Cardiovascular risks of hypertension
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
Hypertension is quantitatively the most important risk factor for premature cardiovascular disease, being more common than cigarette smoking, dyslipidemia, and diabetes, which are the other major risk factors (table 1). Hypertension accounts for an estimated 54 percent of all strokes and 47 percent of all ischemic heart disease events globally . (See "Overview of established risk factors for cardiovascular disease".)
Hypertension increases the risk for a variety of cardiovascular diseases , including stroke, coronary artery disease, heart failure, atrial fibrillation , and peripheral vascular disease. Coronary disease in men and stroke in women are the principal first cardiovascular events noted after hypertension onset, as observed from data from the Framingham Heart Study . In view of the evidence that the mortality rates are rising in younger people in the United States  and the increasing impact of cardiovascular diseases in developing countries , greater attention must be given to prevention of these diseases. (See "Definition and pathogenesis of left ventricular hypertrophy in hypertension" and "Overview of established risk factors for cardiovascular disease".)
The risk for both coronary disease and stroke increases progressively with incremental increases in blood pressure above 115/75 mmHg, as shown in numerous epidemiologic studies (figure 1A-B) [7-10]. However, these observations do not prove a causal relationship, since increasing blood pressure could be a marker for other risk factors such as increasing body weight, which is associated with dyslipidemia, glucose intolerance, and the metabolic syndrome. The best evidence for a causal role of increasing blood pressure in cardiovascular complications is an improvement in outcome with antihypertensive therapy . (See "Hypertension: Who should be treated?" and "The metabolic syndrome (insulin resistance syndrome or syndrome X)".)
The increase in cardiovascular risk has primarily been described in terms of elevated systolic pressure in those over age 60 years  and elevation in diastolic pressure in younger individuals. Pulse pressure, which is the difference between the systolic and diastolic blood pressures and is determined primarily by large artery stiffness, is also a strong predictor of risk . (See "Hypertension: Who should be treated?", section on 'What level of BP increases risk?'.)
Projections have been made for the expected decrease in morbidity and mortality resulting from a 10 to 12 mmHg reduction in systolic pressure and a 5 to 6 mmHg reduction in diastolic pressure using data from multiple clinical trials performed over the past 30 years. Although not proving cause-and-effect, the estimated benefit from this degree of blood pressure lowering is a 38 percent reduction in risk of stroke and a 16 percent reduction in risk of coronary disease .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Lawes CM, Vander Hoorn S, Rodgers A, International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371:1513.
- Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet 2014; 383:1899.
- Angeli F, Reboldi G, Verdecchia P. Hypertension, inflammation and atrial fibrillation. J Hypertens 2014; 32:480.
- Lloyd-Jones DM, Leip EP, Larson MG, et al. Novel approach to examining first cardiovascular events after hypertension onset. Hypertension 2005; 45:39.
- Greenland P, Lloyd-Jones D. Time to end the mixed--and often incorrect--messages about prevention and treatment of atherosclerotic cardiovascular disease. J Am Coll Cardiol 2007; 50:2133.
- Lim SS, Gaziano TA, Gakidou E, et al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. Lancet 2007; 370:2054.
- Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903.
- Pastor-Barriuso R, Banegas JR, Damián J, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 2003; 139:731.
- Pletcher MJ, Bibbins-Domingo K, Lewis CE, et al. Prehypertension during young adulthood and coronary calcium later in life. Ann Intern Med 2008; 149:91.
- Shen L, Ma H, Xiang MX, Wang JA. Meta-analysis of cohort studies of baseline prehypertension and risk of coronary heart disease. Am J Cardiol 2013; 112:266.
- Blood Pressure Lowering Treatment Trialists' Collaboration, Ninomiya T, Perkovic V, et al. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials. BMJ 2013; 347:f5680.
- Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000; 355:865.
- Blood Pressure Lowering Treatment Trialists' Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336:1121.
- Wilson PW. Established risk factors and coronary artery disease: the Framingham Study. Am J Hypertens 1994; 7:7S.
- Kannel WB, Wolf PA. Framingham Study insights on the hazards of elevated blood pressure. JAMA 2008; 300:2545.
- Jackson R, Lawes CM, Bennett DA, et al. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005; 365:434.
- Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA 2005; 294:466.
- Frost PH, Davis BR, Burlando AJ, et al. Coronary heart disease risk factors in men and women aged 60 years and older: findings from the Systolic Hypertension in the Elderly Program. Circulation 1996; 94:26.
- Lowe LP, Greenland P, Ruth KJ, et al. Impact of major cardiovascular disease risk factors, particularly in combination, on 22-year mortality in women and men. Arch Intern Med 1998; 158:2007.
- Bastuji-Garin S, Deverly A, Moyse D, et al. The Framingham prediction rule is not valid in a European population of treated hypertensive patients. J Hypertens 2002; 20:1973.
- Conroy RM, Pyörälä K, Fitzgerald AP, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003; 24:987.
- Zambon A, Arfè A, Corrao G, Zanchetti A. Relationships of different types of event to cardiovascular death in trials of antihypertensive treatment: an aid to definition of total cardiovascular disease risk in hypertension. J Hypertens 2014; 32:495.
- Simon A, Chironi G, Levenson J. Performance of subclinical arterial disease detection as a screening test for coronary heart disease. Hypertension 2006; 48:392.
- Olsen MH, Wachtell K, Nielsen OW, et al. N-terminal brain natriuretic peptide predicted cardiovascular events stronger than high-sensitivity C-reactive protein in hypertension: a LIFE substudy. J Hypertens 2006; 24:1531.
- Cuspidi C, Meani S, Valerio C, et al. Left ventricular hypertrophy and cardiovascular risk stratification: impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives. J Hypertens 2006; 24:1671.
- Sipahi I, Tuzcu EM, Schoenhagen P, et al. Effects of normal, pre-hypertensive, and hypertensive blood pressure levels on progression of coronary atherosclerosis. J Am Coll Cardiol 2006; 48:833.
- Vasan RS, Massaro JM, Wilson PW, et al. Antecedent blood pressure and risk of cardiovascular disease: the Framingham Heart Study . Circulation 2002; 105:48.
- Benfante R, Hwang LJ, Masaki K, Curb JD. To what extent do cardiovascular risk factor values measured in elderly men represent their midlife values measured 25 years earlier? A preliminary report and commentary from the Honolulu Heart Program. Am J Epidemiol 1994; 140:206.