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Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people
Open accessAbstract
BACKGROUND: The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared. In this study, we aimed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease. METHODS: We used linked electronic health records from 1997 to 2010 in the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme to assemble a cohort of 1·25 million patients, 30 years of age or older and initially free from cardiovascular disease, a fifth of whom received blood pressure-lowering treatments. We studied the heterogeneity in the age-specific associations of clinically measured blood pressure with 12 acute and chronic cardiovascular diseases, and estimated the lifetime risks (up to 95 years of age) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30, 60, and 80 years. This study is registered at ClinicalTrials.gov, number NCT01164371. FINDINGS: During 5·2 years median follow-up, we recorded 83,098 initial cardiovascular disease presentations. In each age group, the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90-114 mm Hg and diastolic blood pressure of 60-74 mm Hg, with no evidence of a J-shaped increased risk at lower blood pressures. The effect of high blood pressure varied by cardiovascular disease endpoint, from strongly positive to no effect. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage (hazard ratio 1·44 [95% CI 1·32-1·58]), subarachnoid haemorrhage (1·43 [1·25-1·63]), and stable angina (1·41 [1·36-1·46]), and weakest for abdominal aortic aneurysm (1·08 [1·00-1·17]). Compared with diastolic blood pressure, raised systolic blood pressure had a greater effect on angina, myocardial infarction, and peripheral arterial disease, whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure. Pulse pressure associations were inverse for abdominal aortic aneurysm (HR per 10 mm Hg 0·91 [95% CI 0·86-0·98]) and strongest for peripheral arterial disease (1·23 [1·20-1·27]). People with hypertension (blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3% (95% CI 62·9-63·8) compared with 46·1% (45·5-46·8) for those with normal blood pressure, and developed cardiovascular disease 5·0 years earlier (95% CI 4·8-5·2). Stable and unstable angina accounted for most (43%) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years, whereas heart failure and stable angina accounted for the largest proportion (19% each) of years of life lost from index age 80 years. INTERPRETATION: The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them. FUNDING: Medical Research Council, National Institute for Health Research, and Wellcome Trust.
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“High blood pressure (BP) is the single leading risk factor for cardiovascular disease worldwide,1–4”
From International Consensus on Standardized Clinic Blood Pressure Measurement – A Call to Action (2023) · cites this paper as [4]
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Yahagi, K., Davis, H. R., Arbustini, E., & Virmani, R. (2015) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2015.01.017 · Cited by 310
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“1% in patients with normal blood pressure) and develop CVD 5 years earlier [111].”
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Hypertension and Atrial Fibrillation
Verdecchia, P., Angeli, F., & Reboldi, G. (2018) · Circulation Research · doi:10.1161/circresaha.117.311402 · Cited by 259
“and weaker for abdominal aortic aneurism and transient ischemic attack.(6) AF—the most frequent cardiac arrhythmia—is becom-”
BackgroundJones, D. W., Ferdinand, K. C., Taler, S. J., Johnson, H. M., Shimbo, D., Abdalla, M., Altieri, M. M., Bansal, N., Bello, N. A., Bress, A. P., et al. (2025) · JACC · doi:10.1016/j.jacc.2025.05.007 · Cited by 280
Blood Pressure Measurement in SPRINT (Systolic Blood Pressure Intervention Trial)
Johnson, K., Whelton, P. K., Cushman, W. C., Cutler, J. A., Evans, G. W., Snyder, J. K., Ambrosius, W. T., Beddhu, S., Cheung, A. K., Fine, L. J., et al. (2018) · Hypertension · doi:10.1161/hypertensionaha.117.10479 · Cited by 240
Whelton, S., Mcevoy, J., Shaw, L., Psaty, B., Lima, J., Budoff, M., Nasir, K., Szklo, M., Blumenthal, R., & Blaha, M. (2020) · JAMA cardiology · doi:10.1001/jamacardio.2020.1731 · Cited by 197
The Epidemiology of Blood Pressure and Its Worldwide Management
Rahimi, K., Emdin, C. A., & MacMahon, S. W. (2015) · Circulation Research · doi:10.1161/circresaha.116.304723 · Cited by 242
“angina, myocardial infarction, heart failure but negatively related to abdominal aortic aneurysm.(13) In APCSC, pulse pres-”
BackgroundMethodInfluentialLuo, D., Cheng, Y., Zhang, H., Ba, M., Chen, P., Li, H., Chen, K., Sha, W., Zhang, C., & Chen, H. (2020) · BMJ · doi:10.1136/bmj.m3222 · Cited by 234
Age dependent associations of risk factors with heart failure: pooled population based cohort study
Tromp, J., Paniagua, S. M., Lau, E. S., Allen, N. B., Blaha, M. J., Gansevoort, R. T., Hillege, H. L., Lee, D. S., Levy, D. A., Vasan, R. S., et al. (2021) · BMJ · doi:10.1136/bmj.n461 · Cited by 243
UK phenomics platform for developing and validating electronic health record phenotypes: CALIBER
Denaxas, S., González-Izquierdo, A., Direk, K., Fitzpatrick, N. K., Fatemifar, G., Banerjee, A., Dobson, R., Howe, L. J., Kuan, V., Lumbers, R. T., et al. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz105 · Cited by 219
Self-citationJones, D. W., Ferdinand, K. C., Taler, S. J., Johnson, H. M., Shimbo, D., Abdalla, M., Altieri, M. M., Bansal, N., Bello, N. A., Bress, A. P., et al. (2025) · Circulation · doi:10.1161/cir.0000000000001356 · Cited by 335
Wein, T. H., Lindsay, M. P., Côté, R., Foley, N. C., Berlingieri, J., Bhogal, S. K., Bourgoin, A., Buck, B. H., Cox, J. L., Davidson, D., et al. (2017) · International Journal of Stroke · doi:10.1177/1747493017743062 · Cited by 227
“Using data from 1.25 million people, included in the CALIBER database Rapsomanki et al.29 estimated the lifetime risk of ischemic stroke (from age of 30 years) in persons with hypertension to be 7.6% compared with 6.5% without hypertension, corresponding to loss of life of approximately a half a year due to ischemic s…”
BackgroundInfluentialWilliams, B., Cockcroft, J. R., Kario, K., Zappe, D., Brunel, P., Wang, Q., & Guo, W. (2017) · Hypertension · doi:10.1161/hypertensionaha.116.08556 · Cited by 226
Self-citation2024 Clinical practice guidelines for Hypertension in adults
Кобалава, Ж. Д., Конради, А. О., Nedogoda, S. V., Shlyakhto, E. V., Arutyunov, G. P., Баранова, Е. И., Барбараш, О. Л., Bobkova, N. V., Boytsov, S. A., Bubnova, M. G., et al. (2024) · Russian Journal of Cardiology · doi:10.15829/1560-4071-2024-6117 · Cited by 274
Malhotra, R., Nguyen, H. A., Benavente, O., Mete, M., Howard, B. V., Mant, J., Odden, M. C., Peralta, C. A., Cheung, A. K., Nadkarni, G. N., et al. (2017) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2017.4377 · Cited by 220
Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey
Ramakrishnan, S., Zachariah, G. A., Gupta, K., Rao, J. S., Mohanan, P. P., Venugopal, K. N., Sateesh, S., Sethi, R., Jain, D., Bardolei, N., et al. (2019) · Indian Heart Journal · doi:10.1016/j.ihj.2019.09.012 · Cited by 215
Madhur, M. S., Elijovich, F., Alexander, M. R., Pitzer, A. L., Ishimwe, J., Beusecum, J. P. V., Patrick, D. M., Smart, C. D., Kleyman, T. R., Kingery, J. R., et al. (2021) · Circulation Research · doi:10.1161/circresaha.121.318052 · Cited by 218
“12 The reasons for poor rates of control of hypertension include those pertaining to the health care system: (1) overestimation of office BP by improper recording techniques, which may occur in up to one-third of apparent resistant patients with hypertension in primary care13; (2) lack of recognition of the white-coat…”
Hemingway, H., Asselbergs, F. W., Danesh, J., Dobson, R., Maniadakis, N., Maggioni, A. P., van Thiel, G. J. M. W., Cronin, M., Brobert, G., Vardas, P. E., et al. (2017) · European Heart Journal · doi:10.1093/eurheartj/ehx487 · Cited by 218
“For example, Figure 3 and Table 1 , Rapsomaniki et al. 32 illustrates how the power of large scale health records allows enquiry into less common cardiovascular diseases such as abdominal aortic aneurysm: Here there is a marked discord-ance between the strong association of diastolic blood pressure…”
BackgroundSelf-citationHypertension 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
Hypertension as a risk factor for atherosclerosis: Cardiovascular risk assessment
Poznyak, A. V., Sadykhov, N. K., Kartuesov, A. G., Borisov, E. E., Melnichenko, A. А., Grechko, A. V., & Orekhov, A. N. (2022) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2022.959285 · Cited by 229
Chiang, C., Wang, T., Ueng, K.-C., Lin, T., Yeh, H., Chen, C.-Y., Wu, Y.-J., Tsai, W., Chao, T., Chen, C.-H., et al. (2014) · Journal of the Chinese Medical Association · doi:10.1016/j.jcma.2014.11.005 · Cited by 203
“25 million subjects, initially free from cardiovascular disease, the lowest risk for cardiovascular disease was in people with SBP of 90114 mmHg and DBP of 60-74 mmHg, without any evidence of J-curve phenomenon.(32) In the Multiple Risk Factor Intervention Trial (MRFIT) which enrolled 332,554 subjects without end orga…”
BackgroundResultHow Does Cardiovascular Disease First Present in Women and Men?
George, J., Rapsomaniki, E., Pujades‐Rodríguez, M., Shah, A. D., Denaxas, S., Herrett, E. L., Smeeth, L. L., Timmis, A., & Hemingway, H. (2015) · Circulation · doi:10.1161/circulationaha.114.013797 · Cited by 201
“Diastolic BP, mm Hg 78 (10) 74 (9) 81 (10) 77 (10) 83 (10) 81 (10) 82 (10) 82 (9) 81 (10) 81 (10) 78 (11) 79 (11)”
Self-citationDaskalopoulou, M., George, J., Walters, K. R., Osborn, D., Batty, G. D., Stogiannis, D., Rapsomaniki, E., Pujades‐Rodríguez, M., Denaxas, S., Udumyan, R., et al. (2016) · PLoS ONE · doi:10.1371/journal.pone.0153838 · Cited by 187
“Cardiovascular risk factors demonstrate somewhat specific associations with different cardiovascular diseases; for example, people with type II diabetes have been shown to be at lower risk of subarachnoid haemorrhage, transient ischaemic attack,[29] and risk of abdominal aortic aneurysm[30], compared to people without…”
BackgroundSelf-citationAssociation between periodontitis and arterial hypertension: a systematic review and meta-analysis
Martin-Cabezas, R., Seelam, N., Petit, C., Agossa, K., Gaertner, S., Tenenbaum, H., Davideau, J.-L., & Huck, O. (2016) · American Heart Journal · doi:10.1016/j.ahj.2016.07.018 · Cited by 183
“It is quantitatively the most important risk factor for premature CVD, being more common than other major risk factors such as cigarette smoking, dyslipidemia and diabetes.(10) It accounts for an estimated 54% of all strokes and 47% of all ischemic heart diseases events globally.”
BackgroundPeters, S. A. E., Carcel, C., Millett, E. R. C., & Woodward, M. (2020) · Neurology · doi:10.1212/wnl.0000000000010982 · Cited by 193
“25 million individuals in the United Kingdom demonstrated that the association between SBP and DBP and the risk of several stroke subtypes was similar between the sexes.(15) The current study shows that these findings can be expanded to pulse pressure and mean arterial pressure and suggests that SBP and mean arterial…”
ResultAre cardiovascular risk factors also associated with the incidence of atrial fibrillation?
Allan, V., Honarbakhsh, S., Casas, J. P., Wallace, J., Hunter, R. J., SCHILLING, R. J., Perel, P., Morley, K. I., Banerjee, A., & Hemingway, H. (2017) · Thrombosis and Haemostasis · doi:10.1160/th16-11-0825 · Cited by 188
“Previously, it been demonstrated that blood pressure has markedly different associations with the incidence of 12 individual cardiovascular diseases (not including AF) (103).”
BackgroundSelf-citationBeddhu, S., Chertow, G. M., Cheung, A. K., Cushman, W. C., Rahman, M., Greene, T., Wei, G., Campbell, R. C., Conroy, M., Freedman, B. I., et al. (2017) · Circulation · doi:10.1161/circulationaha.117.030848 · Cited by 173
Cardiovascular Risk of Isolated Systolic or Diastolic Hypertension in Young Adults
Lee, H., Yano, Y., Cho, S. M. J., Park, J. H., Park, S., Lloyd‐Jones, D. M., & Kim, H. C. (2020) · Circulation · doi:10.1161/circulationaha.119.044838 · Cited by 175
Factors leading to high morbidity and mortality of COVID ‐19 in patients with type 2 diabetes
Rajpal, A., Rahimi, L., & Ismail‐Beigi, F. (2020) · Journal of Diabetes · doi:10.1111/1753-0407.13085 · Cited by 178
Kobeissi, E., Hibino, M., Pan, H., & Aune, D. (2019) · European Journal of Epidemiology · doi:10.1007/s10654-019-00510-9 · Cited by 170
Neutrophil Counts and Initial Presentation of 12 Cardiovascular Diseases
Shah, A. D., Denaxas, S., Nicholas, O., Hingorani, A. D., & Hemingway, H. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2016.12.022 · Cited by 168
“CALIBER has been extensively validated, replicating known prospective associations of CVDs with sex (9), smoking (10), blood pressure (11), socioeconomic deprivation (12), and type 2 diabetes (13).”
BackgroundSelf-citationPulsatile arterial haemodynamics in heart failure
Weber, T., & Chirinos, J. A. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy346 · Cited by 164
Epidemiology of Hypertension in Canada: An Update
Padwal, R. S., Bienek, A., McAlister, F. A., & Campbell, N. R. C. (2015) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2015.07.734 · Cited by 162
“[1, 2] Hypertension-related death and disability stem primarily from cardiovascular disease (CVD) (myocardial infarction, stroke, peripheral vascular disease, heart failure), renal failure, and dementia.[3-5] For every 20 mmHg increase in systolic BP above 115 mmHg (or 10 mmHg increase in diastolic BP above 75 mmHg),…”
Santos, H. O., Price, J. C., & Bueno, A. A. (2020) · Nutrients · doi:10.3390/nu12103159 · Cited by 157
“Cardiovascular diseases remain a major Public Health concern, with lipid-associated biomarkers being trusted predictors of major cardiovascular events [1,2].”
BackgroundEmdin, C. A., Anderson, S. G., Callender, T., Conrad, N., Salimi‐Khorshidi, G., Mohseni, H., Woodward, M., & Rahimi, K. (2015) · BMJ · doi:10.1136/bmj.h4865 · Cited by 166
Calcium supplementation for prevention of primary hypertension
Cormick, G., Ciapponi, A., Cafferata, M. L., & Belizán, J. M. (2015) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd010037.pub2 · Cited by 150
Lifetime Risk and Risk Factors for Abdominal Aortic Aneurysm in a 24-Year Prospective Study
Tang, W., Lu, Y., Roetker, N. S., Alonso, Á., Lutsey, P. L., Steenson, C. C., Lederle, F. A., Hunter, D. W., Bengtson, L. G. S., Guan, W., et al. (2016) · Arteriosclerosis Thrombosis and Vascular Biology · doi:10.1161/atvbaha.116.308147 · Cited by 149
Systemic inflammation markers and the prevalence of hypertension: A NHANES cross-sectional study
Xu, J., Zeng, R., Zhang, Y.-Z., Lin, S., Tan, J.-W., Zhu, H.-Y., Mai, X., Guo, L., & Zhang, M. (2023) · Hypertension Research · doi:10.1038/s41440-023-01195-0 · Cited by 146
Herrington, W. G., Smith, M., Bankhead, C., Matsushita, K., Stevens, S., Holt, T., Hobbs, F. D. R., Coresh, J., & Woodward, M. (2017) · PLOS ONE · doi:10.1371/journal.pone.0173515 · Cited by 141
Genetic Architecture of Abdominal Aortic Aneurysm in the Million Veteran Program
Klarin, D. M., Verma, S. S., Judy, R., Dikilitas, O., Wolford, B. N., Paranjpe, I., Levin, M. G., Pan, C., Tcheandjieu, C., Spin, J. M., et al. (2020) · Circulation · doi:10.1161/circulationaha.120.047544 · Cited by 139
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Self-citation
Metadata
- Authors
- Rapsomaniki, E., Timmis, A., George, J., Pujades-Rodriguez, M., Shah, A. D., Denaxas, S., White, I. R., Caulfield, M. J., Deanfield, J. E., Smeeth, L., Williams, B., Hingorani, A., & Hemingway, H.
- Affiliations
- Farr Institute (GB)
- Queen Mary University of London (GB)
- MRC Biostatistics Unit (GB)
- London School of Hygiene & Tropical Medicine (GB)
- National Institute for Health and Care Research (GB)
- Corresponding author
- Rapsomaniki, Eleni
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2014-05
- Volume
- 383
- Issue
- 9932
- Pages
- 1899-1911
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC4042017
- OpenAlex
- W2169428949
- Cited by
- 1,643
- References
- 41
- Citations by year
- 2026: 79 · 2025: 117 · 2024: 145 · 2023: 161 · 2022: 162 · 2021: 192 · 2020: 168 · 2019: 163 · 2018: 142 · 2017: 117 · 2016: 94 · 2015: 66 · 2014: 34
- FWCI
- 71.24
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- The Lancet (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- UCL Discovery (University College London) (submittedVersion, cc-by)
- UCL Discovery (University College London) (submittedVersion)
- Funders
- National Institute for Health Research (NIHR) (RP-PG-0407–10314)
- Wellcome Trust (086091/Z/08/Z, 0938/30/Z/10/Z)
- Medical Research Council Prognosis Research Strategy (PROGRESS) Partnership (G0902393/99558)
- Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, NIHR, National Institute for Social Care and Health Research, and Wellcome Trust (MR/K006584/1)
- NIHR Doctoral Fellowship (DRF-2009–02–50)
- Medical Research Council (U105260558)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
- Health Sciences › Nursing › Nutrition and Dietetics › Sodium Intake and Health
- Keywords
- blood pressure, cardiovascular disease incidence, systolic blood pressure, diastolic blood pressure, pulse pressure, lifetime risk, healthy life years lost, intracerebral hemorrhage, subarachnoid hemorrhage, myocardial infarction, stable angina, peripheral arterial disease, abdominal aortic aneurysm, stroke, hypertension, age-specific associations, blood pressure-lowering treatment, J-curve
- MeSH terms
- Acute Disease, Adult, Aged, Aged, 80 and over, Angina Pectoris, Antihypertensive Agents, Blood Pressure, Cardiovascular Diseases, Chronic Disease, England, Female, Follow-Up Studies, Humans, Hypertension, Male, Medical Record Linkage, Middle Aged, Subarachnoid Hemorrhage, Incidence, Aortic Aneurysm, Abdominal, Age Distribution, Risk Assessment, Intracranial Hemorrhage, Hypertensive
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