Multi-state analysis of hypertension and mortality: Application of semi-Markov model in a longitudinal cohort study

Azra Ramezankhani, Michael J. Blaha, Mohammad Hassan Mirbolouk, Fereidoun Azizi, Farzad Hadaegh

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Background: Most previous research has studied the association of hypertension with cardiovascular disease (CVD) and all-cause mortality by focusing on the transition from the initial state to a single outcome. We investigated the impact of hypertension, defined according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) (new) and the Seventh Report of the Joint National Committee (JNC7) (old), on CVD death and all-cause mortality considering non-fatal CVD as an intermediate event between two CVD-free and mortality states. Methods: A total of 3002 Iranian population (47.4% men), aged ≥50 years were followed from 1999 to 2014. Two multi-state semi-Markov models with three transitions were defined for CVD death and all-cause mortality as two outcomes. The multivariable Cox model was used to estimate the effect of hypertension on transition hazards. The mean of 15-year life expectancy of participants in each transition was estimated using the restricted mean survival time. Results: The ACC/AHA guideline increased the prevalence of hypertension from 43.3 to 68.6%. Among CVD-free individuals, hypertension was significantly associated with increased risk of non-fatal CVD [Hazard Ratio, 1.52 (1.28-1.81) and 1.48 (1.21-1.80)], CVD death [2.96 (2.06-4.25) and 1.98 (1.30-3.04)] and all-cause mortality [1.64 (1.32-2.05) and 1.31 (1.01-1.69)] according the old and new guidelines, respectively. However, after incident non-fatal CVD, the association between hypertension and mortality events was not significant according to both definitions. Hypertensive participants experienced a first non-fatal CVD about 0.9 and 0.6 years earlier than normotensive population according to JNC7 and the 2017 ACC/AHA guidelines, respectively. Conclusion: Hypertension, according to JNC7 and the ACC/AHA guidelines, significantly increased the risk of mortality events among CVD-free population although the risk was attenuated using ACC/AHA guideline. Hypertension also decreased the number of years lived without CVD and early onset of CVD, and consequently, an increase in the time spent with these diseases. After non-fatal CVD, hypertension had no significant impact on mortality risk according to both guidelines.

Original languageEnglish (US)
Article number321
JournalBMC Cardiovascular Disorders
Issue number1
StatePublished - Jul 6 2020


  • Cardiovascular
  • Guideline
  • Hypertension
  • Mortality
  • Multi-state

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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