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Cardiovascular risks of hypertension

Norman M Kaplan, MD
Section Editors
George L Bakris, MD
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor
John P Forman, MD, MSc


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 [1]. (See "Overview of established risk factors for cardiovascular disease".)

Hypertension increases the risk for a variety of cardiovascular diseases [2], including stroke, coronary artery disease, heart failure, atrial fibrillation [3], 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 [4]. In view of the evidence that the mortality rates are rising in younger people in the United States [5] and the increasing impact of cardiovascular diseases in developing countries [6], 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 [11]. (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 [12] 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 [12]. (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 [13].

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Literature review current through: Sep 2017. | This topic last updated: Mar 01, 2016.
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