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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 (275).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [275]
In the citing paper
“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]
In the citing paper
“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 the citing paper
“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 the citing paper
“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 the citing paper
“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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BackgroundMethodSystolic blood pressure and mortality
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BackgroundHypertension management in patients with cardiovascular comorbidities
Lauder, L., Mahfoud, F., Azizi, M., Bhatt, D. L., Ewen, S., Kario, K., Parati, G., Rossignol, P., Schlaich, M. P., Teo, K. K., et al. (2022) · European Heart Journal · doi:10.1093/eurheartj/ehac395 · Cited by 232
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“Clinical heart failure ensues when the myocardium becomes incapable of meeting the work load that is imposed upon it”
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“According to the results of the Framingham study (29) and the Cardiovascular Health Study (30), the factors that contribute most to CHF in the general population are hypertension and coronary heart disease, followed by diabetes, smoking, and other factors.”
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“Hypoxaemiamay also independently lead to oxidative vascular wall injury [23] and contribute to the development of systemic hypertension [24], which is a precursor of CHF [25].”
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Background
Metadata
- 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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