First recorded hypertension and subsequent cardiovascular and kidney outcomes after newly diagnosed type 2 diabetes: a population-based cohort study

Background Coexistence of type 2 diabetes (T2D) and hypertension is associated with adverse cardiovascular and mortality outcomes. However, whether first recorded hypertension during the course of T2D marks a transition to a higher-risk phase remains uncertain. We examined subsequent outcomes and recorded assessments around hypertension recognition. Methods Using regional electronic health records from Ningbo, China, we included 256,221 adults with a first recorded T2D diagnosis from 2012 through 2024 who had no recorded hypertension or major cardiorenal disease. We fitted Cox models with newly recorded hypertension as a time-varying exposure, adjusting for age, sex, calendar year, healthcare contact, comorbidities, medications, blood pressure, glycemia, lipids, kidney function, and liver enzymes. The primary outcome was the first occurrence of myocardial infarction, stroke, heart failure, chronic kidney disease, or all-cause death. Secondary outcomes included individual components above and a modified version of three-point major adverse cardiovascular events (3P-MACE), comprising myocardial infarction, stroke, and all-cause death. Among 107,946 patients with first recorded hypertension, assessment records were compared over six months before and after its recognition. Results Among 256,221 adults, hypertension was first recorded during follow-up in 107,946 (42.13%). During a median follow-up of 4.11 years, 34,371 primary outcomes occurred. Incidence rates were 58.05 and 16.10 per 1,000 person-years during exposed and unexposed time, respectively (adjusted hazard ratio [HR] 2.49; 95% CI 2.43-2.55). The adjusted HR for modified 3P-MACE was 2.47 (95% CI 2.40–2.55). The primary association was strongest within 90 days of recognition (HR 3.37; 95% CI 3.10–3.65) and persisted beyond three years (HR 2.15; 95% CI 2.07–2.23). Outpatient-contact density was 17.42 versus 3.73 per person-year during exposed and unexposed time. Recorded urinary albumin-to-creatinine ratio (UACR) assessment increased from 3.35% to 4.15%, and assessment of both kidney function and UACR from 2.94% to 3.72%. Conclusions First recorded hypertension identified a subsequent period of substantially higher observed cardiorenal and mortality risk, accompanied by limited increases in recorded assessment. New hypertension recognition may offer an opportunity to review existing cardiovascular and kidney assessments. Prospective studies should test whether structured reassessment at recognition improves care and outcomes.