The progression from hypertension to congestive heart failure
Abstract
OBJECTIVES: - To study the relative and population-attributable risks of hypertension for the development of congestive heart failure (CHF), to assess the time course of progression from hypertension to CHF, and to identify risk factors that contribute to the development of overt heart failure in hypertensive subjects. DESIGN: - Inception cohort study. SETTING: - General community. PARTICIPANTS: - Original Framingham Heart Study and Framingham Offspring Study participants aged 40 to 89 years and free of CHF. To reflect more contemporary experience, the starting point of this study was January 1, 1970. EXPOSURE MEASURES: - Hypertension (blood pressure of at least 140 mm Hg systolic or 90 mm Hg diastolic or current use of medications for treatment of high blood pressure) and other potential CHF risk factors were assessed at periodic clinic examinations. OUTCOME MEASURE: - The development of CHF. RESULTS: - A total of 5143 eligible subjects contributed 72422 person-years of observation. During up to 20.1 years of follow-up (mean, 14.1 years), there were 392 new cases of heart failure; in 91% (357/392), hypertension antedated the development of heart failure. Adjusting for age and heart failure risk factors in proportional hazards regression models, the hazard for developing heart failure in hypertensive compared with normotensive subjects was about 2-fold in men and 3-fold in women. Multivariable analyses revealed that hypertension had a high population-attributable risk for CHF, accounting for 39% of cases in men and 59% in women. Among hypertensive subjects, myocardial infarction, diabetes, left ventricular hypertrophy, and valvular heart disease were predictive of increased risk for CHF in both sexes. Survival following the onset of hypertensive CHF was bleak; only 24% of men and 31% of women survived 5 years. CONCLUSIONS: - Hypertension was the most common risk factor for CHF, and it contributed a large proportion of heart failure cases in this population-based sample. Preventive strategies directed toward earlier and more aggressive blood pressure control are likely to offer the greatest promise for reducing the incidence of CHF and its associated mortality.
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Up to 91% of all new heart failure development in the Framingham cohort occurred in people with a previous diagnosis of hypertension.
“up to 91% of all new heart failure development in the Framingham cohort occurred in people with a previous diagnosis of hypertension (275).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [275]
The vast majority of incident heart failure is preceded by hypertension.
“The vast majority of incident heart failure is preceded by hypertension;”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [275]
Up to 91% of all new heart failure development in the Framingham cohort occurred in people with a previous diagnosis of hypertension.
“The vast majority of incident heart failure is preceded by hypertension; up to 91% of all new heart failure development in the Framingham cohort occurred in people with a previous diagnosis of hypertension (272).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [272]
In Framingham, 5-year mortality after heart failure declined in men from 70% in 1950 to 59% in 1999.
“Using 50 years of follow up data, Levy and colleagues reported that the 5 year mortality declined in men from 70% in 1950 to 59% in 1999, and in women from 57% to 45%.58”
From The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective (2014) · cites this paper as [58]
In Framingham, 5-year mortality after heart failure declined in women from 57% in 1950 to 45% in 1999.
“Using 50 years of follow up data, Levy and colleagues reported that the 5 year mortality declined in men from 70% in 1950 to 59% in 1999, and in women from 57% to 45%.58”
From The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective (2014) · cites this paper as [58]
Over 50% of heart disease, stroke, and heart failure are caused by increased blood pressure.
“Over 50% of heart disease, stroke, and heart failure are caused by increased blood pressure.”
From São Paulo call to action for the prevention and control of high blood pressure: 2020 (2019) · cites this paper as [8]
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“13”
Heart Disease and Stroke Statistics—2008 Update
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“† DM is a major risk factor for the development of cardiovascular disease and HF.(176,177) † ACEIs and ARBs can be useful in patients with DM to decrease the risk of end-organ damage and cardiovascular complications and subsequently risk of HF.”
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“major risk factors for developing LV hypertrophy, another form of stage B.(91,92) Although the magnitude of benefit varies”
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Self-citation2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
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Self-citation2013 ACCF/AHA Guideline for the Management of Heart Failure
Yancy, C. W., Jessup, M. L., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T. B., Januzzi, J. L., et al. (2013) · Circulation · doi:10.1161/cir.0b013e31829e8776 · Cited by 2,129 · see citing works
“Elevated levels of diastolic and especially systolic blood pressure are major risk factors for the development of HF (91,92).”
InfluentialEpidemiology and risk profile of heart failure
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“Men with hypertension had a twofold increase in risk of developing HF, and women threefold, whereas the population attributable risk for HF imparted by hypertension was estimated to be 39% in men and 59% in women”
BackgroundClinical epidemiology of heart failure
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The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective
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Self-citationLifetime Risk for Developing Congestive Heart Failure
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Self-citationSleep Apnea and Cardiovascular Disease
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“Hypertension is the most common risk factor for ventricular hypertrophy and failure (173).”
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“High blood pressure increases morbidity and mortality from coronary heart disease, stroke, congestive heart failure, and end-stage renal disease.(1,10,11)”
BackgroundGoldberger, J. J., Cain, M. E., Hohnloser, S. H., Kadish, A. H., Knight, B. P., Lauer, M. S., Maron, B. J., Page, R. L., Passman, R. S., Siscovick, D., et al. (2008) · Circulation · doi:10.1161/circulationaha.107.189375 · Cited by 1,450 · see citing works
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., Jessup, M. L., Konstam, M. A., MANCINI, D. M., Michl, K., et al. (2009) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.11.013 · Cited by 1,367 · see citing works
Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age
Lloyd-Jones, D. M., Leip, E. P., Larson, M. G., D’Agostino, R. B., Beiser, A., Wilson, P. W. F., Wolf, P. A., & Levy, D. (2006) · Circulation · doi:10.1161/circulationaha.105.548206 · Cited by 1,298 · see citing works
Self-citationSleep Apnea and Cardiovascular Disease
Somers, V. K., White, D. P., Amin, R. S., Abraham, W. T., Costa, F., Culebras, A., Daniels, S. R., Floras, J. S., Hunt, C. E., Olson, L. J., et al. (2008) · Circulation · doi:10.1161/circulationaha.107.189420 · Cited by 1,301 · see citing works
HFSA 2010 Comprehensive Heart Failure Practice Guideline
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Mechanical Factors in Arterial Aging
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“Hypertension is a condition arbitrarily efined by blood pressure limits that are achieved by the vast ajority of the population who reach 90 years of age (8), nd is better described by underlying structural change.”
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“In the Framingham Heart Study, CHD, hypertension, left ventricular hypertrophy, valvular heart disease, and diabetes were associated with an increased risk of CHF.(3,4) Diabetes, CHD, elevated pulse pressure, and obesity were associated with an increased risk of CHF in the New Haven, Conn, cohort of the Established Po…”
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Universal Definition and Classification of Heart Failure
Bozkurt, B., Coats, A. J. S., Tsutsui, H., Abdelhamid, M., Adamopoulos, S., Albert, N., Anker, S. D., Atherton, J. J., Böhm, M., Butler, J., et al. (2021) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2021.01.022 · Cited by 1,056 · see citing works
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“Region Midwest 68 (27) 27 (30) Northeast 44 (17) 14 (16) South 87 (34) 34 (38) West 56 (22) 15 (17)”
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Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study
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The Relationship of Left Ventricular Mass and Geometry to Incident Cardiovascular Events
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2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
Yancy, C. W., Jessup, M. L., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., Drazner, M. H., Filippatos, G. S., Fonarow, G. C., Givertz, M. M., et al. (2017) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2017.04.014 · Cited by 769 · see citing works
“I B Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity (164,165).”
BackgroundTreatment of Hypertension in the Prevention and Management of Ischemic Heart Disease
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Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes
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“three-fold higher risk for developing congestive HF or stroke compared with men.(111,112) Hypertensive women develop more”
BackgroundModifiable Risk Factors and Major Cardiac Events Among Adult Survivors of Childhood Cancer
Armstrong, G. T., Oeffinger, K. C., Chen, Y., Kawashima, T. I., Yasui, Y., Leisenring, W. M., Stovall, M., Chow, E. J., Sklar, C. A., Mulrooney, D. A., et al. (2013) · Journal of Clinical Oncology · doi:10.1200/jco.2013.49.3205 · Cited by 737 · see citing works
Mechanistic Pathways of Sex Differences in Cardiovascular Disease
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“Nevertheless, they have an estimated threefold higher risk of developing HF or stroke compared with men (223).”
BackgroundEuropean guidelines on cardiovascular disease prevention in clinical practice: Executive summary
Graham, I. M. (2007) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2007.08.024 · Cited by 715 · see citing works
“[13] Levy D, Larson MG, Vasan RS, Kannel WB, Ho KKL.”
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Sex-Based Differences in the Effect of Digoxin for the Treatment of Heart Failure
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Executive Summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline
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Sleep Apnea and Cardiovascular Disease
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“The most direct mechanism by which long-standing OSA might induce left ventricular systolic dysfunction is by raising BP. Hypertension is the most common risk factor for ventricular hypertrophy and failure (173).”
BackgroundSymptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population
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“Hypertension is a main driver of heart failure progression, especially in women with hypertension compared with women without hypertension (threefold increase in risk in for women vs twofold for men) [75].”
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Premature cardiovascular disease in chronic renal failure
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Insulin Resistance and Risk of Congestive Heart Failure
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“Electrocardiographic LVH was defined as high-amplitude R waves according to the revised Minnesota code(23) together with left ventricular strain pattern.(4) Coding of smoking was based on interview reports, and coding of demographic data was based on the questionnaire.”
MethodGlobal epidemiology of heart failure
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“In the FHS 119 , a 5% and 7% increase in the risk of developing HF was observed in men and women, respectively, per unit of BMI.”
InfluentialBradley, T. D., & Floras, J. S. (2003) · Circulation · doi:10.1161/01.cir.0000061757.12581.15 · Cited by 557 · see citing works
Differences in the Incidence of Congestive Heart Failure by Ethnicity
Bahrami, H., Kronmal, R. A., Bluemke, D. A., Olson, J., Shea, S., Liu, K., Burke, G. L., & Lima, J. A. C. (2008) · Archives of Internal Medicine · doi:10.1001/archinte.168.19.2138 · Cited by 553 · see citing works
Schocken, D. D., Benjamin, E. J., Fonarow, G. C., Krumholz, H. M., Levy, D. A., Mensah, G. A., Narula, J., Stuart‐Shor, E., Young, J. B., & Hong, Y. (2008) · Circulation · doi:10.1161/circulationaha.107.188965 · Cited by 548 · see citing works
Self-citationThe Transition From Hypertension to Heart Failure
Messerli, F. H., Rimoldi, S. F., & Bangalore, S. (2017) · JACC Heart Failure · doi:10.1016/j.jchf.2017.04.012 · Cited by 562 · see citing works
Ambrosius, W. T., Sink, K. M., Foy, C. G., Berlowitz, D. R., Cheung, A. K., Cushman, W. C., Fine, L. J., Goff, D. C., Johnson, K., Killeen, A. A., et al. (2014) · Clinical Trials · doi:10.1177/1740774514537404 · Cited by 544 · see citing works
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“Prospective cohort studies have identified age, coronary artery disease, valvular disease and poorly controlled hypertension as major determinants of CHF (8,9).”
BackgroundHaider, A. W., Larson, M. G., Franklin, S. S., & Levy, D. A. (2003) · Annals of Internal Medicine · doi:10.7326/0003-4819-138-1-200301070-00006 · Cited by 536 · see citing works
“The causal role of hypertension in the pathogenesis of CHF underscores the need to identify high-risk patients because early treatment may prevent or delay the occurrence of CHF (2, 7).”
BackgroundSelf-citationLong-Term Trends in the Incidence of Heart Failure After Myocardial Infarction
Velagaleti, R. S., Pencina, M. J., Murabito, J. M., Wang, T. J., Parikh, N. I., D’Agostino, R. B., Levy, D. A., Kannel, W. B., & Vasan, R. S. (2008) · Circulation · doi:10.1161/circulationaha.108.784215 · Cited by 524 · see citing works
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“By contrast, the PARs for myocardial infarction were 13% and 34% for women and men, respectively.(68)”
BackgroundThe Extracellular Matrix in Ischemic and Nonischemic Heart Failure
Frangogiannis, N. G. (2019) · Circulation Research · doi:10.1161/circresaha.119.311148 · Cited by 520 · see citing works
Bozkurt, B., Aguilar, D. A., Deswal, A. M., Dunbar, S. B., Francis, G. S., Horwich, T. B., Jessup, M. L., Kosiborod, M., Pritchett, A. M., Ramasubbu, K., et al. (2016) · Circulation · doi:10.1161/cir.0000000000000450 · Cited by 532 · see citing works
Sex Differences in Cardiovascular Pathophysiology
Beale, A. L., Meyer, P., Marwick, T. H., Lam, C. S. P., & Kaye, D. M. (2018) · Circulation · doi:10.1161/circulationaha.118.034271 · Cited by 524 · see citing works
Brandt, M. C., Mahfoud, F., Reda, S., Schirmer, S. H., Erdmann, E., Böhm, M., & Hoppe, U. C. (2012) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2011.11.034 · Cited by 498 · see citing works
“Even before clinical events occur, hypertension induces changes of the heart, including left ventricular hypertrophy (LVH) and cardiac fibrosis (1).”
BackgroundGottdiener, J. S., McClelland, R. L., Marshall, R., Shemanski, L., Furberg, C. D., Kitzman, D. W., Cushman, M., Polak, J. F., Gardin, J. M., Gersh, B. J., et al. (2002) · Annals of Internal Medicine · doi:10.7326/0003-4819-137-8-200210150-00006 · Cited by 476 · see citing works
“Moreover, aging of the population, increased susceptibility of elderly hypertensive persons to congestive heart failure (2), decreasing incidence of and death from stroke, and improved survival after acute myocardial infarction have increased the number of patients at risk for congestive heart failure (1, 3, 4).”
BackgroundHunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., Jessup, M. L., Konstam, M. A., MANCINI, D. M., Michl, K., et al. (2005) · Circulation · doi:10.1161/circulationaha.105.167587 · Cited by 461 · see citing works
“Treatment of Hypertension Elevated levels of diastolic and especially systolic blood pressure are major risk factors for the development of HF (21,22), and long-term treatment of both systolic and diastolic hypertension has been shown to reduce the risk of HF (23–25).”
Tsao, C. W., & Vasan, R. S. (2015) · International Journal of Epidemiology · doi:10.1093/ije/dyv337 · Cited by 457 · see citing works
“The FHS was one of the first groups to describe the incidence, prevalence and grim natural history of heart failure in the community(12,46,47) and also identified hypertension, valvular heart disease and coronary disease as key aetiologies for heart failure.(13) The advent of echocardiography made it evident that indi…”
BackgroundDiastolic and Systolic Heart Failure Are Distinct Phenotypes Within the Heart Failure Spectrum
Borlaug, B. A., & Redfield, M. M. (2011) · Circulation · doi:10.1161/circulationaha.110.954388 · Cited by 451 · see citing works
Incidence and Epidemiology of Heart Failure
Kannel, W. B. (2000) · Heart Failure Reviews · doi:10.1023/a:1009884820941 · Cited by 454 · see citing works
“Hypertension increases the risk of developing heart failure in a continuous graded fashion and the average blood pressure of heart failure victims was only 150=90 mm Hg [11].”
BackgroundInfluentialHFSA 2006 Comprehensive Heart Failure Practice Guideline: Introduction and Table of Contents
Heart Failure Society of America (2006) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2005.11.005 · Cited by 447 · see citing works
Epidemiology of Diastolic Heart Failure
Owan, T. E., & Redfield, M. M. (2005) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2005.02.010 · Cited by 419 · see citing works
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10. Cardiovascular Disease and Risk Management: <i>Standards of Care in Diabetes—2024</i>
American Diabetes Association Professional Practice Committee, ElSayed, N. A., Aleppo, G., Bannuru, R. R., Bruemmer, D., Collins, B. S., Das, S. R., Ekhlaspour, L., Hilliard, M. E., Johnson, E. L., et al. (2024) · Diabetes Care · doi:10.2337/dc24-s010 · Cited by 438 · see citing works
Importance of Systolic Blood Pressure in Older Americans
Izzo, J. L., Levy, D. A., & Black, H. R. (2000) · Hypertension · doi:10.1161/01.hyp.35.5.1021 · Cited by 401 · see citing works
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“Hypertension and CHD are the most common aetiologic factors in heart failure for both genders, but hypertensive women appear to have a higher risk of developing heart failure than men.(58) Both the prevalence of diabetes and the risk of heart failure in diabetic patients are higher in women when compared with men even…”
BackgroundDiretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda
Rohde, L. E. P., Montera, M. W., Bocchi, E. A., Clausell, N., de Albuquerque, D. C., Rassi, S., Colafranceschi, A. S., Freitas, A. F., Ferraz, A. S., Biolo, A., et al. (2018) · Arquivos Brasileiros de Cardiologia · doi:10.5935/abc.20180190 · Cited by 462 · see citing works
Blood Pressure Estimation from Photoplethysmogram Using a Spectro-Temporal Deep Neural Network
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“Cuff-based devices remain the golden standard and are commonly recommended by physicians [3].”
BackgroundMatrix Metalloproteinases/Tissue Inhibitors of Metalloproteinases
Ahmed, S. H., Clark, L. L., Pennington, W. R., Webb, C. S., Bonnema, D. D., Leonardi, A. H., McClure, C. D., Spinale, F. G., & Zile, M. R. (2006) · Circulation · doi:10.1161/circulationaha.105.573865 · Cited by 386 · see citing works
“test the hypotheses that (1) changes in the ECM proteolytic system are measurable by plasma assays of selected MMPs and TIMPs; (2) each manifestation of hypertensive heart disease is associated with a specific pattern of changes in the ECM proteolytic system; and (3) hypertensive patients with structural remodeling, d…”
BackgroundMethodInfluentialPotenza, M. A., Marasciulo, F. L., Tarquinio, M., Tiravanti, E., Colantuono, G., Federici, A., Kim, J., Quon, M. J., & Montagnani, M. (2007) · American Journal of Physiology-Endocrinology and Metabolism · doi:10.1152/ajpendo.00698.2006 · Cited by 380 · see citing works
“Endothelial dysfunction and hypertension are important contributors to ischemic heart disease and heart failure (34).”
BackgroundBart, B. A., Shaw, L. K., McCants, C. B., Fortin, D. F., Lee, K. L., Califf, R. M., & O’Connor, C. M. (1997) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(97)00235-0 · Cited by 378 · see citing works
“Hypertension and diabetes are important precursors to the development of heart failure (31) and are associated with increased mortality (2,24,31).”
BackgroundNovel Metabolic Risk Factors for Incident Heart Failure and Their Relationship With Obesity
Bahrami, H., Bluemke, D. A., Kronmal, R. A., Bertoni, A. G., Lloyd‐Jones, D. M., Shahar, E., Szklo, M., & Lima, J. A. C. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2007.12.048 · Cited by 365 · see citing works
- Authors
- Levy, D.
- Affiliations
- Framingham Heart Study (US)
- Corresponding author
- Levy, Daniel
- ORCID
- Levy, Daniel
- Venue
- JAMA: The Journal of the American Medical Association
- Publisher
- American Medical Association (AMA)
- Published
- 1996-05-22
- Volume
- 275
- Issue
- 20
- Pages
- 1557
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2023515446
- Cited by
- 2,155
- References
- 46
- Citations by year
- 2026: 32 · 2025: 62 · 2024: 62 · 2023: 85 · 2022: 82 · 2021: 73 · 2020: 71 · 2019: 86 · 2018: 70 · 2017: 75 · 2016: 68 · 2015: 98 · 2014: 86 · 2013: 102 · 2012: 108
- FWCI
- 27.57
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc038038-022)
- National Heart, Lung, and Blood Institute (N01-HC-38038)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Keywords
- hypertension, congestive heart failure, population attributable risk, heart failure risk factors, myocardial infarction, diabetes mellitus, left ventricular hypertrophy, valvular heart disease, blood pressure control, Framingham Heart Study, Framingham Offspring Study
- MeSH terms
- Adult, Aged, Diastole, Female, Heart Failure, Humans, Hypertension, Longitudinal Studies, Male, Middle Aged, Risk Factors, Systole, Cohort Studies, Multivariate Analysis, Proportional Hazards Models, Survival Analysis, Hypertrophy, Left Ventricular, Disease Progression, Ventricular Dysfunction, Left
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