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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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“Adverse cardiovascular events track blood pressure in linear or log-linear patterns [2, 3].”
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Shetty, D. K., Rodrigues, L. L. R., Shetty, A. K., & Nair, G. (2022) · Engineered Science · doi:10.30919/es8d627 · Cited by 8
Update in Cardiology: Vascular Risk and Cardiac Rehabilitation
Galve, E., Cordero, A., Bertoméu, V., Fácila, L., Mazón, P., Alegría, E., de Bobadilla, J. F., García-Porrero, E., Martínez‐Sellés, M., & González‐Juanatey, J. R. (2015) · Revista Española de Cardiología (English Edition) · doi:10.1016/j.rec.2014.10.005 · Cited by 9
History of infertility and pregnancy outcomes in Project Viva: a prospective study
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Shih, Y.-T., Cheng, H., Sung, S., Chuang, S., Hu, W.-C., & Chen, C. (2015) · American Journal of Hypertension · doi:10.1093/ajh/hpv164 · Cited by 8
Natural History of Treated and Untreated Hypertension
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Gonzalez-Rivas, J. P., Mechanick, J. I., Durán, M., Ugel, E., Marulanda, M. I., & Nieto-Martínez, R. E. (2019) · Annals of Global Health · doi:10.5334/aogh.2346 · Cited by 8
“This conspicuous numerically based change is primarily based on the Systolic Blood Pressure Intervention Trial (SPRINT) [5], and supported by other relevant observational studies [2, 6, 7].”
ResultYears of Potential Life Lost from Cardiovascular Disease Among Hispanics.
Manjunath, L., Hu, J., Palaniappan, L., & Rodriguez, F. (2019) · Ethnicity & Disease · doi:10.18865/ed.29.3.477 · Cited by 7
Relationship between plasma homocysteine and blood pressure in hypertensive Northern-Nigerians
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Improved diagnosis-medication association mining to reduce pseudo-associations
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“The increase in cardiovascular mortality associated with blood pressure (BP)>115/75 mmHg([1,2]) and the benefit of BP lowering to levels<130/80mm Hg, have motivated the redefinition of the arterial hypertension (AH) diagnostic criteria by the American”
BackgroundThe healthy core metabolism: A new paradigm for primary preventive nutrition
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“recently observed a progressive and regular increase of lifetime risk in normal blood pressure and hypertension subjects from index age 30 years (Figure 5) (24).”
Comparison and Implication of the Contemporary Blood Pressure Guidelines on Korean Population
Cho, S. M. J., Lee, H., & Kim, H. C. (2020) · Korean Circulation Journal · doi:10.4070/kcj.2019.0347 · Cited by 8
Park, S., Jeon, Y., Ann, S. H., Kim, Y., Lee, Y. J., Choi, S. H., Han, S., & Park, G. (2023) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2023.04.011 · Cited by 7
Das, S. (2024) · Human Nutrition & Metabolism · doi:10.1016/j.hnm.2024.200273 · Cited by 8
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Wei, G., Li, B., Wang, H., Chen, L., Chen, W., Chen, K., Wang, W., Wang, S., Zeng, H., Liu, Y., et al. (2024) · BMC Cardiovascular Disorders · doi:10.1186/s12872-024-04169-3 · Cited by 8
“In a cohort study based on the electronic health records of 1.25 million adults, the risk of death from coronary atherosclerosis increased by 26% for every 20mmHg increase in unadjusted SBP [17].”
BackgroundInfluentialXu, J., Peng, X., Guo, L., Zhao, X., Chen, M., Mai, X., Tan, J.-W., Chen, Q., Zeng, R., & Zhang, M. (2024) · Frontiers in Endocrinology · doi:10.3389/fendo.2024.1469055 · Cited by 7
Hsu, R.-Y., Lo, H.-Y., Chen, C.-H., Wu, Y.-J., Chan, D., Wu, C., Wang, T., Kao, H., Sun, W., Lin, Y., et al. (2025) · Journal of the Formosan Medical Association · doi:10.1016/j.jfma.2025.05.007 · Cited by 8
Heart Stress and Blood Pressure Management in Older Adults: Post Hoc Analysis of the ASPREE Trial
Cai, A., Bayés‐Genís, A., Ryan, J. L., Feng, Y., Januzzi, J. L., Tonkin, A. M., Zheng, J., Nelson, M. R., Neumann, F., Woods, R. L., et al. (2025) · Circulation · doi:10.1161/circulationaha.125.076263 · Cited by 8
Niu, C., Zhang, P., Wei, L. X., Dong, J., Xu, C., Yang, Q., Lyu, D., Li, N., Li, M., & Zhang, L. (2025) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2025.1619445 · Cited by 8
Gender disparities in coronary artery disease: a review of factors influencing clinical outcomes
Siddiqui, A. K., Gill, R., Ringor, M., Dugal, J. K., Malhi, A. S., Abdallah, A. W., Hawwass, D., Houshmand, N., & Tak, T. (2025) · Netherlands Heart Journal · doi:10.1007/s12471-025-01996-7 · Cited by 7
Ma, H., Zhang, Y., Guo, X., Zhao, Q., Yang, P., Liu, Y., Guan, Y., Wei, Y., & Ma, H. (2026) · Journal of Clinical Investigation · doi:10.1172/jci195536 · Cited by 7
“Hypertension affects over 1 billion adults worldwide and remains a leading cause of cardiovascular morbidity and mortality, contributing to severe complications such as stroke, heart failure, and chronic kidney disease (1, 2).”
Shin, Y. K., Hsieh, Y.-S., Han, A. Y., Lee, K., & Seol, G. H. (2019) · Phytotherapy Research · doi:10.1002/ptr.6520 · Cited by 7
“Moreover, the risk of cardiovascular disease begins with a BP of 115/75 mmHg and doubles every 20/10 mmHg (Rapsomaniki et al., 2014).”
BackgroundDesai, T. A., Clarke, R., Ross, S., Grimsgaard, S., Njølstad, I., & Lewington, S. (2023) · Scandinavian Journal of Public Health · doi:10.1177/14034948221122395 · Cited by 7
“The present analyses focused on SBP as this is most strongly associated with risk of CVD [8-10].”
MethodMousa, M., Elzahwy, S. S., Tamara, A. F., Samir, W., & Tantawy, M. A. (2023) · CVIR Endovascular · doi:10.1186/s42155-023-00395-6 · Cited by 7
“[3].”
Charles, J. A., Habibullah, N. K., Bautista, S., Davis, B. C., Joshi, S., & Hull, S. C. (2024) · Current Cardiology Reports · doi:10.1007/s11886-023-02008-z · Cited by 7
“…daily fiber intake of 14 g per 1000 cal ■ For age 18–50 y, 25 g for women and 38 g for men ■ For age 51 y and older, 21 g for women and 30 g for men • Include a wide variety of fiber-containing foods, including those rich in soluble fiber such as legumes, oats, barley, flaxseeds, and chia seeds 3.”
BackgroundChao, T.-H., Lin, T., Cheng, C., Wu, Y., Ueng, K., Wu, Y., Lin, W.-W., Leu, H.-B., Cheng, H., Huang, C., et al. (2024) · PubMed Central · doi:10.6515/acs.202409_40(5).20240724a · Cited by 7
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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