adult Treatment Panel III) final report. Circulation. 2002;106:
is a cross-sectional study which is less powerful. A longitudinal 3143–3421.
study may yield more conclusive results. Second, it should be 11. Ford ES. Risks for all-cause mortality, cardiovascular disease, and
noted that only Chinese were enrolled in this study. In other diabetes associated with the metabolic syndrome: a summary of the
words, it should be exercised with caution when being extrapo- evidence. Diabetes Care. 2005;28:1769–1778.
lated to other ethnic groups.30 Third, some important confound- 12. McNeill AM, Rosamond WD, Girman CJ, et al. The metabolic
ing factors were not available in the data bank such as exercise syndrome and 11-year risk of incident cardiovascular disease in the
and smoking status and thus could not be adjusted. This would atherosclerosis risk in communities study. Diabetes Care.
reduce the reliability of our results. However, because of the 2005;28:385–390.
number of cohort is quite substantial, this drawback could 13. Wilson PW, D’Agostino RB, Parise H, et al. Metabolic syndrome as
be justified. a precursor of cardiovascular disease and type 2 diabetes mellitus.
In conclusion, by using the presence of MetS as the Circulation. 2005;112:3066–3072.
surrogate of CVD and diabetes outcomes, the regression 14. Franklin SS, Gustin Wt, Wong ND, et al. Hemodynamic patterns of
equations between SBP, DBP, and age were built, respectively, age-related changes in blood pressure. The Framingham Heart Study.
in males and females. All the regression lines are straight Circulation. 1997;96:308–315.
except for the DBP in males. From these equations, cutoff 15. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the
values for normotension are redefined. By using ROC curves, metabolic syndrome: a joint interim statement of the International
these new criteria are proved to have better sensitivity and Diabetes Federation Task Force on Epidemiology and Prevention;
specificity for MetS compared to either 140/90 or 130/ National Heart, Lung, and Blood Institute; American Heart Associa-
85 mmHg. We believe that these simple equations should be tion; World Heart Federation; International Atherosclerosis Society;
used in clinical settings for early detection of and prevention and International Association for the Study of Obesity. Circulation.
of CVD. 2009;120:1640–1645.
16. http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.aspx?
ACKNOWLEDGMENTS No¼200712250123&parentid¼200712250023. Accessed March 20,
The authors thank all participants in the study. 2015.
17. Alderman MH. JNC 7: brief summary and critique. Clin Exp
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