HYPERTENSION AND CARDIOVASCULAR DISEASE

The fragmented nature of previous research has obscured a comprehensive understanding of the causes of cardiovascular disease (CVD). Among the risk factors, high blood pressure (BP) has the strongest evidence for causality and a high prevalence. Normal biological levels of BP are significantly lower than what has traditionally been considered normal in both research and clinical practice. We propose that CVD is largely driven by a rightward shift in the population distribution of BP. Our view, which positions BP as the primary risk factor for CVD, is supported by conceptual frameworks tested in observational studies and clinical trials. Large cohort studies have identified high BP as a major risk factor for heart failure, atrial fibrillation, chronic kidney disease, heart valve disorders, aortic syndromes, and dementia, in addition to coronary heart disease and stroke. Multivariate modeling has shown that the attributable risk of high BP for stroke and coronary heart disease has increased as definitions of normal BP have shifted to lower values. Meta-analyses of BP-lowering randomized controlled trials have shown benefits closely matching predictions based on BP risk relationships in cohort studies. Preventing age-related increases in BP, along with intensive treatment of established hypertension, could significantly reduce the vascular outcomes typically associated with aging and alleviate much of the population's burden of BP-related CVD.