High Blood Pressure and Cardiovascular Disease

Flávio D Fuchs, Paul K Whelton, Flávio D Fuchs, Paul K Whelton

Abstract

Fragmented investigation has masked the overall picture for causes of cardiovascular disease (CVD). Among the risk factors for CVD, high blood pressure (BP) is associated with the strongest evidence for causation and it has a high prevalence of exposure. Biologically, normal levels of BP are considerably lower than what has typically been characterized as normal in research and clinical practice. We propose that CVD is primarily caused by a right-sided shift in the population distribution of BP. Our view that BP is the predominant risk factor for CVD is based on conceptual postulates that have been tested in observational investigations and clinical trials. Large cohort studies have demonstrated that high BP is an important risk factor for heart failure, atrial fibrillation, chronic kidney disease, heart valve diseases, aortic syndromes, and dementia, in addition to coronary heart disease and stroke. In multivariate modeling, the presumed attributable risk of high BP for stroke and coronary heart disease has increased steadily with progressive use of lower values for normal BP. Meta-analysis of BP-lowering randomized controlled trials has demonstrated a benefit which is almost identical to that predicted from BP risk relationships in cohort studies. Prevention of age-related increases in BP would, in large part, reduce the vascular consequences usually attributed to aging, and together with intensive treatment of established hypertension would eliminate a large proportion of the population burden of BP-related CVD.

Conflict of interest statement

Conflicts of interest: none

Figures

Figure 1.
Figure 1.
Blood pressure for men by age in Mundurucus and Carajás Indians, showing a rise with aging in the “acculturated” Mundurucus but not in the “unacculturated” Carajás (reprinted with permission from the reference 8).
Figure 2.
Figure 2.
Left-hand panel depicts distribution of systolic and diastolic BP in unacculturated and acculturated populations. Shaded areas identify distribution of a high blood pressure definition (systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg) for adults in unacculturated societies and for their counterparts living in acculturated societies using the traditional definition for diagnosis of hypertension (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg). Shaded areas in the right-hand panel highlight distribution of high systolic and diastolic blood pressure applying the definition used for high blood pressure in unacculturated societies (SBP ≥120 mm Hg or diastolic BP ≥70 mm Hg).
Figure 3.
Figure 3.
Log transformed (left-hand panel) and untransformed (right-hand panel) absolute risk of coronary heart disease or stroke in adults, by systolic and diastolic blood pressure, stratified by age. (Reprinted with permission from references and 21).
Figure 4.
Figure 4.
Disease-free age survival for cardiovascular disease (CVD), dementia, stroke and hypertension (HTN) in controls (individuals without a familial predisposition for exceptional longevity (black line), and centenarians (color lines), stratified by age in years at death. The data demonstrate a consistent delay in onset of CVD, dementia and stroke when HTN starts late in life. (Reprinted with permission from reference 35).
Figure 5.
Figure 5.
Relative risk estimates of coronary heart disease (top panel) and stroke (bottom panel) for systolic blood pressure reduction of 10 mm Hg or diastolic blood pressure reduction of 5 mm Hg in clinical trials meta-analysis and corresponding difference in meta-analysis of observational cohort studies. (Reprinted with permission from reference 42)

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