https://orcid.org/0000-0002-4533-1722
Abstract
Several observational studies have investigated the association between hypertension or elevated systolic blood pressure and diastolic blood pressure and risk of heart failure, but not all the studies have been consistent. This systematic review and meta-analysis aimed to summarize the available data from cohort studies on the association between hypertension, systolic and diastolic blood pressure, and the risk of heart failure.
PubMed and Embase databases were searched for relevant articles from inception to 10 June 2022. Cohort studies on hypertension or blood pressure and heart failure were included. Random effect models were used to calculate summary relative risks (RRs) and 95% confidence intervals (CIs) for the association between hypertension or blood pressure and heart failure. Forty-seven cohort studies were included. The summary RR was 1.71 (95% CI: 1.53–1.90, I2 = 98.4%) for hypertension vs. no hypertension (n = 43 studies, 166 798 cases, 20 359 997 participants), 1.28 (95% CI: 1.22–1.35, I2 = 90.3%) per 20 mmHg of systolic blood pressure (24 studies, 31 639 cases and 2 557 975 participants), and 1.12 (95% CI: 1.04–1.21, I2 = 92.6%) per 10 mmHg of diastolic blood pressure (16 studies, 23 127 cases and 2 419 972 participants). There was a steeper increase in heart failure risk at higher blood pressure levels and a three- to five-fold increase in RR at around 180/120 mmHg of systolic and diastolic blood pressure compared with 100/60 mmHg, respectively. There was little indication of publication bias across analyses.
This meta-analysis suggests a strong positive association between hypertension and systolic and diastolic blood pressure and the risk of heart failure. These results support efforts to reduce blood pressure in the general population to reduce the risk of heart failure.
Lay Summary
Hypertension is associated with a 71% increase in the risk of heart failure.
A 20 mmHg increment in systolic blood pressure is associated with a 28% increment in heart failure risk, and a 10 mmHg increment in diastolic blood pressure is associated with a 12% increase in heart failure risk.
The results support public health policies and interventions to reduce the prevalence of elevated blood pressure (e.g. through lifestyle changes and medication use).
Introduction
Heart failure is a major cause of morbidity and mortality worldwide. Globally, there were an estimated 64.3 million prevalent heart failure cases in 2017.1 In the USA, about 1 million persons are hospitalized every year due to heart failure.2 Mortality in heart failure remains high, at between 20% and 40%.3,4 Heart failure is accountable for one in nine annual deaths in the USA and has been estimated to be responsible for health costs of approximately $30.7 billion per year.5 Some established risk factors for heart failure include age, sex, ethnicity, overweight and obesity, low physical activity, smoking, and a history of coronary heart disease, atrial fibrillation, and diabetes.6–8
Hypertension or high blood pressure, classically defined as systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg9 and recently defined as a systolic blood pressure of ≥130 mmHg or diastolic blood pressure of ≥80 mmHg by the 2017 guidelines from the American College of Cardiology/American Heart Association (ACC/AHA),10 is an important risk factor for cardiovascular diseases and the leading cause of death and disability-adjusted life-years worldwide according to the Global Burden of disease Study.11 Hypertension affects around 1 billion individuals worldwide, making it a very common risk factor for cardiovascular diseases.12 Although hypertension or elevated blood pressure is an established risk factor for a wide range of cardiovascular disease outcomes,13,14 data on blood pressure in relation to the risk of heart failure have, to our knowledge, not been summarized previously and have also not been incorporated in the Global Burden of Disease Study,11 and this could lead to underestimation of the disease and mortality burden attributable to high blood pressure. A large number of cohort studies have investigated the association between hypertension and heart failure risk,2,6,15–48 and the vast majority of the studies published to date have reported an increase in heart failure risk with hypertension,2,6,15,16,18–31,34–41,43–48 while a few studies did not detect a clear association.17,32,33,42 In most of these studies, the relative risks (RRs) associated with hypertension have ranged between 1.2 and 2.5, so there has been some heterogeneity with regard to the size of the association across studies. Several additional studies have reported on systolic blood pressure6,13,19,28,31,42,49–66 and diastolic blood pressure13,50–52,54,55,57,59–62,64,65,67,68 and the risk of heart failure. Most of the studies on systolic blood pressure and heart failure have shown an increased risk,13,19,28,31,42,49,50,52–66 although, in a few studies, statistical power may have been insufficient to detect a clear association.6,42,51 Again, the available studies have differed with regard to the strength of the observed associations, with RRs ranging between a 28% increase in risk and a 316% increase in risk for high vs. low systolic blood pressure. Studies on diastolic blood pressure and heart failure have shown more mixed results with some cohort studies showing an increased risk,13,50,52,55,62,67,68 five studies reporting no clear association51,57,60,61,64,65 and two studies reporting inverse associations.54,59
To clarify the strength of the association between hypertension and systolic and diastolic blood pressure and the risk of heart failure and the shape of the dose–response relationship between blood pressure and heart failure, we conducted a systematic review and dose–response meta-analysis of the published cohort studies on this association. We also aimed to investigate potential sources of heterogeneity in the results as well as the robustness of the findings between studies by conducting subgroup and sensitivity analyses.
Methods
Standard criteria for reporting meta-analyses such as the PRISMA criteria (see Supplementary material online, Files S1 and S2) were adopted.69 A protocol was developed for the study that was submitted to the administration at the Norwegian University of Science and Technology, but the protocol was not registered in a public registry.
Search strategy for identification of studies
Relevant studies were identified by searching PubMed and Embase databases up to 10 June 2022 using the search strategy described in Supplementary material online, Table S1. Relevant articles were screened using Reference Manager software.
Study selection and inclusion criteria
Published retrospective cohort studies, prospective cohort studies, case-cohort studies, and nested case-control studies within cohort studies that investigated the association between hypertension, systolic or diastolic blood pressure and the risk of heart failure were included. The studies had to report adjusted estimates of RR, such as hazard ratios, odds ratios, or incidence rate ratios, with 95% confidence intervals (CIs). Studies published in English were considered, while non-English language publications were not included. Conference abstracts, grey literature, and unpublished studies were not considered because the information published in such formats is often too crude for study quality to be assessed and for the data to be included in dose–response analyses. Pooled analyses were included when there was little overlap with individual published studies, but if most or all individual studies had published data separately from the pooled analysis, the individual studies were prioritized for inclusion in the analysis. Retrospective case-control and cross-sectional studies were excluded because of potential biases that can affect these studies including recall bias and selection bias in case-control studies and because of the lack of temporality between the exposure and the outcome in cross-sectional studies. To ease updating of the literature search, the RefMan databases for PubMed and Embase were screened separately, and the selected studies from each database were merged in a separate data set and de-duplicated before each article was inspected in more detail. P.K.B., L.J., S.J., A.S., and D.A. conducted the literature search screening in duplicate. A list of the excluded studies and exclusion reasons are provided in Supplementary material online, Table S2.
Data extraction and synthesis
The following data were extracted from each study into tables: the author’s name, publication year and country, study name, study period, number of participants and cases, age and sex of participants, exposure (hypertension or blood pressure) and subgroups (e.g. by sex, ethnicity), comparison, RRs and 95% CIs, and lastly adjustment for confounders (Tables 1 and 2). The data extraction was done by P.K.B. and checked for accuracy by D.A.
Prospective studies of hypertension and heart failure
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | RR (95% CI) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Eriksson H, 1989, Sweden | Study of Men Born in 1913 | 1963–1980–NA 17 years of follow-up | 973 men, age 50 years: 67 HF cases | Hypertension | Yes vs. no | 1.7 (1.4–5.7) | Smoking, body weight, heart volume, ECG T-wave, heart rate variability, peak flow, Fy-antigen, stress |
| Alexander M, 1995, USA | Northern California Kaiser Permanente Medical Care Program | 1978–1984–1991, 9.5 years of follow-up | 64 877 men and women, age ≥40 years: 1330 HF cases | Hypertension, uncontrolled, women age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, uncontrolled, men age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, age ≥60 years Hypertension, controlled Hypertension, unrecognized | Yes vs. noYes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 2.06 (1.07–3.95)1.32 (0.84–2.07) 2.67 (1.32–5.42) 2.90 (1.78–4.70)1.51 (1.05–2.17) 0.88 (0.32–2.42) 1.53 (1.16–2.01) 1.34 (1.09–1.65) 1.50 (1.14–1.97) | Age, sex, race/ethnicity, education, diabetes, smoking, MI, chest pain, total cholesterol, BMI, creatinine, uric acid, urine protein, left ventricular hypertrophy, alcohol |
| Levy D, 1996, USA | Framingham Heart Study | NA–NA, 20 years of follow-up | 2334 men and 2809 women, 40–89 years: 392 HF cases | Hypertension, men Hypertension, women | Yes vs. no Yes vs. no | 1.84 (1.35–2.51) 2.60 (1.77–3.81) | Myocardial infarction, left ventricular hypertrophy, diabetes, angina pectoris |
| Aronow WS, 1999, USA | New York | NA–NA, 3.6 years of follow-up | 2737 men and women, age 60–103 years: 739 HF cases | Hypertension | Yes vs. no | 2.52 (2.14–2.98) | Age, sex, diabetes, coronary artery disease |
| Trenkwalder P, 1999, Germany | The Prospective STEPHY II Study | 1992–1995–NA, 2.7 years of follow-up | 647 men and women, 60–99 years: 60 HF cases | Hypertension, all | Yes vs. no | 1.17 (0.9–2.9) | Age, sex, acute myocardial infarction |
| Wilhelmsen L, 2001, Sweden | The Multifactor Primary Prevention Study | 1970–1973–1996, 25.2 years of follow-up | 7495 men, age 47–55 years: 754 HF cases | Antihypertensive treatment or blood pressure of ≥175/≥115 | Yes vs. no | 1.50 (1.22–1.84) | Age, MI in brothers or sisters, diabetes, chest pain, smoking, coffee, alcohol abuse, BMI |
| Williams SA, 2001, USA | Established Populations for Epidemiologic Studies in the Elderly Program (EPESE)—New Haven | 1982–1996, 14 years of follow-up | 2501 men and women, age ≥65 years: 313 HF cases | Hypertension | None Stage 1 Stage 2 | 1.00 1.10 (0.62–1.94) 1.59 (1.18–2.15) | Age, sex, depression, diabetes, pulse pressure, functional limitations, myocardial infarction |
| He J, 2001, USA | NHANES 1—Epidemiologic Follow-up Study | 1971–1975–1992, 19 years of follow-up | 13 643 men and women, age 25–74 years: 1382 HF cases | Hypertension, all Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.50 (1.34–1.68) 1.44 (1.25–1.67) 1.58 (1.36–1.82) | Age, sex, race/ethnicity, education, physical activity, smoking, alcohol, BMI, diabetes, valvular heart disease, coronary heart disease |
| Johansson S, 2001, UK | UK General Practice Research Database | 1996–1996, −NA, 1 year of follow-up | Nested case-control study: 938 HF cases 5000 controls Age 69–100 years | Hypertension Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.7 (1.4–2.0) 1.6 (1.2–2.0) 1.8 (1.4–2.2) | Age, sex, smoking, BMI, hyperlipidaemia, dyspnoea, prior comorbidities–CHD, valvular disease, diabetes, other cardiac disease, chronic respiratory disease, other diseases (anaemia, renal failure, hyperthyroidism) |
| Crowson CR, 2005, USA | Mayo Clinic, Rochester | NA-NA, 16.1 years of follow-up | 1158 men and women (575 with RA, 583 non-RA), mean age 57.3 years: 280 HF cases | Hypertension, RA Hypertension, non-RA | Yes vs. no Yes vs. no | 1.60 (0.94–2.73) 2.99 (1.18–7.53) | Age, sex, FH–IHD, IHD, cigarette smoking, dyslipidaemia, BMI, diabetes mellitus, alcohol abuse |
| Nielson C, 2005, USA | Veterans Affairs Medical Centers | 1994–2003, 3.45 years of follow-up | 20 810 men and women, mean age 58.7 years: 926 HF cases | Hypertension | Yes vs. no | 1.35 P < 0.01 | Age, sex, BMI, creatinine, blood pressure, smoking, coronary artery disease, LDL cholesterol, HDL cholesterol, thiazide diuretic, hydroxy-methylglutaryl-CoA reductase inhibitor, ACE inhibitors, angiotensin receptor blockers, beta-blockers |
| Ingelsson E, 2005, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–NA, 28.8 years of follow-up | 2321 men, age 50 years: 259 HF cases | Hypertension | Yes vs. no | 1.93 (1.48–2.52) | Serum cholesterol, BMI, ECG-LVH, smoking, diabetes, prior AMI, serum uric acid, beta-carotene, triglycerides, apolipoprotein B/A-1 ratio, LDL cholesterol, HDL cholesterol |
| Hsia J, 2007, USA | Women’s Health Initiative | 1978–1983–NA, 7.7 years of follow-up | 60 785 post-menopausal women, age 60–70 years: 1336 HF cases | Hypertension, all Hypertension, White Hypertension, Black Hypertension, Hispanic Hypertension, Asian | Yes vs.no Yes vs.no Yes vs.no Yes vs.no Yes vs.no | 2.53 (2.26–2.84) 2.45 (2.17–2.76) 2.83 (1.76–4.53) 5.18 (2.30–11.65) 8.16 (2.40–27.80) | Age, smoking, BMI, diabetes, hypercholesterolemia and alcohol |
| Mujib M, 2010, USA | Cardiovascular Health Study | 1989–1990, 1992–1993–NA, 12 years follow-up | 5324 men and women, age 65–100 years: 1091 HF cases | Hypertension | Yes vs. no | 1.24 P = 0.01 | Age, sex, race/ethnicity, smoking status, self-reported health, coronary artery disease, diabetes mellitus, stroke, COPD, atrial fibrillation, left ventricular hypertrophy, systolic blood pressure, peripheral artery disease, serum creatinine, serum uric acid, serum albumin, serum insulin, C-reactive protein, haemoglobin |
| Wang J, 2010, Finland | Kuopio | 1986–1988–2008, 20 years of follow-up | 1032 men and women, age 65–74 years: 303 HF cases | Hypertension | Yes vs. no | 1.52 (1.05–2.22) | Age, sex, leisure-time physical activity, smoking, alcohol, antihypertensive medications, total cholesterol, prevalent diabetes |
| Fedorowski A, 2010, Sweden | Malmo Preventive Project | 1974–1992–2006, 24 years of follow-up | 32 669 men and women, mean age 26–61 years: 1293 HF cases | Hypertension | Yes vs. no | 1.72 (1.52–1.94) | Age, sex, BMI, cholesterol, smoking orthostatic hypotension, diabetes |
| De Simone G, 2010, USA | Strong Heart Study | 1989–1992–NA, 11.9 years of follow-up | 2740 men and women, age 45–74 years: 291 HF cases | Hypertension | Yes vs. no | 1.45 (1.11–1.88) | Age, sex, HF risk factors, HbA1c, smoking, alcohol, education, physical activity |
| Goyal A, 2010, USA | Kaiser Permanente Georgia data Study | 2000–2005–NA, 6 years of follow-up | 168 551 men, and 191 396 women ≥18 years: 4001 HF cases | Hypertension, women Hypertension, men | Yes vs. no Yes vs. no | 3.18 (2.80–3.60) 3.00 (2.66–3.39) | Age, hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, and valvular heart disease. |
| Voulgari C, 2011, Greece | Athens University Medical School | 2003–2005–NA, 6 years of follow-up | 550 men and women, mean age 60 years: 185 HF cases | Hypertension (130/85 mmHg or antihypertensive medication use) | Yes vs. no | 4.86 (3.30–8.61) | Age, sex, impaired glucose tolerance, dyslipidaemia, cigarette smoking, physical inactivity, left ventricular hypertrophy and function on echocardiography |
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Use of blood pressure-lowering medications | Yes vs. no | 2.03 (1.74–2.37) | Age, sex, foreign-born, waist circumference, systolic blood pressure, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Brouwers F, 2013, the Netherlands | Prevention of Renal and Vascular End-stage Disease (PREVEND) | 1997–1998–2010, 11.5 years of follow-up | 8592 men and women, age 28–75 years: 374 HF cases | Hypertension | Yes vs. no | 1.17 (0.77–1.77) | Age, sex, obesity, diabetes, smoking, MI, atrial fibrillation, hypercholesterolemia, cystatine, UAE, hs-CRP, NT-proBNP, hs-TnT |
| Eaton CB, 2016, USA | Women's Health Initiative | 1993–1998–2015, 13.2 years of follow-up | 42170 post-menopausal women, age 50–79 years: 1952 HF cases | Hypertension, HFpEF Hypertension, HFrEF Hypertension, Whites, HFpEF Hypertension, Whites, HFrEF Hypertension, African Americans, HFpEF Hypertension, African Americans, HFrEF Hypertension, Hispanics, HFpEF Hypertension, Hispanics, HFrEF | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no | 1.57 (1.33–1.86) 1.99 (1.59–2.51) 1.57 (1.30–1.90) 2.07 (1.58–2.71) 1.80 (1.22–2.67)1.60 (1.01–2.54) 1.22 (0.57–2.60) 4.24 (1.25–14.32) | Age, study component, race/ ethnicity, income, education, diabetes, heart rate, MI, CHD other than MI, stroke, smoking, dyslipidaemia, oophorectomy, cancer, BMI, smoking, physical activity, chronic lung disease, anaemia, atrial fibrillation, beta-blocker use, aspirin use, hormone therapy, alcohol, insurance, interim CHD—not MI, interim DM, interim cancer |
| Fox ER, 2016, USA | Jackson Heart Study | 2000–2004–2011, 9.1 years of follow-up | 3689 men and women, mean age 53 years: 104 HF cases | Anti-hypertensive therapy | Yes vs. no | 1.7 (0.9–3.2) | Age, sex, systolic blood pressure, diabetes, total:HDL cholesterol ratio, eGFR, smoking, BNP, ABI (subclinical disease) |
| Silverman MG, 2016, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 11.2 years of follow-up | 6781 men and women, age 45–84 years: 257 HF cases | Hypertension, HFpEF Hypertension, HFrEF | Yes vs. no Yes vs. no | 1.81 (1.14–2.90) 2.04 (1.23–3.36) | Age, sex, race/ethnicity, socioeconomic status, MESA site, |
| Jacobs L, 2017, International (USA, Italy, Scotland, Ireland, and the Netherlands, UK) | The Heart ‘OMics’ in AGEing (HOMAGE) study (The Health Aging and Body Composition Study, The PREDICTOR Study, PROSPER) | 1997–1998 2007–2010 1997–1999 3.5 years of follow-up | 10 236 men and women, mean age 74.5 years: 470 HF cases | Antihypertensive medication use | Yes vs. no | 1.65 (1.33–2.06) | Age, sex, BMI, smoking, CAD, diabetes, SBP, heart rate, serum creatinine |
| Ogunmoroti O, 2017, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 12.2 years of follow-up | 6506 men and women, age 45–84 years: 262 HF cases | Blood pressure, all Blood pressure, Whites Blood pressure, Chinese American Blood pressure, Blacks Blood pressure, Hispanics | ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 | 1.00 0.55 (0.41–0.75) 0.40 (0.27–0.57) 1.00 0.52 (0.32–0.83) 0.45 (0.27–0.75) 1.00 0.41 (0.11–1.47) 0.34 (0.09–1.25) 1.00 0.37 (0.19–0.72) 0.40 (0.19–0.85) 1.00 1.01 (0.57–1.79) 0.33 (0.13–0.82) | Age, sex, race/ethnicity (all), education, income, health insurance |
| Myers J, 2017, USA | Veterans Exercise Testing Study | 1987–2014–NA, 12.3 years of follow-up | 21 080 men and women, mean age 58.3 years: 1902 HF cases | Hypertension | Yes vs. no | 1.80 (1.59–2.04) | Age, BMI, ethnicity, beta-blockers, calcium-channel blockers, angiotensin-converting enzymes, angiotensin receptor blockers, aspirin, diuretics, lipid-lowering agents, hypoglycaemic agents, smoking, diabetes, chronic kidney failure, HIV/AIDS |
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK DanMONICA Moli-sani Northern Sweden MONICA | 1982–2002–2010 1982–1984, 1986–1987, 1991–1992, –2010, 2005–2011 1986–2011, 12.7 years of follow-up (across cohorts) | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Antihypertensive medication use, men Antihypertensive medication use, women | Yes vs. noYes vs. no | 1.49 (1.34–1.64)1.47 (1.33–1.61) | Age, BMI, systolic blood pressure, total cholesterol, diabetes, daily smoking |
| Wang ID, 2019, Taiwan | Taiwan National Health Insurance Research Database | 2000–2013, 10.44 years of follow-up | 40 000 men and women, age ≥20 years: 6185 HF cases | Hypertension | Yes vs. no | 1.60 (1.30–1.87) | Age, sex, non-apnoea sleep disorder, diabetes mellitus, hyperlipidaemia, chronic kidney disease, IHD, stroke, obesity, anxiety, depression |
| Uijl A, 2019, the Netherlands | EPIC-Netherlands | 1993–1997–NA, 15.2 years of follow-up | 37 803 men and women, age 20–70 years: 690 HF cases | Blood pressure | ≥140/≥90 mmHg 120 to <140/80 to <90, or treated <120/80 <120/<80, not treated | 1.00 0.62 (0.52–0.74) 0.72 (0.58–0.89) | Age, sex, education, blood glucose, smoking status, BMI, physical activity, diet, blood cholesterol |
| Uijl A, 2019, UK | CALIBER | 2000–2010, 5.8 years of follow-up | 871 687 men and women, age ≥55 years: 47 987 HF cases | Hypertension, men, age 55–64 years Hypertension, men, age 65–74 years Hypertension, men, age ≥75 years Hypertension, women, age 55–64 years Hypertension, women, age 65–74 years Hypertension, women, age ≥75 years | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.14 (1.07–1.22) 1.03 (0.97–1.09) 1.10 (1.05–1.15) 1.09 (1.00–1.19) 0.98 (0.92–1.04) 1.02 (0.99–1.07) | Age, haemoglobin, total white blood cells, total cholesterol, triglycerides, albumin, creatinine, ethnicity, smoking habits, multiple deprivation index, blood pressure-lowering medication, lipid-lowering drugs, COPD, atrial fibrillation, obesity, sedentary lifestyle, diabetes |
| Lee H, 2019, Korea | Korea National Health Insurance Research Database | 2003–2007–2017, 9.75 years of follow-up | 15 508 537 men and women, age 20–94 years: 21 535 HF cases | Hypertension, age 20–34 years Hypertension, age 35–49 years Hypertension, age 50–64 years Hypertension, age 65–79 years Hypertension, age 80–94 years | Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension | 1.00 1.20 (0.90–1.60) 1.40 (1.15–1.71) 3.04 (2.42–3.84) 1.00 1.20 (1.04–1.39) 1.29 (1.17–1.44) 2.14 (1.91–2.40) 1.00 1.07 (0.97–1.18) 1.18 (1.10–1.27) 1.58 (1.47–1.69) 1.00 1.00 (0.92–1.07) 1.10 (1.04–1.16)1.26 (1.19–1.33) 1.00 1.12 (0.91–1.38) 1.14 (0.96–1.32) 1.22 (1.06–1.41) | Age, sex, household income, Charlson comorbidity index, use of glucose-lowering drugs, use of lipid-lowering drugs, smoking, alcohol, exercise, BMI, fasting glucose, total cholesterol |
| Kubicki M, 2020, USA | Southern Community Cohort Study | 2002–2009–NA, 5.2–6.7 years of follow-up | 27 078 men and women, age 56 years: 4341 HF cases | Hypertension, all Hypertension, Black men Hypertension, Black women Hypertension, White men Hypertension, White women | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.69 (1.59–1.84) 2.07 (1.75–2.45) 1.64 (1.43–1.87) 1.45 (1.16–1.83) 1.61 (1.34–1.92) | Age, sex, race, smoking, BMI, poor diet, diabetes, high cholesterol, physical activity |
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Hypertension | Yes vs. no | 1.31 (0.80–2.15) | Hyperlipidaemia, diabetes, sedentary lifestyle, smoking, BMI |
| Mefford MT, 2020, USA | REasons for Geographic And Racial Differences in Stroke Study (REGARDS) | 2003–2007–2015, 8.3 years of follow-up | 25 770 men and women, age ≥45 years: 947 HF cases | Hypertension, all, Whites Hypertension, HFpEF, Whites Hypertension, HFrEF, Whites Hypertension duration, Whites Hypertension control, Whites Hypertension, all, Blacks Hypertension, HFpEF, Blacks Hypertension, HFrEF, Blacks Hypertension duration, Blacks Hypertension control, Blacks | Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled | 1.90 (1.49–2.41) 2.01 (1.34–3.01) 1.69 (1.23–2.33) 1.00 1.59 (1.19–2.11) 1.87 (1.42–2.46) 2.21 (1.70–2.89) 1.00 1.52 (1.14–2.04) 1.93 (1.44–2.58) 2.27 (1.74–2.97) 2.36 (1.53–3.65) 2.70 (1.25–5.83) 2.29 (1.26–4.15) 1.00 1.55 (0.93–2.58) 2.13 (1.33–3.42) 2.96 (1.89–4.64) 1.00 1.50 (0.89–2.54) 2.01 (1.22–3.29) 2.93 (1.86–4.63) | Age, sex, BMI, smoking, diabetes, reduced eGFR, total cholesterol, statin use, income, region of residence, health insurance, physical activity, perceived stress, depressive symptoms |
| Vasan RS, 2021, USA | Atherosclerosis Risk in Communities Study (ARIC) | 1993–1996–NA, 19.0 years of follow-up | 1871 Black men and women, mean age 59 years: 309 HF cases | Hypertension | Yes vs. no | 1.73 (1.34–2.23) | Age, sex, BMI, diabetes mellitus, smoking status, total: HDL cholesterol ratio |
| Suzuki Y, 2022, Japan | JMDC Claims Database | 2005–2020, 3.3 years of follow-up | 2 612 570 men and women, age 20–75 years: 43 415 HF cases | Hypertension, age 20–49 years, all Hypertension, age 50–59 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.35 (1.31–1.40) 2.03 (1.90–2.16) 1.96 (1.81–2.11) 3.10 (2.95–3.25) 1.00 1.28 (1.23–1.33) 1.63 (1.52–1.75) 1.72 (1.60–1.84) 2.12 (2.02–2.23) | Age, sex, obesity, diabetes, dyslipidaemia, cigarette smoking, alcohol consumption |
| Hypertension, age 60–75 years Hypertension, age 20–49 years, men Hypertension, age 50–59 years Hypertension, age 60–75 years Hypertension, age 20–49 years, women Hypertension, age 50–59 years Hypertension, age 60–75 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.14 (1.08–1.21) 1.36 (1.19–1.54) 1.44 (1.34–1.56) 1.72 (1.60–1.85) 1.00 1.35 (1.30–1.41) 2.03 (1.89–2.19) 1.98 (1.81–2.17) 3.16 (2.99–3.34) 1.00 1.28 (1.22–1.34) 1.62 (1.49–1.75) 1.79 (1.64–1.96) 2.16 (2.03–2.29) 1.00 1.11 (1.01–1.19) 1.27 (1.10–1.47) 1.43 (1.30–1.57) 1.72 (1.57–1.87) 1.00 1.37 (1.29–1.46) 1.99 (1.71–2.31) 1.95 (1.70–2.23) 2.93 (2.67–3.22) 1.00 1.29 (1.20–1.38) 1.76 (1.49–2.08) 1.60 (1.42–1.80) 2.04 (1.85–2.25) 1.00 1.20 (1.08–1.32) 1.69 (1.29–2.21) 1.45 (1.28–1.64) 1.68 (1.46–1.93) | |||||
| Rastogi, 2022, UK | UK Biobank | 2006–2010–NA, 11.8 years of follow-up | 500 001 men and women, age 37–73 years: 14 216 HF cases | Hypertension, patients with history of MI Hypertension, patients without history of MI | Yes vs. no Yes vs. no | 1.14 (1.08–1.22) 1.61 (1.54–1.69) | Age, sex, eGFR, HbA1c, BMI, smoking status, type 2 diabetes |
| Vasan RS, 2022, USA | Framingham Heart Study | 1965–1989, 15 years of follow-up 1990–2014, 13.5 years of follow-up | 7500 men and women, mean age 47.6 years: 624 HF cases 9540 men and women, mean age 47.6 years: 875 HF cases | Hypertension, epoch 1 Hypertension, epoch 2 Hypertension, epoch 2, HFpEF Hypertension, epoch 2, HFrEF | Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension | 1.00 1.38 (1.06–1.79) 2.17 (1.70–2.77) 1.00 1.54 (1.29–1.84) 2.11 (1.77–2.52) 1.00 1.43 (1.07–1.91) 2.11 (1.59–2.81) 1.00 1.66 (1.28–2.15) 2.06 (1.59–2.67) | Age, sex, BMI, diabetes |
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | RR (95% CI) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Eriksson H, 1989, Sweden | Study of Men Born in 1913 | 1963–1980–NA 17 years of follow-up | 973 men, age 50 years: 67 HF cases | Hypertension | Yes vs. no | 1.7 (1.4–5.7) | Smoking, body weight, heart volume, ECG T-wave, heart rate variability, peak flow, Fy-antigen, stress |
| Alexander M, 1995, USA | Northern California Kaiser Permanente Medical Care Program | 1978–1984–1991, 9.5 years of follow-up | 64 877 men and women, age ≥40 years: 1330 HF cases | Hypertension, uncontrolled, women age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, uncontrolled, men age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, age ≥60 years Hypertension, controlled Hypertension, unrecognized | Yes vs. noYes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 2.06 (1.07–3.95)1.32 (0.84–2.07) 2.67 (1.32–5.42) 2.90 (1.78–4.70)1.51 (1.05–2.17) 0.88 (0.32–2.42) 1.53 (1.16–2.01) 1.34 (1.09–1.65) 1.50 (1.14–1.97) | Age, sex, race/ethnicity, education, diabetes, smoking, MI, chest pain, total cholesterol, BMI, creatinine, uric acid, urine protein, left ventricular hypertrophy, alcohol |
| Levy D, 1996, USA | Framingham Heart Study | NA–NA, 20 years of follow-up | 2334 men and 2809 women, 40–89 years: 392 HF cases | Hypertension, men Hypertension, women | Yes vs. no Yes vs. no | 1.84 (1.35–2.51) 2.60 (1.77–3.81) | Myocardial infarction, left ventricular hypertrophy, diabetes, angina pectoris |
| Aronow WS, 1999, USA | New York | NA–NA, 3.6 years of follow-up | 2737 men and women, age 60–103 years: 739 HF cases | Hypertension | Yes vs. no | 2.52 (2.14–2.98) | Age, sex, diabetes, coronary artery disease |
| Trenkwalder P, 1999, Germany | The Prospective STEPHY II Study | 1992–1995–NA, 2.7 years of follow-up | 647 men and women, 60–99 years: 60 HF cases | Hypertension, all | Yes vs. no | 1.17 (0.9–2.9) | Age, sex, acute myocardial infarction |
| Wilhelmsen L, 2001, Sweden | The Multifactor Primary Prevention Study | 1970–1973–1996, 25.2 years of follow-up | 7495 men, age 47–55 years: 754 HF cases | Antihypertensive treatment or blood pressure of ≥175/≥115 | Yes vs. no | 1.50 (1.22–1.84) | Age, MI in brothers or sisters, diabetes, chest pain, smoking, coffee, alcohol abuse, BMI |
| Williams SA, 2001, USA | Established Populations for Epidemiologic Studies in the Elderly Program (EPESE)—New Haven | 1982–1996, 14 years of follow-up | 2501 men and women, age ≥65 years: 313 HF cases | Hypertension | None Stage 1 Stage 2 | 1.00 1.10 (0.62–1.94) 1.59 (1.18–2.15) | Age, sex, depression, diabetes, pulse pressure, functional limitations, myocardial infarction |
| He J, 2001, USA | NHANES 1—Epidemiologic Follow-up Study | 1971–1975–1992, 19 years of follow-up | 13 643 men and women, age 25–74 years: 1382 HF cases | Hypertension, all Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.50 (1.34–1.68) 1.44 (1.25–1.67) 1.58 (1.36–1.82) | Age, sex, race/ethnicity, education, physical activity, smoking, alcohol, BMI, diabetes, valvular heart disease, coronary heart disease |
| Johansson S, 2001, UK | UK General Practice Research Database | 1996–1996, −NA, 1 year of follow-up | Nested case-control study: 938 HF cases 5000 controls Age 69–100 years | Hypertension Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.7 (1.4–2.0) 1.6 (1.2–2.0) 1.8 (1.4–2.2) | Age, sex, smoking, BMI, hyperlipidaemia, dyspnoea, prior comorbidities–CHD, valvular disease, diabetes, other cardiac disease, chronic respiratory disease, other diseases (anaemia, renal failure, hyperthyroidism) |
| Crowson CR, 2005, USA | Mayo Clinic, Rochester | NA-NA, 16.1 years of follow-up | 1158 men and women (575 with RA, 583 non-RA), mean age 57.3 years: 280 HF cases | Hypertension, RA Hypertension, non-RA | Yes vs. no Yes vs. no | 1.60 (0.94–2.73) 2.99 (1.18–7.53) | Age, sex, FH–IHD, IHD, cigarette smoking, dyslipidaemia, BMI, diabetes mellitus, alcohol abuse |
| Nielson C, 2005, USA | Veterans Affairs Medical Centers | 1994–2003, 3.45 years of follow-up | 20 810 men and women, mean age 58.7 years: 926 HF cases | Hypertension | Yes vs. no | 1.35 P < 0.01 | Age, sex, BMI, creatinine, blood pressure, smoking, coronary artery disease, LDL cholesterol, HDL cholesterol, thiazide diuretic, hydroxy-methylglutaryl-CoA reductase inhibitor, ACE inhibitors, angiotensin receptor blockers, beta-blockers |
| Ingelsson E, 2005, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–NA, 28.8 years of follow-up | 2321 men, age 50 years: 259 HF cases | Hypertension | Yes vs. no | 1.93 (1.48–2.52) | Serum cholesterol, BMI, ECG-LVH, smoking, diabetes, prior AMI, serum uric acid, beta-carotene, triglycerides, apolipoprotein B/A-1 ratio, LDL cholesterol, HDL cholesterol |
| Hsia J, 2007, USA | Women’s Health Initiative | 1978–1983–NA, 7.7 years of follow-up | 60 785 post-menopausal women, age 60–70 years: 1336 HF cases | Hypertension, all Hypertension, White Hypertension, Black Hypertension, Hispanic Hypertension, Asian | Yes vs.no Yes vs.no Yes vs.no Yes vs.no Yes vs.no | 2.53 (2.26–2.84) 2.45 (2.17–2.76) 2.83 (1.76–4.53) 5.18 (2.30–11.65) 8.16 (2.40–27.80) | Age, smoking, BMI, diabetes, hypercholesterolemia and alcohol |
| Mujib M, 2010, USA | Cardiovascular Health Study | 1989–1990, 1992–1993–NA, 12 years follow-up | 5324 men and women, age 65–100 years: 1091 HF cases | Hypertension | Yes vs. no | 1.24 P = 0.01 | Age, sex, race/ethnicity, smoking status, self-reported health, coronary artery disease, diabetes mellitus, stroke, COPD, atrial fibrillation, left ventricular hypertrophy, systolic blood pressure, peripheral artery disease, serum creatinine, serum uric acid, serum albumin, serum insulin, C-reactive protein, haemoglobin |
| Wang J, 2010, Finland | Kuopio | 1986–1988–2008, 20 years of follow-up | 1032 men and women, age 65–74 years: 303 HF cases | Hypertension | Yes vs. no | 1.52 (1.05–2.22) | Age, sex, leisure-time physical activity, smoking, alcohol, antihypertensive medications, total cholesterol, prevalent diabetes |
| Fedorowski A, 2010, Sweden | Malmo Preventive Project | 1974–1992–2006, 24 years of follow-up | 32 669 men and women, mean age 26–61 years: 1293 HF cases | Hypertension | Yes vs. no | 1.72 (1.52–1.94) | Age, sex, BMI, cholesterol, smoking orthostatic hypotension, diabetes |
| De Simone G, 2010, USA | Strong Heart Study | 1989–1992–NA, 11.9 years of follow-up | 2740 men and women, age 45–74 years: 291 HF cases | Hypertension | Yes vs. no | 1.45 (1.11–1.88) | Age, sex, HF risk factors, HbA1c, smoking, alcohol, education, physical activity |
| Goyal A, 2010, USA | Kaiser Permanente Georgia data Study | 2000–2005–NA, 6 years of follow-up | 168 551 men, and 191 396 women ≥18 years: 4001 HF cases | Hypertension, women Hypertension, men | Yes vs. no Yes vs. no | 3.18 (2.80–3.60) 3.00 (2.66–3.39) | Age, hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, and valvular heart disease. |
| Voulgari C, 2011, Greece | Athens University Medical School | 2003–2005–NA, 6 years of follow-up | 550 men and women, mean age 60 years: 185 HF cases | Hypertension (130/85 mmHg or antihypertensive medication use) | Yes vs. no | 4.86 (3.30–8.61) | Age, sex, impaired glucose tolerance, dyslipidaemia, cigarette smoking, physical inactivity, left ventricular hypertrophy and function on echocardiography |
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Use of blood pressure-lowering medications | Yes vs. no | 2.03 (1.74–2.37) | Age, sex, foreign-born, waist circumference, systolic blood pressure, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Brouwers F, 2013, the Netherlands | Prevention of Renal and Vascular End-stage Disease (PREVEND) | 1997–1998–2010, 11.5 years of follow-up | 8592 men and women, age 28–75 years: 374 HF cases | Hypertension | Yes vs. no | 1.17 (0.77–1.77) | Age, sex, obesity, diabetes, smoking, MI, atrial fibrillation, hypercholesterolemia, cystatine, UAE, hs-CRP, NT-proBNP, hs-TnT |
| Eaton CB, 2016, USA | Women's Health Initiative | 1993–1998–2015, 13.2 years of follow-up | 42170 post-menopausal women, age 50–79 years: 1952 HF cases | Hypertension, HFpEF Hypertension, HFrEF Hypertension, Whites, HFpEF Hypertension, Whites, HFrEF Hypertension, African Americans, HFpEF Hypertension, African Americans, HFrEF Hypertension, Hispanics, HFpEF Hypertension, Hispanics, HFrEF | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no | 1.57 (1.33–1.86) 1.99 (1.59–2.51) 1.57 (1.30–1.90) 2.07 (1.58–2.71) 1.80 (1.22–2.67)1.60 (1.01–2.54) 1.22 (0.57–2.60) 4.24 (1.25–14.32) | Age, study component, race/ ethnicity, income, education, diabetes, heart rate, MI, CHD other than MI, stroke, smoking, dyslipidaemia, oophorectomy, cancer, BMI, smoking, physical activity, chronic lung disease, anaemia, atrial fibrillation, beta-blocker use, aspirin use, hormone therapy, alcohol, insurance, interim CHD—not MI, interim DM, interim cancer |
| Fox ER, 2016, USA | Jackson Heart Study | 2000–2004–2011, 9.1 years of follow-up | 3689 men and women, mean age 53 years: 104 HF cases | Anti-hypertensive therapy | Yes vs. no | 1.7 (0.9–3.2) | Age, sex, systolic blood pressure, diabetes, total:HDL cholesterol ratio, eGFR, smoking, BNP, ABI (subclinical disease) |
| Silverman MG, 2016, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 11.2 years of follow-up | 6781 men and women, age 45–84 years: 257 HF cases | Hypertension, HFpEF Hypertension, HFrEF | Yes vs. no Yes vs. no | 1.81 (1.14–2.90) 2.04 (1.23–3.36) | Age, sex, race/ethnicity, socioeconomic status, MESA site, |
| Jacobs L, 2017, International (USA, Italy, Scotland, Ireland, and the Netherlands, UK) | The Heart ‘OMics’ in AGEing (HOMAGE) study (The Health Aging and Body Composition Study, The PREDICTOR Study, PROSPER) | 1997–1998 2007–2010 1997–1999 3.5 years of follow-up | 10 236 men and women, mean age 74.5 years: 470 HF cases | Antihypertensive medication use | Yes vs. no | 1.65 (1.33–2.06) | Age, sex, BMI, smoking, CAD, diabetes, SBP, heart rate, serum creatinine |
| Ogunmoroti O, 2017, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 12.2 years of follow-up | 6506 men and women, age 45–84 years: 262 HF cases | Blood pressure, all Blood pressure, Whites Blood pressure, Chinese American Blood pressure, Blacks Blood pressure, Hispanics | ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 | 1.00 0.55 (0.41–0.75) 0.40 (0.27–0.57) 1.00 0.52 (0.32–0.83) 0.45 (0.27–0.75) 1.00 0.41 (0.11–1.47) 0.34 (0.09–1.25) 1.00 0.37 (0.19–0.72) 0.40 (0.19–0.85) 1.00 1.01 (0.57–1.79) 0.33 (0.13–0.82) | Age, sex, race/ethnicity (all), education, income, health insurance |
| Myers J, 2017, USA | Veterans Exercise Testing Study | 1987–2014–NA, 12.3 years of follow-up | 21 080 men and women, mean age 58.3 years: 1902 HF cases | Hypertension | Yes vs. no | 1.80 (1.59–2.04) | Age, BMI, ethnicity, beta-blockers, calcium-channel blockers, angiotensin-converting enzymes, angiotensin receptor blockers, aspirin, diuretics, lipid-lowering agents, hypoglycaemic agents, smoking, diabetes, chronic kidney failure, HIV/AIDS |
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK DanMONICA Moli-sani Northern Sweden MONICA | 1982–2002–2010 1982–1984, 1986–1987, 1991–1992, –2010, 2005–2011 1986–2011, 12.7 years of follow-up (across cohorts) | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Antihypertensive medication use, men Antihypertensive medication use, women | Yes vs. noYes vs. no | 1.49 (1.34–1.64)1.47 (1.33–1.61) | Age, BMI, systolic blood pressure, total cholesterol, diabetes, daily smoking |
| Wang ID, 2019, Taiwan | Taiwan National Health Insurance Research Database | 2000–2013, 10.44 years of follow-up | 40 000 men and women, age ≥20 years: 6185 HF cases | Hypertension | Yes vs. no | 1.60 (1.30–1.87) | Age, sex, non-apnoea sleep disorder, diabetes mellitus, hyperlipidaemia, chronic kidney disease, IHD, stroke, obesity, anxiety, depression |
| Uijl A, 2019, the Netherlands | EPIC-Netherlands | 1993–1997–NA, 15.2 years of follow-up | 37 803 men and women, age 20–70 years: 690 HF cases | Blood pressure | ≥140/≥90 mmHg 120 to <140/80 to <90, or treated <120/80 <120/<80, not treated | 1.00 0.62 (0.52–0.74) 0.72 (0.58–0.89) | Age, sex, education, blood glucose, smoking status, BMI, physical activity, diet, blood cholesterol |
| Uijl A, 2019, UK | CALIBER | 2000–2010, 5.8 years of follow-up | 871 687 men and women, age ≥55 years: 47 987 HF cases | Hypertension, men, age 55–64 years Hypertension, men, age 65–74 years Hypertension, men, age ≥75 years Hypertension, women, age 55–64 years Hypertension, women, age 65–74 years Hypertension, women, age ≥75 years | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.14 (1.07–1.22) 1.03 (0.97–1.09) 1.10 (1.05–1.15) 1.09 (1.00–1.19) 0.98 (0.92–1.04) 1.02 (0.99–1.07) | Age, haemoglobin, total white blood cells, total cholesterol, triglycerides, albumin, creatinine, ethnicity, smoking habits, multiple deprivation index, blood pressure-lowering medication, lipid-lowering drugs, COPD, atrial fibrillation, obesity, sedentary lifestyle, diabetes |
| Lee H, 2019, Korea | Korea National Health Insurance Research Database | 2003–2007–2017, 9.75 years of follow-up | 15 508 537 men and women, age 20–94 years: 21 535 HF cases | Hypertension, age 20–34 years Hypertension, age 35–49 years Hypertension, age 50–64 years Hypertension, age 65–79 years Hypertension, age 80–94 years | Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension | 1.00 1.20 (0.90–1.60) 1.40 (1.15–1.71) 3.04 (2.42–3.84) 1.00 1.20 (1.04–1.39) 1.29 (1.17–1.44) 2.14 (1.91–2.40) 1.00 1.07 (0.97–1.18) 1.18 (1.10–1.27) 1.58 (1.47–1.69) 1.00 1.00 (0.92–1.07) 1.10 (1.04–1.16)1.26 (1.19–1.33) 1.00 1.12 (0.91–1.38) 1.14 (0.96–1.32) 1.22 (1.06–1.41) | Age, sex, household income, Charlson comorbidity index, use of glucose-lowering drugs, use of lipid-lowering drugs, smoking, alcohol, exercise, BMI, fasting glucose, total cholesterol |
| Kubicki M, 2020, USA | Southern Community Cohort Study | 2002–2009–NA, 5.2–6.7 years of follow-up | 27 078 men and women, age 56 years: 4341 HF cases | Hypertension, all Hypertension, Black men Hypertension, Black women Hypertension, White men Hypertension, White women | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.69 (1.59–1.84) 2.07 (1.75–2.45) 1.64 (1.43–1.87) 1.45 (1.16–1.83) 1.61 (1.34–1.92) | Age, sex, race, smoking, BMI, poor diet, diabetes, high cholesterol, physical activity |
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Hypertension | Yes vs. no | 1.31 (0.80–2.15) | Hyperlipidaemia, diabetes, sedentary lifestyle, smoking, BMI |
| Mefford MT, 2020, USA | REasons for Geographic And Racial Differences in Stroke Study (REGARDS) | 2003–2007–2015, 8.3 years of follow-up | 25 770 men and women, age ≥45 years: 947 HF cases | Hypertension, all, Whites Hypertension, HFpEF, Whites Hypertension, HFrEF, Whites Hypertension duration, Whites Hypertension control, Whites Hypertension, all, Blacks Hypertension, HFpEF, Blacks Hypertension, HFrEF, Blacks Hypertension duration, Blacks Hypertension control, Blacks | Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled | 1.90 (1.49–2.41) 2.01 (1.34–3.01) 1.69 (1.23–2.33) 1.00 1.59 (1.19–2.11) 1.87 (1.42–2.46) 2.21 (1.70–2.89) 1.00 1.52 (1.14–2.04) 1.93 (1.44–2.58) 2.27 (1.74–2.97) 2.36 (1.53–3.65) 2.70 (1.25–5.83) 2.29 (1.26–4.15) 1.00 1.55 (0.93–2.58) 2.13 (1.33–3.42) 2.96 (1.89–4.64) 1.00 1.50 (0.89–2.54) 2.01 (1.22–3.29) 2.93 (1.86–4.63) | Age, sex, BMI, smoking, diabetes, reduced eGFR, total cholesterol, statin use, income, region of residence, health insurance, physical activity, perceived stress, depressive symptoms |
| Vasan RS, 2021, USA | Atherosclerosis Risk in Communities Study (ARIC) | 1993–1996–NA, 19.0 years of follow-up | 1871 Black men and women, mean age 59 years: 309 HF cases | Hypertension | Yes vs. no | 1.73 (1.34–2.23) | Age, sex, BMI, diabetes mellitus, smoking status, total: HDL cholesterol ratio |
| Suzuki Y, 2022, Japan | JMDC Claims Database | 2005–2020, 3.3 years of follow-up | 2 612 570 men and women, age 20–75 years: 43 415 HF cases | Hypertension, age 20–49 years, all Hypertension, age 50–59 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.35 (1.31–1.40) 2.03 (1.90–2.16) 1.96 (1.81–2.11) 3.10 (2.95–3.25) 1.00 1.28 (1.23–1.33) 1.63 (1.52–1.75) 1.72 (1.60–1.84) 2.12 (2.02–2.23) | Age, sex, obesity, diabetes, dyslipidaemia, cigarette smoking, alcohol consumption |
| Hypertension, age 60–75 years Hypertension, age 20–49 years, men Hypertension, age 50–59 years Hypertension, age 60–75 years Hypertension, age 20–49 years, women Hypertension, age 50–59 years Hypertension, age 60–75 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.14 (1.08–1.21) 1.36 (1.19–1.54) 1.44 (1.34–1.56) 1.72 (1.60–1.85) 1.00 1.35 (1.30–1.41) 2.03 (1.89–2.19) 1.98 (1.81–2.17) 3.16 (2.99–3.34) 1.00 1.28 (1.22–1.34) 1.62 (1.49–1.75) 1.79 (1.64–1.96) 2.16 (2.03–2.29) 1.00 1.11 (1.01–1.19) 1.27 (1.10–1.47) 1.43 (1.30–1.57) 1.72 (1.57–1.87) 1.00 1.37 (1.29–1.46) 1.99 (1.71–2.31) 1.95 (1.70–2.23) 2.93 (2.67–3.22) 1.00 1.29 (1.20–1.38) 1.76 (1.49–2.08) 1.60 (1.42–1.80) 2.04 (1.85–2.25) 1.00 1.20 (1.08–1.32) 1.69 (1.29–2.21) 1.45 (1.28–1.64) 1.68 (1.46–1.93) | |||||
| Rastogi, 2022, UK | UK Biobank | 2006–2010–NA, 11.8 years of follow-up | 500 001 men and women, age 37–73 years: 14 216 HF cases | Hypertension, patients with history of MI Hypertension, patients without history of MI | Yes vs. no Yes vs. no | 1.14 (1.08–1.22) 1.61 (1.54–1.69) | Age, sex, eGFR, HbA1c, BMI, smoking status, type 2 diabetes |
| Vasan RS, 2022, USA | Framingham Heart Study | 1965–1989, 15 years of follow-up 1990–2014, 13.5 years of follow-up | 7500 men and women, mean age 47.6 years: 624 HF cases 9540 men and women, mean age 47.6 years: 875 HF cases | Hypertension, epoch 1 Hypertension, epoch 2 Hypertension, epoch 2, HFpEF Hypertension, epoch 2, HFrEF | Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension | 1.00 1.38 (1.06–1.79) 2.17 (1.70–2.77) 1.00 1.54 (1.29–1.84) 2.11 (1.77–2.52) 1.00 1.43 (1.07–1.91) 2.11 (1.59–2.81) 1.00 1.66 (1.28–2.15) 2.06 (1.59–2.67) | Age, sex, BMI, diabetes |
ACE, angiotensin-converting enzyme; AIDS, acquired immunodeficiency syndrome; AMI, acute myocardial infarction; ARIC, Atherosclerosis Risk in Communities Study; BMI, body mass index; CAD, coronary artery disease; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; DM, diabetes mellitus; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; FH, family history; Hb, haemoglobin; HDL, high-density lipoprotein; HF, heart failure; HIV, human immunodeficiency virus; IHD, ischaemic heart disease; LDL, low-density lipoprotein; LVH, left ventricular hypertrophy; MESA, Multi-Ethnic Study of Atherosclerosis; MI, myocardial infarction; NA, not available; NT-proBNP, B-type natriuretic peptide; hs-TnT, high-sensitivity troponin.
Prospective studies of hypertension and heart failure
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | RR (95% CI) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Eriksson H, 1989, Sweden | Study of Men Born in 1913 | 1963–1980–NA 17 years of follow-up | 973 men, age 50 years: 67 HF cases | Hypertension | Yes vs. no | 1.7 (1.4–5.7) | Smoking, body weight, heart volume, ECG T-wave, heart rate variability, peak flow, Fy-antigen, stress |
| Alexander M, 1995, USA | Northern California Kaiser Permanente Medical Care Program | 1978–1984–1991, 9.5 years of follow-up | 64 877 men and women, age ≥40 years: 1330 HF cases | Hypertension, uncontrolled, women age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, uncontrolled, men age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, age ≥60 years Hypertension, controlled Hypertension, unrecognized | Yes vs. noYes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 2.06 (1.07–3.95)1.32 (0.84–2.07) 2.67 (1.32–5.42) 2.90 (1.78–4.70)1.51 (1.05–2.17) 0.88 (0.32–2.42) 1.53 (1.16–2.01) 1.34 (1.09–1.65) 1.50 (1.14–1.97) | Age, sex, race/ethnicity, education, diabetes, smoking, MI, chest pain, total cholesterol, BMI, creatinine, uric acid, urine protein, left ventricular hypertrophy, alcohol |
| Levy D, 1996, USA | Framingham Heart Study | NA–NA, 20 years of follow-up | 2334 men and 2809 women, 40–89 years: 392 HF cases | Hypertension, men Hypertension, women | Yes vs. no Yes vs. no | 1.84 (1.35–2.51) 2.60 (1.77–3.81) | Myocardial infarction, left ventricular hypertrophy, diabetes, angina pectoris |
| Aronow WS, 1999, USA | New York | NA–NA, 3.6 years of follow-up | 2737 men and women, age 60–103 years: 739 HF cases | Hypertension | Yes vs. no | 2.52 (2.14–2.98) | Age, sex, diabetes, coronary artery disease |
| Trenkwalder P, 1999, Germany | The Prospective STEPHY II Study | 1992–1995–NA, 2.7 years of follow-up | 647 men and women, 60–99 years: 60 HF cases | Hypertension, all | Yes vs. no | 1.17 (0.9–2.9) | Age, sex, acute myocardial infarction |
| Wilhelmsen L, 2001, Sweden | The Multifactor Primary Prevention Study | 1970–1973–1996, 25.2 years of follow-up | 7495 men, age 47–55 years: 754 HF cases | Antihypertensive treatment or blood pressure of ≥175/≥115 | Yes vs. no | 1.50 (1.22–1.84) | Age, MI in brothers or sisters, diabetes, chest pain, smoking, coffee, alcohol abuse, BMI |
| Williams SA, 2001, USA | Established Populations for Epidemiologic Studies in the Elderly Program (EPESE)—New Haven | 1982–1996, 14 years of follow-up | 2501 men and women, age ≥65 years: 313 HF cases | Hypertension | None Stage 1 Stage 2 | 1.00 1.10 (0.62–1.94) 1.59 (1.18–2.15) | Age, sex, depression, diabetes, pulse pressure, functional limitations, myocardial infarction |
| He J, 2001, USA | NHANES 1—Epidemiologic Follow-up Study | 1971–1975–1992, 19 years of follow-up | 13 643 men and women, age 25–74 years: 1382 HF cases | Hypertension, all Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.50 (1.34–1.68) 1.44 (1.25–1.67) 1.58 (1.36–1.82) | Age, sex, race/ethnicity, education, physical activity, smoking, alcohol, BMI, diabetes, valvular heart disease, coronary heart disease |
| Johansson S, 2001, UK | UK General Practice Research Database | 1996–1996, −NA, 1 year of follow-up | Nested case-control study: 938 HF cases 5000 controls Age 69–100 years | Hypertension Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.7 (1.4–2.0) 1.6 (1.2–2.0) 1.8 (1.4–2.2) | Age, sex, smoking, BMI, hyperlipidaemia, dyspnoea, prior comorbidities–CHD, valvular disease, diabetes, other cardiac disease, chronic respiratory disease, other diseases (anaemia, renal failure, hyperthyroidism) |
| Crowson CR, 2005, USA | Mayo Clinic, Rochester | NA-NA, 16.1 years of follow-up | 1158 men and women (575 with RA, 583 non-RA), mean age 57.3 years: 280 HF cases | Hypertension, RA Hypertension, non-RA | Yes vs. no Yes vs. no | 1.60 (0.94–2.73) 2.99 (1.18–7.53) | Age, sex, FH–IHD, IHD, cigarette smoking, dyslipidaemia, BMI, diabetes mellitus, alcohol abuse |
| Nielson C, 2005, USA | Veterans Affairs Medical Centers | 1994–2003, 3.45 years of follow-up | 20 810 men and women, mean age 58.7 years: 926 HF cases | Hypertension | Yes vs. no | 1.35 P < 0.01 | Age, sex, BMI, creatinine, blood pressure, smoking, coronary artery disease, LDL cholesterol, HDL cholesterol, thiazide diuretic, hydroxy-methylglutaryl-CoA reductase inhibitor, ACE inhibitors, angiotensin receptor blockers, beta-blockers |
| Ingelsson E, 2005, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–NA, 28.8 years of follow-up | 2321 men, age 50 years: 259 HF cases | Hypertension | Yes vs. no | 1.93 (1.48–2.52) | Serum cholesterol, BMI, ECG-LVH, smoking, diabetes, prior AMI, serum uric acid, beta-carotene, triglycerides, apolipoprotein B/A-1 ratio, LDL cholesterol, HDL cholesterol |
| Hsia J, 2007, USA | Women’s Health Initiative | 1978–1983–NA, 7.7 years of follow-up | 60 785 post-menopausal women, age 60–70 years: 1336 HF cases | Hypertension, all Hypertension, White Hypertension, Black Hypertension, Hispanic Hypertension, Asian | Yes vs.no Yes vs.no Yes vs.no Yes vs.no Yes vs.no | 2.53 (2.26–2.84) 2.45 (2.17–2.76) 2.83 (1.76–4.53) 5.18 (2.30–11.65) 8.16 (2.40–27.80) | Age, smoking, BMI, diabetes, hypercholesterolemia and alcohol |
| Mujib M, 2010, USA | Cardiovascular Health Study | 1989–1990, 1992–1993–NA, 12 years follow-up | 5324 men and women, age 65–100 years: 1091 HF cases | Hypertension | Yes vs. no | 1.24 P = 0.01 | Age, sex, race/ethnicity, smoking status, self-reported health, coronary artery disease, diabetes mellitus, stroke, COPD, atrial fibrillation, left ventricular hypertrophy, systolic blood pressure, peripheral artery disease, serum creatinine, serum uric acid, serum albumin, serum insulin, C-reactive protein, haemoglobin |
| Wang J, 2010, Finland | Kuopio | 1986–1988–2008, 20 years of follow-up | 1032 men and women, age 65–74 years: 303 HF cases | Hypertension | Yes vs. no | 1.52 (1.05–2.22) | Age, sex, leisure-time physical activity, smoking, alcohol, antihypertensive medications, total cholesterol, prevalent diabetes |
| Fedorowski A, 2010, Sweden | Malmo Preventive Project | 1974–1992–2006, 24 years of follow-up | 32 669 men and women, mean age 26–61 years: 1293 HF cases | Hypertension | Yes vs. no | 1.72 (1.52–1.94) | Age, sex, BMI, cholesterol, smoking orthostatic hypotension, diabetes |
| De Simone G, 2010, USA | Strong Heart Study | 1989–1992–NA, 11.9 years of follow-up | 2740 men and women, age 45–74 years: 291 HF cases | Hypertension | Yes vs. no | 1.45 (1.11–1.88) | Age, sex, HF risk factors, HbA1c, smoking, alcohol, education, physical activity |
| Goyal A, 2010, USA | Kaiser Permanente Georgia data Study | 2000–2005–NA, 6 years of follow-up | 168 551 men, and 191 396 women ≥18 years: 4001 HF cases | Hypertension, women Hypertension, men | Yes vs. no Yes vs. no | 3.18 (2.80–3.60) 3.00 (2.66–3.39) | Age, hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, and valvular heart disease. |
| Voulgari C, 2011, Greece | Athens University Medical School | 2003–2005–NA, 6 years of follow-up | 550 men and women, mean age 60 years: 185 HF cases | Hypertension (130/85 mmHg or antihypertensive medication use) | Yes vs. no | 4.86 (3.30–8.61) | Age, sex, impaired glucose tolerance, dyslipidaemia, cigarette smoking, physical inactivity, left ventricular hypertrophy and function on echocardiography |
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Use of blood pressure-lowering medications | Yes vs. no | 2.03 (1.74–2.37) | Age, sex, foreign-born, waist circumference, systolic blood pressure, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Brouwers F, 2013, the Netherlands | Prevention of Renal and Vascular End-stage Disease (PREVEND) | 1997–1998–2010, 11.5 years of follow-up | 8592 men and women, age 28–75 years: 374 HF cases | Hypertension | Yes vs. no | 1.17 (0.77–1.77) | Age, sex, obesity, diabetes, smoking, MI, atrial fibrillation, hypercholesterolemia, cystatine, UAE, hs-CRP, NT-proBNP, hs-TnT |
| Eaton CB, 2016, USA | Women's Health Initiative | 1993–1998–2015, 13.2 years of follow-up | 42170 post-menopausal women, age 50–79 years: 1952 HF cases | Hypertension, HFpEF Hypertension, HFrEF Hypertension, Whites, HFpEF Hypertension, Whites, HFrEF Hypertension, African Americans, HFpEF Hypertension, African Americans, HFrEF Hypertension, Hispanics, HFpEF Hypertension, Hispanics, HFrEF | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no | 1.57 (1.33–1.86) 1.99 (1.59–2.51) 1.57 (1.30–1.90) 2.07 (1.58–2.71) 1.80 (1.22–2.67)1.60 (1.01–2.54) 1.22 (0.57–2.60) 4.24 (1.25–14.32) | Age, study component, race/ ethnicity, income, education, diabetes, heart rate, MI, CHD other than MI, stroke, smoking, dyslipidaemia, oophorectomy, cancer, BMI, smoking, physical activity, chronic lung disease, anaemia, atrial fibrillation, beta-blocker use, aspirin use, hormone therapy, alcohol, insurance, interim CHD—not MI, interim DM, interim cancer |
| Fox ER, 2016, USA | Jackson Heart Study | 2000–2004–2011, 9.1 years of follow-up | 3689 men and women, mean age 53 years: 104 HF cases | Anti-hypertensive therapy | Yes vs. no | 1.7 (0.9–3.2) | Age, sex, systolic blood pressure, diabetes, total:HDL cholesterol ratio, eGFR, smoking, BNP, ABI (subclinical disease) |
| Silverman MG, 2016, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 11.2 years of follow-up | 6781 men and women, age 45–84 years: 257 HF cases | Hypertension, HFpEF Hypertension, HFrEF | Yes vs. no Yes vs. no | 1.81 (1.14–2.90) 2.04 (1.23–3.36) | Age, sex, race/ethnicity, socioeconomic status, MESA site, |
| Jacobs L, 2017, International (USA, Italy, Scotland, Ireland, and the Netherlands, UK) | The Heart ‘OMics’ in AGEing (HOMAGE) study (The Health Aging and Body Composition Study, The PREDICTOR Study, PROSPER) | 1997–1998 2007–2010 1997–1999 3.5 years of follow-up | 10 236 men and women, mean age 74.5 years: 470 HF cases | Antihypertensive medication use | Yes vs. no | 1.65 (1.33–2.06) | Age, sex, BMI, smoking, CAD, diabetes, SBP, heart rate, serum creatinine |
| Ogunmoroti O, 2017, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 12.2 years of follow-up | 6506 men and women, age 45–84 years: 262 HF cases | Blood pressure, all Blood pressure, Whites Blood pressure, Chinese American Blood pressure, Blacks Blood pressure, Hispanics | ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 | 1.00 0.55 (0.41–0.75) 0.40 (0.27–0.57) 1.00 0.52 (0.32–0.83) 0.45 (0.27–0.75) 1.00 0.41 (0.11–1.47) 0.34 (0.09–1.25) 1.00 0.37 (0.19–0.72) 0.40 (0.19–0.85) 1.00 1.01 (0.57–1.79) 0.33 (0.13–0.82) | Age, sex, race/ethnicity (all), education, income, health insurance |
| Myers J, 2017, USA | Veterans Exercise Testing Study | 1987–2014–NA, 12.3 years of follow-up | 21 080 men and women, mean age 58.3 years: 1902 HF cases | Hypertension | Yes vs. no | 1.80 (1.59–2.04) | Age, BMI, ethnicity, beta-blockers, calcium-channel blockers, angiotensin-converting enzymes, angiotensin receptor blockers, aspirin, diuretics, lipid-lowering agents, hypoglycaemic agents, smoking, diabetes, chronic kidney failure, HIV/AIDS |
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK DanMONICA Moli-sani Northern Sweden MONICA | 1982–2002–2010 1982–1984, 1986–1987, 1991–1992, –2010, 2005–2011 1986–2011, 12.7 years of follow-up (across cohorts) | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Antihypertensive medication use, men Antihypertensive medication use, women | Yes vs. noYes vs. no | 1.49 (1.34–1.64)1.47 (1.33–1.61) | Age, BMI, systolic blood pressure, total cholesterol, diabetes, daily smoking |
| Wang ID, 2019, Taiwan | Taiwan National Health Insurance Research Database | 2000–2013, 10.44 years of follow-up | 40 000 men and women, age ≥20 years: 6185 HF cases | Hypertension | Yes vs. no | 1.60 (1.30–1.87) | Age, sex, non-apnoea sleep disorder, diabetes mellitus, hyperlipidaemia, chronic kidney disease, IHD, stroke, obesity, anxiety, depression |
| Uijl A, 2019, the Netherlands | EPIC-Netherlands | 1993–1997–NA, 15.2 years of follow-up | 37 803 men and women, age 20–70 years: 690 HF cases | Blood pressure | ≥140/≥90 mmHg 120 to <140/80 to <90, or treated <120/80 <120/<80, not treated | 1.00 0.62 (0.52–0.74) 0.72 (0.58–0.89) | Age, sex, education, blood glucose, smoking status, BMI, physical activity, diet, blood cholesterol |
| Uijl A, 2019, UK | CALIBER | 2000–2010, 5.8 years of follow-up | 871 687 men and women, age ≥55 years: 47 987 HF cases | Hypertension, men, age 55–64 years Hypertension, men, age 65–74 years Hypertension, men, age ≥75 years Hypertension, women, age 55–64 years Hypertension, women, age 65–74 years Hypertension, women, age ≥75 years | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.14 (1.07–1.22) 1.03 (0.97–1.09) 1.10 (1.05–1.15) 1.09 (1.00–1.19) 0.98 (0.92–1.04) 1.02 (0.99–1.07) | Age, haemoglobin, total white blood cells, total cholesterol, triglycerides, albumin, creatinine, ethnicity, smoking habits, multiple deprivation index, blood pressure-lowering medication, lipid-lowering drugs, COPD, atrial fibrillation, obesity, sedentary lifestyle, diabetes |
| Lee H, 2019, Korea | Korea National Health Insurance Research Database | 2003–2007–2017, 9.75 years of follow-up | 15 508 537 men and women, age 20–94 years: 21 535 HF cases | Hypertension, age 20–34 years Hypertension, age 35–49 years Hypertension, age 50–64 years Hypertension, age 65–79 years Hypertension, age 80–94 years | Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension | 1.00 1.20 (0.90–1.60) 1.40 (1.15–1.71) 3.04 (2.42–3.84) 1.00 1.20 (1.04–1.39) 1.29 (1.17–1.44) 2.14 (1.91–2.40) 1.00 1.07 (0.97–1.18) 1.18 (1.10–1.27) 1.58 (1.47–1.69) 1.00 1.00 (0.92–1.07) 1.10 (1.04–1.16)1.26 (1.19–1.33) 1.00 1.12 (0.91–1.38) 1.14 (0.96–1.32) 1.22 (1.06–1.41) | Age, sex, household income, Charlson comorbidity index, use of glucose-lowering drugs, use of lipid-lowering drugs, smoking, alcohol, exercise, BMI, fasting glucose, total cholesterol |
| Kubicki M, 2020, USA | Southern Community Cohort Study | 2002–2009–NA, 5.2–6.7 years of follow-up | 27 078 men and women, age 56 years: 4341 HF cases | Hypertension, all Hypertension, Black men Hypertension, Black women Hypertension, White men Hypertension, White women | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.69 (1.59–1.84) 2.07 (1.75–2.45) 1.64 (1.43–1.87) 1.45 (1.16–1.83) 1.61 (1.34–1.92) | Age, sex, race, smoking, BMI, poor diet, diabetes, high cholesterol, physical activity |
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Hypertension | Yes vs. no | 1.31 (0.80–2.15) | Hyperlipidaemia, diabetes, sedentary lifestyle, smoking, BMI |
| Mefford MT, 2020, USA | REasons for Geographic And Racial Differences in Stroke Study (REGARDS) | 2003–2007–2015, 8.3 years of follow-up | 25 770 men and women, age ≥45 years: 947 HF cases | Hypertension, all, Whites Hypertension, HFpEF, Whites Hypertension, HFrEF, Whites Hypertension duration, Whites Hypertension control, Whites Hypertension, all, Blacks Hypertension, HFpEF, Blacks Hypertension, HFrEF, Blacks Hypertension duration, Blacks Hypertension control, Blacks | Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled | 1.90 (1.49–2.41) 2.01 (1.34–3.01) 1.69 (1.23–2.33) 1.00 1.59 (1.19–2.11) 1.87 (1.42–2.46) 2.21 (1.70–2.89) 1.00 1.52 (1.14–2.04) 1.93 (1.44–2.58) 2.27 (1.74–2.97) 2.36 (1.53–3.65) 2.70 (1.25–5.83) 2.29 (1.26–4.15) 1.00 1.55 (0.93–2.58) 2.13 (1.33–3.42) 2.96 (1.89–4.64) 1.00 1.50 (0.89–2.54) 2.01 (1.22–3.29) 2.93 (1.86–4.63) | Age, sex, BMI, smoking, diabetes, reduced eGFR, total cholesterol, statin use, income, region of residence, health insurance, physical activity, perceived stress, depressive symptoms |
| Vasan RS, 2021, USA | Atherosclerosis Risk in Communities Study (ARIC) | 1993–1996–NA, 19.0 years of follow-up | 1871 Black men and women, mean age 59 years: 309 HF cases | Hypertension | Yes vs. no | 1.73 (1.34–2.23) | Age, sex, BMI, diabetes mellitus, smoking status, total: HDL cholesterol ratio |
| Suzuki Y, 2022, Japan | JMDC Claims Database | 2005–2020, 3.3 years of follow-up | 2 612 570 men and women, age 20–75 years: 43 415 HF cases | Hypertension, age 20–49 years, all Hypertension, age 50–59 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.35 (1.31–1.40) 2.03 (1.90–2.16) 1.96 (1.81–2.11) 3.10 (2.95–3.25) 1.00 1.28 (1.23–1.33) 1.63 (1.52–1.75) 1.72 (1.60–1.84) 2.12 (2.02–2.23) | Age, sex, obesity, diabetes, dyslipidaemia, cigarette smoking, alcohol consumption |
| Hypertension, age 60–75 years Hypertension, age 20–49 years, men Hypertension, age 50–59 years Hypertension, age 60–75 years Hypertension, age 20–49 years, women Hypertension, age 50–59 years Hypertension, age 60–75 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.14 (1.08–1.21) 1.36 (1.19–1.54) 1.44 (1.34–1.56) 1.72 (1.60–1.85) 1.00 1.35 (1.30–1.41) 2.03 (1.89–2.19) 1.98 (1.81–2.17) 3.16 (2.99–3.34) 1.00 1.28 (1.22–1.34) 1.62 (1.49–1.75) 1.79 (1.64–1.96) 2.16 (2.03–2.29) 1.00 1.11 (1.01–1.19) 1.27 (1.10–1.47) 1.43 (1.30–1.57) 1.72 (1.57–1.87) 1.00 1.37 (1.29–1.46) 1.99 (1.71–2.31) 1.95 (1.70–2.23) 2.93 (2.67–3.22) 1.00 1.29 (1.20–1.38) 1.76 (1.49–2.08) 1.60 (1.42–1.80) 2.04 (1.85–2.25) 1.00 1.20 (1.08–1.32) 1.69 (1.29–2.21) 1.45 (1.28–1.64) 1.68 (1.46–1.93) | |||||
| Rastogi, 2022, UK | UK Biobank | 2006–2010–NA, 11.8 years of follow-up | 500 001 men and women, age 37–73 years: 14 216 HF cases | Hypertension, patients with history of MI Hypertension, patients without history of MI | Yes vs. no Yes vs. no | 1.14 (1.08–1.22) 1.61 (1.54–1.69) | Age, sex, eGFR, HbA1c, BMI, smoking status, type 2 diabetes |
| Vasan RS, 2022, USA | Framingham Heart Study | 1965–1989, 15 years of follow-up 1990–2014, 13.5 years of follow-up | 7500 men and women, mean age 47.6 years: 624 HF cases 9540 men and women, mean age 47.6 years: 875 HF cases | Hypertension, epoch 1 Hypertension, epoch 2 Hypertension, epoch 2, HFpEF Hypertension, epoch 2, HFrEF | Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension | 1.00 1.38 (1.06–1.79) 2.17 (1.70–2.77) 1.00 1.54 (1.29–1.84) 2.11 (1.77–2.52) 1.00 1.43 (1.07–1.91) 2.11 (1.59–2.81) 1.00 1.66 (1.28–2.15) 2.06 (1.59–2.67) | Age, sex, BMI, diabetes |
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | RR (95% CI) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Eriksson H, 1989, Sweden | Study of Men Born in 1913 | 1963–1980–NA 17 years of follow-up | 973 men, age 50 years: 67 HF cases | Hypertension | Yes vs. no | 1.7 (1.4–5.7) | Smoking, body weight, heart volume, ECG T-wave, heart rate variability, peak flow, Fy-antigen, stress |
| Alexander M, 1995, USA | Northern California Kaiser Permanente Medical Care Program | 1978–1984–1991, 9.5 years of follow-up | 64 877 men and women, age ≥40 years: 1330 HF cases | Hypertension, uncontrolled, women age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, uncontrolled, men age <60 years Hypertension, controlled Hypertension, unrecognized Hypertension, age ≥60 years Hypertension, controlled Hypertension, unrecognized | Yes vs. noYes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 2.06 (1.07–3.95)1.32 (0.84–2.07) 2.67 (1.32–5.42) 2.90 (1.78–4.70)1.51 (1.05–2.17) 0.88 (0.32–2.42) 1.53 (1.16–2.01) 1.34 (1.09–1.65) 1.50 (1.14–1.97) | Age, sex, race/ethnicity, education, diabetes, smoking, MI, chest pain, total cholesterol, BMI, creatinine, uric acid, urine protein, left ventricular hypertrophy, alcohol |
| Levy D, 1996, USA | Framingham Heart Study | NA–NA, 20 years of follow-up | 2334 men and 2809 women, 40–89 years: 392 HF cases | Hypertension, men Hypertension, women | Yes vs. no Yes vs. no | 1.84 (1.35–2.51) 2.60 (1.77–3.81) | Myocardial infarction, left ventricular hypertrophy, diabetes, angina pectoris |
| Aronow WS, 1999, USA | New York | NA–NA, 3.6 years of follow-up | 2737 men and women, age 60–103 years: 739 HF cases | Hypertension | Yes vs. no | 2.52 (2.14–2.98) | Age, sex, diabetes, coronary artery disease |
| Trenkwalder P, 1999, Germany | The Prospective STEPHY II Study | 1992–1995–NA, 2.7 years of follow-up | 647 men and women, 60–99 years: 60 HF cases | Hypertension, all | Yes vs. no | 1.17 (0.9–2.9) | Age, sex, acute myocardial infarction |
| Wilhelmsen L, 2001, Sweden | The Multifactor Primary Prevention Study | 1970–1973–1996, 25.2 years of follow-up | 7495 men, age 47–55 years: 754 HF cases | Antihypertensive treatment or blood pressure of ≥175/≥115 | Yes vs. no | 1.50 (1.22–1.84) | Age, MI in brothers or sisters, diabetes, chest pain, smoking, coffee, alcohol abuse, BMI |
| Williams SA, 2001, USA | Established Populations for Epidemiologic Studies in the Elderly Program (EPESE)—New Haven | 1982–1996, 14 years of follow-up | 2501 men and women, age ≥65 years: 313 HF cases | Hypertension | None Stage 1 Stage 2 | 1.00 1.10 (0.62–1.94) 1.59 (1.18–2.15) | Age, sex, depression, diabetes, pulse pressure, functional limitations, myocardial infarction |
| He J, 2001, USA | NHANES 1—Epidemiologic Follow-up Study | 1971–1975–1992, 19 years of follow-up | 13 643 men and women, age 25–74 years: 1382 HF cases | Hypertension, all Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.50 (1.34–1.68) 1.44 (1.25–1.67) 1.58 (1.36–1.82) | Age, sex, race/ethnicity, education, physical activity, smoking, alcohol, BMI, diabetes, valvular heart disease, coronary heart disease |
| Johansson S, 2001, UK | UK General Practice Research Database | 1996–1996, −NA, 1 year of follow-up | Nested case-control study: 938 HF cases 5000 controls Age 69–100 years | Hypertension Hypertension, men Hypertension, women | Yes vs. no Yes vs. no Yes vs. no | 1.7 (1.4–2.0) 1.6 (1.2–2.0) 1.8 (1.4–2.2) | Age, sex, smoking, BMI, hyperlipidaemia, dyspnoea, prior comorbidities–CHD, valvular disease, diabetes, other cardiac disease, chronic respiratory disease, other diseases (anaemia, renal failure, hyperthyroidism) |
| Crowson CR, 2005, USA | Mayo Clinic, Rochester | NA-NA, 16.1 years of follow-up | 1158 men and women (575 with RA, 583 non-RA), mean age 57.3 years: 280 HF cases | Hypertension, RA Hypertension, non-RA | Yes vs. no Yes vs. no | 1.60 (0.94–2.73) 2.99 (1.18–7.53) | Age, sex, FH–IHD, IHD, cigarette smoking, dyslipidaemia, BMI, diabetes mellitus, alcohol abuse |
| Nielson C, 2005, USA | Veterans Affairs Medical Centers | 1994–2003, 3.45 years of follow-up | 20 810 men and women, mean age 58.7 years: 926 HF cases | Hypertension | Yes vs. no | 1.35 P < 0.01 | Age, sex, BMI, creatinine, blood pressure, smoking, coronary artery disease, LDL cholesterol, HDL cholesterol, thiazide diuretic, hydroxy-methylglutaryl-CoA reductase inhibitor, ACE inhibitors, angiotensin receptor blockers, beta-blockers |
| Ingelsson E, 2005, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–NA, 28.8 years of follow-up | 2321 men, age 50 years: 259 HF cases | Hypertension | Yes vs. no | 1.93 (1.48–2.52) | Serum cholesterol, BMI, ECG-LVH, smoking, diabetes, prior AMI, serum uric acid, beta-carotene, triglycerides, apolipoprotein B/A-1 ratio, LDL cholesterol, HDL cholesterol |
| Hsia J, 2007, USA | Women’s Health Initiative | 1978–1983–NA, 7.7 years of follow-up | 60 785 post-menopausal women, age 60–70 years: 1336 HF cases | Hypertension, all Hypertension, White Hypertension, Black Hypertension, Hispanic Hypertension, Asian | Yes vs.no Yes vs.no Yes vs.no Yes vs.no Yes vs.no | 2.53 (2.26–2.84) 2.45 (2.17–2.76) 2.83 (1.76–4.53) 5.18 (2.30–11.65) 8.16 (2.40–27.80) | Age, smoking, BMI, diabetes, hypercholesterolemia and alcohol |
| Mujib M, 2010, USA | Cardiovascular Health Study | 1989–1990, 1992–1993–NA, 12 years follow-up | 5324 men and women, age 65–100 years: 1091 HF cases | Hypertension | Yes vs. no | 1.24 P = 0.01 | Age, sex, race/ethnicity, smoking status, self-reported health, coronary artery disease, diabetes mellitus, stroke, COPD, atrial fibrillation, left ventricular hypertrophy, systolic blood pressure, peripheral artery disease, serum creatinine, serum uric acid, serum albumin, serum insulin, C-reactive protein, haemoglobin |
| Wang J, 2010, Finland | Kuopio | 1986–1988–2008, 20 years of follow-up | 1032 men and women, age 65–74 years: 303 HF cases | Hypertension | Yes vs. no | 1.52 (1.05–2.22) | Age, sex, leisure-time physical activity, smoking, alcohol, antihypertensive medications, total cholesterol, prevalent diabetes |
| Fedorowski A, 2010, Sweden | Malmo Preventive Project | 1974–1992–2006, 24 years of follow-up | 32 669 men and women, mean age 26–61 years: 1293 HF cases | Hypertension | Yes vs. no | 1.72 (1.52–1.94) | Age, sex, BMI, cholesterol, smoking orthostatic hypotension, diabetes |
| De Simone G, 2010, USA | Strong Heart Study | 1989–1992–NA, 11.9 years of follow-up | 2740 men and women, age 45–74 years: 291 HF cases | Hypertension | Yes vs. no | 1.45 (1.11–1.88) | Age, sex, HF risk factors, HbA1c, smoking, alcohol, education, physical activity |
| Goyal A, 2010, USA | Kaiser Permanente Georgia data Study | 2000–2005–NA, 6 years of follow-up | 168 551 men, and 191 396 women ≥18 years: 4001 HF cases | Hypertension, women Hypertension, men | Yes vs. no Yes vs. no | 3.18 (2.80–3.60) 3.00 (2.66–3.39) | Age, hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, and valvular heart disease. |
| Voulgari C, 2011, Greece | Athens University Medical School | 2003–2005–NA, 6 years of follow-up | 550 men and women, mean age 60 years: 185 HF cases | Hypertension (130/85 mmHg or antihypertensive medication use) | Yes vs. no | 4.86 (3.30–8.61) | Age, sex, impaired glucose tolerance, dyslipidaemia, cigarette smoking, physical inactivity, left ventricular hypertrophy and function on echocardiography |
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Use of blood pressure-lowering medications | Yes vs. no | 2.03 (1.74–2.37) | Age, sex, foreign-born, waist circumference, systolic blood pressure, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Brouwers F, 2013, the Netherlands | Prevention of Renal and Vascular End-stage Disease (PREVEND) | 1997–1998–2010, 11.5 years of follow-up | 8592 men and women, age 28–75 years: 374 HF cases | Hypertension | Yes vs. no | 1.17 (0.77–1.77) | Age, sex, obesity, diabetes, smoking, MI, atrial fibrillation, hypercholesterolemia, cystatine, UAE, hs-CRP, NT-proBNP, hs-TnT |
| Eaton CB, 2016, USA | Women's Health Initiative | 1993–1998–2015, 13.2 years of follow-up | 42170 post-menopausal women, age 50–79 years: 1952 HF cases | Hypertension, HFpEF Hypertension, HFrEF Hypertension, Whites, HFpEF Hypertension, Whites, HFrEF Hypertension, African Americans, HFpEF Hypertension, African Americans, HFrEF Hypertension, Hispanics, HFpEF Hypertension, Hispanics, HFrEF | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. noYes vs. no Yes vs. no Yes vs. no | 1.57 (1.33–1.86) 1.99 (1.59–2.51) 1.57 (1.30–1.90) 2.07 (1.58–2.71) 1.80 (1.22–2.67)1.60 (1.01–2.54) 1.22 (0.57–2.60) 4.24 (1.25–14.32) | Age, study component, race/ ethnicity, income, education, diabetes, heart rate, MI, CHD other than MI, stroke, smoking, dyslipidaemia, oophorectomy, cancer, BMI, smoking, physical activity, chronic lung disease, anaemia, atrial fibrillation, beta-blocker use, aspirin use, hormone therapy, alcohol, insurance, interim CHD—not MI, interim DM, interim cancer |
| Fox ER, 2016, USA | Jackson Heart Study | 2000–2004–2011, 9.1 years of follow-up | 3689 men and women, mean age 53 years: 104 HF cases | Anti-hypertensive therapy | Yes vs. no | 1.7 (0.9–3.2) | Age, sex, systolic blood pressure, diabetes, total:HDL cholesterol ratio, eGFR, smoking, BNP, ABI (subclinical disease) |
| Silverman MG, 2016, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 11.2 years of follow-up | 6781 men and women, age 45–84 years: 257 HF cases | Hypertension, HFpEF Hypertension, HFrEF | Yes vs. no Yes vs. no | 1.81 (1.14–2.90) 2.04 (1.23–3.36) | Age, sex, race/ethnicity, socioeconomic status, MESA site, |
| Jacobs L, 2017, International (USA, Italy, Scotland, Ireland, and the Netherlands, UK) | The Heart ‘OMics’ in AGEing (HOMAGE) study (The Health Aging and Body Composition Study, The PREDICTOR Study, PROSPER) | 1997–1998 2007–2010 1997–1999 3.5 years of follow-up | 10 236 men and women, mean age 74.5 years: 470 HF cases | Antihypertensive medication use | Yes vs. no | 1.65 (1.33–2.06) | Age, sex, BMI, smoking, CAD, diabetes, SBP, heart rate, serum creatinine |
| Ogunmoroti O, 2017, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 12.2 years of follow-up | 6506 men and women, age 45–84 years: 262 HF cases | Blood pressure, all Blood pressure, Whites Blood pressure, Chinese American Blood pressure, Blacks Blood pressure, Hispanics | ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 ≥140/≥90 mmHg 120–139/80–89 <120/<80 | 1.00 0.55 (0.41–0.75) 0.40 (0.27–0.57) 1.00 0.52 (0.32–0.83) 0.45 (0.27–0.75) 1.00 0.41 (0.11–1.47) 0.34 (0.09–1.25) 1.00 0.37 (0.19–0.72) 0.40 (0.19–0.85) 1.00 1.01 (0.57–1.79) 0.33 (0.13–0.82) | Age, sex, race/ethnicity (all), education, income, health insurance |
| Myers J, 2017, USA | Veterans Exercise Testing Study | 1987–2014–NA, 12.3 years of follow-up | 21 080 men and women, mean age 58.3 years: 1902 HF cases | Hypertension | Yes vs. no | 1.80 (1.59–2.04) | Age, BMI, ethnicity, beta-blockers, calcium-channel blockers, angiotensin-converting enzymes, angiotensin receptor blockers, aspirin, diuretics, lipid-lowering agents, hypoglycaemic agents, smoking, diabetes, chronic kidney failure, HIV/AIDS |
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK DanMONICA Moli-sani Northern Sweden MONICA | 1982–2002–2010 1982–1984, 1986–1987, 1991–1992, –2010, 2005–2011 1986–2011, 12.7 years of follow-up (across cohorts) | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Antihypertensive medication use, men Antihypertensive medication use, women | Yes vs. noYes vs. no | 1.49 (1.34–1.64)1.47 (1.33–1.61) | Age, BMI, systolic blood pressure, total cholesterol, diabetes, daily smoking |
| Wang ID, 2019, Taiwan | Taiwan National Health Insurance Research Database | 2000–2013, 10.44 years of follow-up | 40 000 men and women, age ≥20 years: 6185 HF cases | Hypertension | Yes vs. no | 1.60 (1.30–1.87) | Age, sex, non-apnoea sleep disorder, diabetes mellitus, hyperlipidaemia, chronic kidney disease, IHD, stroke, obesity, anxiety, depression |
| Uijl A, 2019, the Netherlands | EPIC-Netherlands | 1993–1997–NA, 15.2 years of follow-up | 37 803 men and women, age 20–70 years: 690 HF cases | Blood pressure | ≥140/≥90 mmHg 120 to <140/80 to <90, or treated <120/80 <120/<80, not treated | 1.00 0.62 (0.52–0.74) 0.72 (0.58–0.89) | Age, sex, education, blood glucose, smoking status, BMI, physical activity, diet, blood cholesterol |
| Uijl A, 2019, UK | CALIBER | 2000–2010, 5.8 years of follow-up | 871 687 men and women, age ≥55 years: 47 987 HF cases | Hypertension, men, age 55–64 years Hypertension, men, age 65–74 years Hypertension, men, age ≥75 years Hypertension, women, age 55–64 years Hypertension, women, age 65–74 years Hypertension, women, age ≥75 years | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.14 (1.07–1.22) 1.03 (0.97–1.09) 1.10 (1.05–1.15) 1.09 (1.00–1.19) 0.98 (0.92–1.04) 1.02 (0.99–1.07) | Age, haemoglobin, total white blood cells, total cholesterol, triglycerides, albumin, creatinine, ethnicity, smoking habits, multiple deprivation index, blood pressure-lowering medication, lipid-lowering drugs, COPD, atrial fibrillation, obesity, sedentary lifestyle, diabetes |
| Lee H, 2019, Korea | Korea National Health Insurance Research Database | 2003–2007–2017, 9.75 years of follow-up | 15 508 537 men and women, age 20–94 years: 21 535 HF cases | Hypertension, age 20–34 years Hypertension, age 35–49 years Hypertension, age 50–64 years Hypertension, age 65–79 years Hypertension, age 80–94 years | Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension Normal BP Elevated BP Stage 1 hypertension Stage 2 hypertension | 1.00 1.20 (0.90–1.60) 1.40 (1.15–1.71) 3.04 (2.42–3.84) 1.00 1.20 (1.04–1.39) 1.29 (1.17–1.44) 2.14 (1.91–2.40) 1.00 1.07 (0.97–1.18) 1.18 (1.10–1.27) 1.58 (1.47–1.69) 1.00 1.00 (0.92–1.07) 1.10 (1.04–1.16)1.26 (1.19–1.33) 1.00 1.12 (0.91–1.38) 1.14 (0.96–1.32) 1.22 (1.06–1.41) | Age, sex, household income, Charlson comorbidity index, use of glucose-lowering drugs, use of lipid-lowering drugs, smoking, alcohol, exercise, BMI, fasting glucose, total cholesterol |
| Kubicki M, 2020, USA | Southern Community Cohort Study | 2002–2009–NA, 5.2–6.7 years of follow-up | 27 078 men and women, age 56 years: 4341 HF cases | Hypertension, all Hypertension, Black men Hypertension, Black women Hypertension, White men Hypertension, White women | Yes vs. no Yes vs. no Yes vs. no Yes vs. no Yes vs. no | 1.69 (1.59–1.84) 2.07 (1.75–2.45) 1.64 (1.43–1.87) 1.45 (1.16–1.83) 1.61 (1.34–1.92) | Age, sex, race, smoking, BMI, poor diet, diabetes, high cholesterol, physical activity |
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Hypertension | Yes vs. no | 1.31 (0.80–2.15) | Hyperlipidaemia, diabetes, sedentary lifestyle, smoking, BMI |
| Mefford MT, 2020, USA | REasons for Geographic And Racial Differences in Stroke Study (REGARDS) | 2003–2007–2015, 8.3 years of follow-up | 25 770 men and women, age ≥45 years: 947 HF cases | Hypertension, all, Whites Hypertension, HFpEF, Whites Hypertension, HFrEF, Whites Hypertension duration, Whites Hypertension control, Whites Hypertension, all, Blacks Hypertension, HFpEF, Blacks Hypertension, HFrEF, Blacks Hypertension duration, Blacks Hypertension control, Blacks | Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled Yes vs. no Yes vs. no Yes vs. no No Undetermined <10 years ≥10 years No Untreated Controlled Uncontrolled | 1.90 (1.49–2.41) 2.01 (1.34–3.01) 1.69 (1.23–2.33) 1.00 1.59 (1.19–2.11) 1.87 (1.42–2.46) 2.21 (1.70–2.89) 1.00 1.52 (1.14–2.04) 1.93 (1.44–2.58) 2.27 (1.74–2.97) 2.36 (1.53–3.65) 2.70 (1.25–5.83) 2.29 (1.26–4.15) 1.00 1.55 (0.93–2.58) 2.13 (1.33–3.42) 2.96 (1.89–4.64) 1.00 1.50 (0.89–2.54) 2.01 (1.22–3.29) 2.93 (1.86–4.63) | Age, sex, BMI, smoking, diabetes, reduced eGFR, total cholesterol, statin use, income, region of residence, health insurance, physical activity, perceived stress, depressive symptoms |
| Vasan RS, 2021, USA | Atherosclerosis Risk in Communities Study (ARIC) | 1993–1996–NA, 19.0 years of follow-up | 1871 Black men and women, mean age 59 years: 309 HF cases | Hypertension | Yes vs. no | 1.73 (1.34–2.23) | Age, sex, BMI, diabetes mellitus, smoking status, total: HDL cholesterol ratio |
| Suzuki Y, 2022, Japan | JMDC Claims Database | 2005–2020, 3.3 years of follow-up | 2 612 570 men and women, age 20–75 years: 43 415 HF cases | Hypertension, age 20–49 years, all Hypertension, age 50–59 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.35 (1.31–1.40) 2.03 (1.90–2.16) 1.96 (1.81–2.11) 3.10 (2.95–3.25) 1.00 1.28 (1.23–1.33) 1.63 (1.52–1.75) 1.72 (1.60–1.84) 2.12 (2.02–2.23) | Age, sex, obesity, diabetes, dyslipidaemia, cigarette smoking, alcohol consumption |
| Hypertension, age 60–75 years Hypertension, age 20–49 years, men Hypertension, age 50–59 years Hypertension, age 60–75 years Hypertension, age 20–49 years, women Hypertension, age 50–59 years Hypertension, age 60–75 years | Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH Non-hypertension Stage 1 IDH ISH SDH | 1.00 1.14 (1.08–1.21) 1.36 (1.19–1.54) 1.44 (1.34–1.56) 1.72 (1.60–1.85) 1.00 1.35 (1.30–1.41) 2.03 (1.89–2.19) 1.98 (1.81–2.17) 3.16 (2.99–3.34) 1.00 1.28 (1.22–1.34) 1.62 (1.49–1.75) 1.79 (1.64–1.96) 2.16 (2.03–2.29) 1.00 1.11 (1.01–1.19) 1.27 (1.10–1.47) 1.43 (1.30–1.57) 1.72 (1.57–1.87) 1.00 1.37 (1.29–1.46) 1.99 (1.71–2.31) 1.95 (1.70–2.23) 2.93 (2.67–3.22) 1.00 1.29 (1.20–1.38) 1.76 (1.49–2.08) 1.60 (1.42–1.80) 2.04 (1.85–2.25) 1.00 1.20 (1.08–1.32) 1.69 (1.29–2.21) 1.45 (1.28–1.64) 1.68 (1.46–1.93) | |||||
| Rastogi, 2022, UK | UK Biobank | 2006–2010–NA, 11.8 years of follow-up | 500 001 men and women, age 37–73 years: 14 216 HF cases | Hypertension, patients with history of MI Hypertension, patients without history of MI | Yes vs. no Yes vs. no | 1.14 (1.08–1.22) 1.61 (1.54–1.69) | Age, sex, eGFR, HbA1c, BMI, smoking status, type 2 diabetes |
| Vasan RS, 2022, USA | Framingham Heart Study | 1965–1989, 15 years of follow-up 1990–2014, 13.5 years of follow-up | 7500 men and women, mean age 47.6 years: 624 HF cases 9540 men and women, mean age 47.6 years: 875 HF cases | Hypertension, epoch 1 Hypertension, epoch 2 Hypertension, epoch 2, HFpEF Hypertension, epoch 2, HFrEF | Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension Normal Intermediate Hypertension | 1.00 1.38 (1.06–1.79) 2.17 (1.70–2.77) 1.00 1.54 (1.29–1.84) 2.11 (1.77–2.52) 1.00 1.43 (1.07–1.91) 2.11 (1.59–2.81) 1.00 1.66 (1.28–2.15) 2.06 (1.59–2.67) | Age, sex, BMI, diabetes |
ACE, angiotensin-converting enzyme; AIDS, acquired immunodeficiency syndrome; AMI, acute myocardial infarction; ARIC, Atherosclerosis Risk in Communities Study; BMI, body mass index; CAD, coronary artery disease; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; DM, diabetes mellitus; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; FH, family history; Hb, haemoglobin; HDL, high-density lipoprotein; HF, heart failure; HIV, human immunodeficiency virus; IHD, ischaemic heart disease; LDL, low-density lipoprotein; LVH, left ventricular hypertrophy; MESA, Multi-Ethnic Study of Atherosclerosis; MI, myocardial infarction; NA, not available; NT-proBNP, B-type natriuretic peptide; hs-TnT, high-sensitivity troponin.
Prospective studies of blood pressure and heart failure
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | Relative risk (95% confidence interval) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Gottdiener J, 2000, USA | Cardiovascular Health Study | 1989–1990–1994–1995, 6.3 years of follow-up | 5625 men and women, age 65–100 years: 597 HF cases | Systolic blood pressure | Per 20 mmHg | 1.09 (1.01–1.18) | Age, sex, CHD, stroke or TIA, diabetes, FEV, creatinine, CRP, ankle-arm index, ECG atrial fibrillation, ECG left ventricular mass, major ST-T segment abnormality, minor ST-T segment abnormality, internal carotid, abnormal LV ejection fraction |
| Haider AW, 2003, USA | Framingham Heart Study | 1968–1973–1994, 17.4 years of follow-up | 2040 men and women, age 50–79 years: 234 HF cases | Systolic blood pressure | 87–125 mmHg | 1.00 | Age, sex, smoking, left ventricular hypertrophy, BMI, diabetes mellitus, HDL cholesterol, heart rate |
| 126–141 | 1.48 (0.99–2.21) | ||||||
| Diastolic blood pressure | ≥142 | 3.07 (2.10–4.49) | |||||
| 49–74 mmHg | 1.00 | ||||||
| 75–82 | 1.33 (0.94–1.87) | ||||||
| ≥83 | 1.67 (1.18–2.37) | ||||||
| Ingelsson E, 2006, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1990–1995–2002, 9.1 years of follow-up | 951 men, age 70 years: 70 HF cases | Office measurement: | Antihypertensive treatment, prior acute myocardial infarction, diabetes, smoking, BMI, serum cholesterol | ||
| Diastolic blood pressure | Per 10 mmHg | 1.16 (0.91–1.49) | |||||
| Mosley WJ, 2007, USA | Chicago Heart Association Detection Project Study | 1967–1973–2002, 33 years of follow-up | 36 314 men and women, mean age 39 years: 599 HF cases | Systolic blood pressure, | Per 18.5 mmHg | 1.32 (1.28–1.36) | Age, sex, pulse pressure, BMI, smoking, total cholesterol |
| Diastolic blood pressure | Per 11.6mmHg | 1.34 (1.29–1.39) | |||||
| Butler J, 2008, USA | Health ABC | 1997–1998–NA, 6.5 years of follow-up | 2935 men and women, mean age 73.6 years: 258 HF cases | Systolic blood pressure | Per 1 mmHg | 1.02 (1.01–1.02) | Age, CHD, smoking status, creatinine, heart rate, albumin, glucose, VHD, left ventricular hypertrophy |
| Nichols GA, 2009, USA | Kaiser Permanente Northwest medical records | 1997–1998–2005, 6.5 years of follow-up | 10 113 men and women, age ≥50 years: 809 HF cases | Systolic blood pressure | Per 5 mmHg | 1.02 (1.01–1.04) | Age, sex, fasting glucose, BMI, CVD diagnosis, total cholesterol, smoking, eGFR, ACE/ARB inhibitor use, beta-blocker use, statin use, hydrochlorothiazide use, diabetes |
| Diastolic blood pressure | Per 5 mmHg | 0.96 (0.93–0.99) | |||||
| Bibbins-Domingo B, 2009, USA | The CARDIA study | 1985–1986–NA, 20 years of follow-up | 5115 Black men and women, age 18–30 years: 27 HF cases | Systolic blood pressure | Per 10.9 mmHg | 1.7 (1.4–2.0) | Age, sex, diabetes, BMI, cholesterol, alcohol, LVH, smoking |
| Diastolic blood pressure | Per 10.0 mmHg | 1.8 (1.52.2) | |||||
| Britton KA, 2009, USA | Physicians' Health Study 1 | 1982–2008, 20.7 years of follow-up | 18 876 men, mean age 53.8 years: 1098 HF cases | Systolic blood pressure | Not treated: | Age, smoking, BMI, alcohol, diabetes, atrial fibrillation, physical activity, egg intake, breakfast cereal intake | |
| <120 mmHg | 1.00 | ||||||
| 120–129 | 1.10 (0.89–1.37) | ||||||
| 130–139 | 1.35 (1.09–1.68) | ||||||
| Treated: | |||||||
| <130 | 1.71 (1.22–2.40) | ||||||
| 130–139 | 2.30 (1.79–2.95) | ||||||
| 140–149 | 1.66 (1.32–2.09) | ||||||
| 150–159 | 2.02 (1.51–2.71) | ||||||
| ≥160 | 2.46 (1.67–3.63) | ||||||
| Conen D, 2010, USA | Established Populations for Epidemiologic Studies in the Elderly (EPESE) | 1982–1983–1992, 4.3 years of follow-up | 4655 men and women, age 65 years: 642 HF cases | Systolic blood pressure | <120 mmHg | 1.00 | Age, sex, diabetes mellitus, CHD, valvular heart disease, atrial fibrillation, antihypertensive drug use, mutual adjustment between systolic and diastolic blood pressure |
| 120–139 | 1.17 (0.91–1.52) | ||||||
| 140–159 | 1.02 (0.77–1.35) | ||||||
| ≥160 | 1.61 (1.17–2.20) | ||||||
| Diastolic blood pressure | <70 mmHg | 1.46 (1.20–1.76) | |||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.11 (0.90–1.38) | ||||||
| ≥90 | 1.09 (0.78–1.51) | ||||||
| Fedorowski A, 2011, Sweden | Malmö Preventive Project | 1974–1992 - 2006, 24 years follow-up | 32 669 men and women, mean age: 26–61 years: 1293 HF cases | Systolic blood pressure | Per 10 mmHg | 1.17 (1.14–1.20) | Age, gender, antihypertensive treatment, hypertension, cholesterol, diabetes, BMI, smoking |
| Diastolic blood pressure | 71.9 mmHg | 1.00 | |||||
| 80.0 | 1.23 (0.99–1.50) | ||||||
| 87.5 | 1.52 (1.24–1.85) | ||||||
| 100.0 | 2.05 (1.65–2.54) | ||||||
| Butler J, 2011, USA | Cardiovascular Health Study | 1989–1990/1992–1992–NA | 4408 men and women, mean age 72.8 years: 493 HF cases | Systolic blood pressure, all | <120 mmHg | 1.00 | Age, sex, cohort, race/ethnicity, BMI, CHD, smoking, diabetes, electrocardiographic left ventricular hypertrophy, heart rate, fasting glucose, creatinine, albumin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride levels |
| 120–139 | 1.63 (1.23–2.16) | ||||||
| 140–159 | 2.21 (1.65–2.96) | ||||||
| Health ABC Study | 1997–1998–NA, 10 years of follow-up | ≥160 | 2.60 (1.85–3.64) | ||||
| Systolic blood pressure, men | <120 mmHg | 1.00 | |||||
| 120–139 | 1.25 (0.88–1.77) | ||||||
| 140–159 | 1.84 (1.28–2.64) | ||||||
| ≥160 | 2.11 (1.38–3.23) | ||||||
| Systolic blood pressure, women | <120 mmHg | 1.00 | |||||
| 120–139 | 2.51 (1.55–4.06) | ||||||
| 140–159 | 3.09 (1.87–5.11) | ||||||
| ≥160 | 3.74 (2.15–6.50) | ||||||
| Systolic blood pressure, Whites | <120 mmHg | 1.00 | |||||
| 120–139 | 1.62 (1.20–2.19) | ||||||
| 140–159 | 2.17 (1.59–2.97) | ||||||
| ≥160 | 2.59 (1.81–3.72) | ||||||
| Systolic blood pressure, Blacks | <120 mmHg | 1.00 | |||||
| 120–139 | 1.68 (0.73–3.87) | ||||||
| 140–159 | 2.49 (1.07–5.78) | ||||||
| ≥160 | 2.69 (1.05–6.91) | ||||||
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Systolic blood pressure | Per 10 mmHg | 1.15 (1.11–1.20) | Age, sex, foreign-born, waist circumference, use of blood pressure-lowering medications, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Ho JE, 2013, USA | Framingham Heart Study | 1981–2008, 8 years of follow-up | 6340 men and women, age mean age 60.7 years: 512 HF cases | Systolic blood pressure, HFpEF | 19.79 mmHg | 1.17 (1.03–1.34) | Age, sex |
| Diastolic blood pressure, HFpEF | Per 10.07 mmHg | 0.92 (0.80–1.05) | |||||
| Systolic blood pressure, HFrEF | 19.79 mmHg | 1.30 (1.16–1.46) | |||||
| Diastolic blood pressure, HFrEF | Per 10.07 mmHg | 0.97 (0.86–1.10) | |||||
| Rapsomaniki E, 2014, UK | CALIBER | 1997–2010–NA, 5.2 years of follow-up | 1 937 360 men and women, age 30–100 years: 10 437 HF cases | Systolic blood pressure, all | Per 20 mmHg | 1.27 (1.23–1.32) | Age, age group, interaction between blood pressure and age, sex, primary care practice |
| Diastolic blood pressure, all | Per 10 mmHg | 1.23 (1.19–1.28) | |||||
| Systolic blood pressure, men | Per 20 mmHg | 1.30 (1.23–1.37) | |||||
| Diastolic blood pressure, men | Per 10 mmHg | 1.25 (1.18–1.32) | |||||
| Systolic blood pressure, women | Per 20 mmHg | 1.26 (1.20–1.31) | |||||
| Diastolic blood pressure, women | Per 10 mmHg | 1.22 (1.17–1.28) | |||||
| Chirinos JA, 2015, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 8.5 years of follow-up | 6124 men and women, age 45–84 years: 135 HF cases | Systolic blood pressure | 21.4 mmHg | 1.28 (1.00–1.62) | Ethnicity, antihypertensive medication use, eGFR, total cholesterol, HDL cholesterol, smoking status |
| Diastolic blood pressure | 10.3 mmHg | 0.77 (0.60–0.99) | |||||
| Randolph C, 2016, USA | Jackson Heart Study | 2000–2011, 8 years of follow-up | 5280 Black men and women, median age 56 years: 340 HF cases | Systolic blood pressure | Per 10 mmHg | 1.10 (1.06–1.16) | Age, diabetes, BMI, LVH, high cholesterol |
| Diastolic blood pressure | Per 10 mmHg | 0.92 (0.81–1.04) | |||||
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK | 1982–2002–2010 | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Systolic blood pressure, men | Per 21 mmHg | 1.09 (1.05–1.14) | BMI, antihypertensive medication use, total cholesterol, diabetes, daily smoking |
| Systolic blood pressure, women | Per 21 mmHg | 1.19 (1.14–1.24) | |||||
| DanMONICA | 1982–1984, 1986–1987, 1991–1992–2010, 2005–2011 | ||||||
| Moli-sani | |||||||
| Northern Sweden MONICA | 1986–2011, 12.7 years of follow-up (across cohorts) | ||||||
| Choi YJ, 2019, Korea | Korea National Health Insurance Research Database | 2002–2003–2013, 6.7 years of follow-up | 290 600 men and women, age ≥40 years: 5248 HF cases | Systolic blood pressure | <90 mmHg | 2.70 (1.36–5.37) | Age, sex, BMI, income levels, diabetes, dyslipidaemia, malignancy, chronic renal disease, chronic liver disease, chronic pulmonary disease, rheumatic disease, smoking, statin use |
| 90–99 | 1.00 | ||||||
| 100–109 | 1.31 (0.89–1.93) | ||||||
| 110–119 | 1.43 (0.99–2.06) | ||||||
| 120–129 | 1.60 (1.11–2.29) | ||||||
| 130–139 | 1.99 (1.38–2.86) | ||||||
| 140–149 | 2.47 (1.71–3.57) | ||||||
| 150–159 | 2.89 (1.98–4.21) | ||||||
| ≥160 | 4.16 (2.86–6.06) | ||||||
| Diastolic blood pressure | <40 mmHg | 5.80 (0.79–42.50) | |||||
| 40–49 | 0.49 (0.07–3.60) | ||||||
| 50–59 | 1.00 | ||||||
| 60–69 | 1.13 (0.78–1.61) | ||||||
| 70–79 | 1.20 (0.85–1.70) | ||||||
| 80–89 | 1.32 (0.93–1.87) | ||||||
| 90–99 | 2.00 (1.40–2.85) | ||||||
| ≥100 | 2.55 (1.76–3.68) | ||||||
| Sillars A, 2020, UK | UK Biobank | 2007–2010–NA, 8.2 years of follow-up | 33 595 men and women, age 40–60 years: 1812 HF cases | Systolic blood pressure, men | ≤125 mmHg | 1.00 | Age, diabetes, BMI, pulse pressure, women, sleep duration, smoking, physical activity |
| >125 to 138 | 0.88 (0.69–1.12) | ||||||
| >138 to 152 | 1.14 (0.92–1.41) | ||||||
| >152 | 1.23 (1.00–1.51) | ||||||
| Diastolic blood pressure, men | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.83 (0.69–1.00) | ||||||
| >82 to 89 | 0.85 (0.71–1.02) | ||||||
| >89 | 0.91 (0.76–1.08) | ||||||
| Systolic blood pressure, women | ≤125 mmHg | 1.00 | |||||
| >125 to 138 | 1.16 (0.88–1.53) | ||||||
| >138 to 152 | 1.45 (1.12–1.88) | ||||||
| >152 | 1.53 (1.18–1.99) | ||||||
| Diastolic blood pressure, women | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.86 (0.68–1.09) | ||||||
| >82 to 89 | 1.06 (0.84–1.33) | ||||||
| >89 | 1.16 (0.92–1.47) | ||||||
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Systolic blood pressure | Per 10 mmHg | 1.12 (0.98–1.27) | BMI, smoking, sedentary lifestyle, glucose, cholesterol |
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1913 | 1963–1994, 21 years of follow-up | 855 men, age 50 years: 80 HF cases | Systolic blood pressure, <median | Per 10 mmHg | 1.09 (0.75–1.59) | Age |
| Systolic blood pressure, ≥median | Per 10 mmHg | 1.10 (0.97–1.24) | |||||
| Diastolic blood pressure | Per 5 mmHg | 1.09 (1.00–1.18) | |||||
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 797 men, age 50 years: 42 HF cases | Diastolic blood pressure | Per 5 mmHg | 1.18 (1.03–1.35) | Age |
| Cordola Hsu AR, 2021, USA | Women's Health Initiative | 1993–1998–NA, 11.28 years of follow-up | 19 412 women, age 50–79 years: 455 HF cases | Systolic blood pressure | Per 17.58 mmHg | 1.47 (1.32–1.64) | Age, race/ethnicity, income, diabetes, ever smoking, total healthy eating index score, recreational physical activity, total cholesterol |
| Diastolic blood pressure | Per 9.25 mmHg | 0.94 (0.84–1.05) | |||||
| Lind L, 2021, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–2014, ∼40 years of follow-up | 2322 men, age 50 years: 405 HF cases | Systolic blood pressure | Per 10 mmHg | 1.35 (1.23–1.48) | Triglycerides, HDL cholesterol, LDL cholesterol, BMI, diabetes, smoking |
| Cohen LH, 2021, USA | Atherosclerosis Risk in Communities | NA–NA, 12 years of follow-up | 23 861 men and women, mean age 61.8 years: 3666 HF cases | Systolic blood pressure, HFrEF | <120 mmHg | 1.00 | Study cohort, birth year, race/ethnicity, sex, smoking status, use of lipid-lowering medications, antihypertensive medications, anti-diabetic medications, BMI, HDL cholesterol |
| 120–129 | 1.17 (0.90–1.52) | ||||||
| 130–139 | 1.44 (1.03–2.01) | ||||||
| Cardiovascular Health Study | ≥140 | 1.74 (1.15–2.65) | |||||
| Diastolic blood pressure, HFrEF | <70 mmHg70–79 | 1.000.96 (0.72–1.29) | |||||
| Health ABC Study | 80–89 | 0.91 (0.62–1.34) | |||||
| Multi-Ethnic Study of Atherosclerosis | ≥90 | 1.07 (0.52–2.19) | |||||
| Systolic blood pressure, HFpEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.27 (1.03–1.58) | ||||||
| 130–139 | 1.53 (1.18–1.98) | ||||||
| ≥140 | 2.25 (1.51–3.36) | ||||||
| Diastolic blood pressure, HFpEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.74 (0.57–0.95) | ||||||
| 80–89 | 0.59 (0.42–0.83) | ||||||
| ≥90 | 0.61 (0.26–1.41) | ||||||
| Systolic blood pressure, HFbEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.21 (0.74–1.97) | ||||||
| 130–139 | 1.39 (0.78–2.45) | ||||||
| ≥140 | 2.02 (0.94–4.34) | ||||||
| Diastolic blood pressure, HFbEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.88 (0.51–1.52) | ||||||
| 80–89 | 0.90 (0.43–1.86) | ||||||
| ≥90 | 1.29 (0.30–5.58) | ||||||
| Itoga NK, 2021, USA | Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) | 1994–2002, 4.4 years of follow-up | 33 357 men and women, age ≥55 years: 866 HF cases | Systolic blood pressure | <120 mmHg | 1.44 (1.14–1.83) | Age, sex, race, BMI, ethnicity, smoking status, randomized blood pressure medication group, history of ECG changes, MI or stroke, coronary vascularization, other atherosclerotic disease, baseline aspirin use, diabetes mellitus, CHD, baseline antihypertensive medication use |
| 120–129 | 1.00 | ||||||
| 130–139 | 1.16 (0.95–1.41) | ||||||
| 140–149 | 1.14 (0.92–1.42) | ||||||
| 150–159 | 1.29 (1.02–1.64) | ||||||
| ≥160 | 1.96 (1.58–2.43) | ||||||
| Diastolic blood pressure | <60 mmHg | 1.42 (1.06–1.91) | |||||
| 60–69 | 1.13 (0.95–1.36) | ||||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.10 (0.95–1.28) | ||||||
| 90–99 | 1.22 (0.99–1.52) | ||||||
| ≥100 | 1.88 (1.36–2.59) |
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | Relative risk (95% confidence interval) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Gottdiener J, 2000, USA | Cardiovascular Health Study | 1989–1990–1994–1995, 6.3 years of follow-up | 5625 men and women, age 65–100 years: 597 HF cases | Systolic blood pressure | Per 20 mmHg | 1.09 (1.01–1.18) | Age, sex, CHD, stroke or TIA, diabetes, FEV, creatinine, CRP, ankle-arm index, ECG atrial fibrillation, ECG left ventricular mass, major ST-T segment abnormality, minor ST-T segment abnormality, internal carotid, abnormal LV ejection fraction |
| Haider AW, 2003, USA | Framingham Heart Study | 1968–1973–1994, 17.4 years of follow-up | 2040 men and women, age 50–79 years: 234 HF cases | Systolic blood pressure | 87–125 mmHg | 1.00 | Age, sex, smoking, left ventricular hypertrophy, BMI, diabetes mellitus, HDL cholesterol, heart rate |
| 126–141 | 1.48 (0.99–2.21) | ||||||
| Diastolic blood pressure | ≥142 | 3.07 (2.10–4.49) | |||||
| 49–74 mmHg | 1.00 | ||||||
| 75–82 | 1.33 (0.94–1.87) | ||||||
| ≥83 | 1.67 (1.18–2.37) | ||||||
| Ingelsson E, 2006, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1990–1995–2002, 9.1 years of follow-up | 951 men, age 70 years: 70 HF cases | Office measurement: | Antihypertensive treatment, prior acute myocardial infarction, diabetes, smoking, BMI, serum cholesterol | ||
| Diastolic blood pressure | Per 10 mmHg | 1.16 (0.91–1.49) | |||||
| Mosley WJ, 2007, USA | Chicago Heart Association Detection Project Study | 1967–1973–2002, 33 years of follow-up | 36 314 men and women, mean age 39 years: 599 HF cases | Systolic blood pressure, | Per 18.5 mmHg | 1.32 (1.28–1.36) | Age, sex, pulse pressure, BMI, smoking, total cholesterol |
| Diastolic blood pressure | Per 11.6mmHg | 1.34 (1.29–1.39) | |||||
| Butler J, 2008, USA | Health ABC | 1997–1998–NA, 6.5 years of follow-up | 2935 men and women, mean age 73.6 years: 258 HF cases | Systolic blood pressure | Per 1 mmHg | 1.02 (1.01–1.02) | Age, CHD, smoking status, creatinine, heart rate, albumin, glucose, VHD, left ventricular hypertrophy |
| Nichols GA, 2009, USA | Kaiser Permanente Northwest medical records | 1997–1998–2005, 6.5 years of follow-up | 10 113 men and women, age ≥50 years: 809 HF cases | Systolic blood pressure | Per 5 mmHg | 1.02 (1.01–1.04) | Age, sex, fasting glucose, BMI, CVD diagnosis, total cholesterol, smoking, eGFR, ACE/ARB inhibitor use, beta-blocker use, statin use, hydrochlorothiazide use, diabetes |
| Diastolic blood pressure | Per 5 mmHg | 0.96 (0.93–0.99) | |||||
| Bibbins-Domingo B, 2009, USA | The CARDIA study | 1985–1986–NA, 20 years of follow-up | 5115 Black men and women, age 18–30 years: 27 HF cases | Systolic blood pressure | Per 10.9 mmHg | 1.7 (1.4–2.0) | Age, sex, diabetes, BMI, cholesterol, alcohol, LVH, smoking |
| Diastolic blood pressure | Per 10.0 mmHg | 1.8 (1.52.2) | |||||
| Britton KA, 2009, USA | Physicians' Health Study 1 | 1982–2008, 20.7 years of follow-up | 18 876 men, mean age 53.8 years: 1098 HF cases | Systolic blood pressure | Not treated: | Age, smoking, BMI, alcohol, diabetes, atrial fibrillation, physical activity, egg intake, breakfast cereal intake | |
| <120 mmHg | 1.00 | ||||||
| 120–129 | 1.10 (0.89–1.37) | ||||||
| 130–139 | 1.35 (1.09–1.68) | ||||||
| Treated: | |||||||
| <130 | 1.71 (1.22–2.40) | ||||||
| 130–139 | 2.30 (1.79–2.95) | ||||||
| 140–149 | 1.66 (1.32–2.09) | ||||||
| 150–159 | 2.02 (1.51–2.71) | ||||||
| ≥160 | 2.46 (1.67–3.63) | ||||||
| Conen D, 2010, USA | Established Populations for Epidemiologic Studies in the Elderly (EPESE) | 1982–1983–1992, 4.3 years of follow-up | 4655 men and women, age 65 years: 642 HF cases | Systolic blood pressure | <120 mmHg | 1.00 | Age, sex, diabetes mellitus, CHD, valvular heart disease, atrial fibrillation, antihypertensive drug use, mutual adjustment between systolic and diastolic blood pressure |
| 120–139 | 1.17 (0.91–1.52) | ||||||
| 140–159 | 1.02 (0.77–1.35) | ||||||
| ≥160 | 1.61 (1.17–2.20) | ||||||
| Diastolic blood pressure | <70 mmHg | 1.46 (1.20–1.76) | |||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.11 (0.90–1.38) | ||||||
| ≥90 | 1.09 (0.78–1.51) | ||||||
| Fedorowski A, 2011, Sweden | Malmö Preventive Project | 1974–1992 - 2006, 24 years follow-up | 32 669 men and women, mean age: 26–61 years: 1293 HF cases | Systolic blood pressure | Per 10 mmHg | 1.17 (1.14–1.20) | Age, gender, antihypertensive treatment, hypertension, cholesterol, diabetes, BMI, smoking |
| Diastolic blood pressure | 71.9 mmHg | 1.00 | |||||
| 80.0 | 1.23 (0.99–1.50) | ||||||
| 87.5 | 1.52 (1.24–1.85) | ||||||
| 100.0 | 2.05 (1.65–2.54) | ||||||
| Butler J, 2011, USA | Cardiovascular Health Study | 1989–1990/1992–1992–NA | 4408 men and women, mean age 72.8 years: 493 HF cases | Systolic blood pressure, all | <120 mmHg | 1.00 | Age, sex, cohort, race/ethnicity, BMI, CHD, smoking, diabetes, electrocardiographic left ventricular hypertrophy, heart rate, fasting glucose, creatinine, albumin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride levels |
| 120–139 | 1.63 (1.23–2.16) | ||||||
| 140–159 | 2.21 (1.65–2.96) | ||||||
| Health ABC Study | 1997–1998–NA, 10 years of follow-up | ≥160 | 2.60 (1.85–3.64) | ||||
| Systolic blood pressure, men | <120 mmHg | 1.00 | |||||
| 120–139 | 1.25 (0.88–1.77) | ||||||
| 140–159 | 1.84 (1.28–2.64) | ||||||
| ≥160 | 2.11 (1.38–3.23) | ||||||
| Systolic blood pressure, women | <120 mmHg | 1.00 | |||||
| 120–139 | 2.51 (1.55–4.06) | ||||||
| 140–159 | 3.09 (1.87–5.11) | ||||||
| ≥160 | 3.74 (2.15–6.50) | ||||||
| Systolic blood pressure, Whites | <120 mmHg | 1.00 | |||||
| 120–139 | 1.62 (1.20–2.19) | ||||||
| 140–159 | 2.17 (1.59–2.97) | ||||||
| ≥160 | 2.59 (1.81–3.72) | ||||||
| Systolic blood pressure, Blacks | <120 mmHg | 1.00 | |||||
| 120–139 | 1.68 (0.73–3.87) | ||||||
| 140–159 | 2.49 (1.07–5.78) | ||||||
| ≥160 | 2.69 (1.05–6.91) | ||||||
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Systolic blood pressure | Per 10 mmHg | 1.15 (1.11–1.20) | Age, sex, foreign-born, waist circumference, use of blood pressure-lowering medications, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Ho JE, 2013, USA | Framingham Heart Study | 1981–2008, 8 years of follow-up | 6340 men and women, age mean age 60.7 years: 512 HF cases | Systolic blood pressure, HFpEF | 19.79 mmHg | 1.17 (1.03–1.34) | Age, sex |
| Diastolic blood pressure, HFpEF | Per 10.07 mmHg | 0.92 (0.80–1.05) | |||||
| Systolic blood pressure, HFrEF | 19.79 mmHg | 1.30 (1.16–1.46) | |||||
| Diastolic blood pressure, HFrEF | Per 10.07 mmHg | 0.97 (0.86–1.10) | |||||
| Rapsomaniki E, 2014, UK | CALIBER | 1997–2010–NA, 5.2 years of follow-up | 1 937 360 men and women, age 30–100 years: 10 437 HF cases | Systolic blood pressure, all | Per 20 mmHg | 1.27 (1.23–1.32) | Age, age group, interaction between blood pressure and age, sex, primary care practice |
| Diastolic blood pressure, all | Per 10 mmHg | 1.23 (1.19–1.28) | |||||
| Systolic blood pressure, men | Per 20 mmHg | 1.30 (1.23–1.37) | |||||
| Diastolic blood pressure, men | Per 10 mmHg | 1.25 (1.18–1.32) | |||||
| Systolic blood pressure, women | Per 20 mmHg | 1.26 (1.20–1.31) | |||||
| Diastolic blood pressure, women | Per 10 mmHg | 1.22 (1.17–1.28) | |||||
| Chirinos JA, 2015, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 8.5 years of follow-up | 6124 men and women, age 45–84 years: 135 HF cases | Systolic blood pressure | 21.4 mmHg | 1.28 (1.00–1.62) | Ethnicity, antihypertensive medication use, eGFR, total cholesterol, HDL cholesterol, smoking status |
| Diastolic blood pressure | 10.3 mmHg | 0.77 (0.60–0.99) | |||||
| Randolph C, 2016, USA | Jackson Heart Study | 2000–2011, 8 years of follow-up | 5280 Black men and women, median age 56 years: 340 HF cases | Systolic blood pressure | Per 10 mmHg | 1.10 (1.06–1.16) | Age, diabetes, BMI, LVH, high cholesterol |
| Diastolic blood pressure | Per 10 mmHg | 0.92 (0.81–1.04) | |||||
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK | 1982–2002–2010 | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Systolic blood pressure, men | Per 21 mmHg | 1.09 (1.05–1.14) | BMI, antihypertensive medication use, total cholesterol, diabetes, daily smoking |
| Systolic blood pressure, women | Per 21 mmHg | 1.19 (1.14–1.24) | |||||
| DanMONICA | 1982–1984, 1986–1987, 1991–1992–2010, 2005–2011 | ||||||
| Moli-sani | |||||||
| Northern Sweden MONICA | 1986–2011, 12.7 years of follow-up (across cohorts) | ||||||
| Choi YJ, 2019, Korea | Korea National Health Insurance Research Database | 2002–2003–2013, 6.7 years of follow-up | 290 600 men and women, age ≥40 years: 5248 HF cases | Systolic blood pressure | <90 mmHg | 2.70 (1.36–5.37) | Age, sex, BMI, income levels, diabetes, dyslipidaemia, malignancy, chronic renal disease, chronic liver disease, chronic pulmonary disease, rheumatic disease, smoking, statin use |
| 90–99 | 1.00 | ||||||
| 100–109 | 1.31 (0.89–1.93) | ||||||
| 110–119 | 1.43 (0.99–2.06) | ||||||
| 120–129 | 1.60 (1.11–2.29) | ||||||
| 130–139 | 1.99 (1.38–2.86) | ||||||
| 140–149 | 2.47 (1.71–3.57) | ||||||
| 150–159 | 2.89 (1.98–4.21) | ||||||
| ≥160 | 4.16 (2.86–6.06) | ||||||
| Diastolic blood pressure | <40 mmHg | 5.80 (0.79–42.50) | |||||
| 40–49 | 0.49 (0.07–3.60) | ||||||
| 50–59 | 1.00 | ||||||
| 60–69 | 1.13 (0.78–1.61) | ||||||
| 70–79 | 1.20 (0.85–1.70) | ||||||
| 80–89 | 1.32 (0.93–1.87) | ||||||
| 90–99 | 2.00 (1.40–2.85) | ||||||
| ≥100 | 2.55 (1.76–3.68) | ||||||
| Sillars A, 2020, UK | UK Biobank | 2007–2010–NA, 8.2 years of follow-up | 33 595 men and women, age 40–60 years: 1812 HF cases | Systolic blood pressure, men | ≤125 mmHg | 1.00 | Age, diabetes, BMI, pulse pressure, women, sleep duration, smoking, physical activity |
| >125 to 138 | 0.88 (0.69–1.12) | ||||||
| >138 to 152 | 1.14 (0.92–1.41) | ||||||
| >152 | 1.23 (1.00–1.51) | ||||||
| Diastolic blood pressure, men | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.83 (0.69–1.00) | ||||||
| >82 to 89 | 0.85 (0.71–1.02) | ||||||
| >89 | 0.91 (0.76–1.08) | ||||||
| Systolic blood pressure, women | ≤125 mmHg | 1.00 | |||||
| >125 to 138 | 1.16 (0.88–1.53) | ||||||
| >138 to 152 | 1.45 (1.12–1.88) | ||||||
| >152 | 1.53 (1.18–1.99) | ||||||
| Diastolic blood pressure, women | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.86 (0.68–1.09) | ||||||
| >82 to 89 | 1.06 (0.84–1.33) | ||||||
| >89 | 1.16 (0.92–1.47) | ||||||
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Systolic blood pressure | Per 10 mmHg | 1.12 (0.98–1.27) | BMI, smoking, sedentary lifestyle, glucose, cholesterol |
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1913 | 1963–1994, 21 years of follow-up | 855 men, age 50 years: 80 HF cases | Systolic blood pressure, <median | Per 10 mmHg | 1.09 (0.75–1.59) | Age |
| Systolic blood pressure, ≥median | Per 10 mmHg | 1.10 (0.97–1.24) | |||||
| Diastolic blood pressure | Per 5 mmHg | 1.09 (1.00–1.18) | |||||
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 797 men, age 50 years: 42 HF cases | Diastolic blood pressure | Per 5 mmHg | 1.18 (1.03–1.35) | Age |
| Cordola Hsu AR, 2021, USA | Women's Health Initiative | 1993–1998–NA, 11.28 years of follow-up | 19 412 women, age 50–79 years: 455 HF cases | Systolic blood pressure | Per 17.58 mmHg | 1.47 (1.32–1.64) | Age, race/ethnicity, income, diabetes, ever smoking, total healthy eating index score, recreational physical activity, total cholesterol |
| Diastolic blood pressure | Per 9.25 mmHg | 0.94 (0.84–1.05) | |||||
| Lind L, 2021, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–2014, ∼40 years of follow-up | 2322 men, age 50 years: 405 HF cases | Systolic blood pressure | Per 10 mmHg | 1.35 (1.23–1.48) | Triglycerides, HDL cholesterol, LDL cholesterol, BMI, diabetes, smoking |
| Cohen LH, 2021, USA | Atherosclerosis Risk in Communities | NA–NA, 12 years of follow-up | 23 861 men and women, mean age 61.8 years: 3666 HF cases | Systolic blood pressure, HFrEF | <120 mmHg | 1.00 | Study cohort, birth year, race/ethnicity, sex, smoking status, use of lipid-lowering medications, antihypertensive medications, anti-diabetic medications, BMI, HDL cholesterol |
| 120–129 | 1.17 (0.90–1.52) | ||||||
| 130–139 | 1.44 (1.03–2.01) | ||||||
| Cardiovascular Health Study | ≥140 | 1.74 (1.15–2.65) | |||||
| Diastolic blood pressure, HFrEF | <70 mmHg70–79 | 1.000.96 (0.72–1.29) | |||||
| Health ABC Study | 80–89 | 0.91 (0.62–1.34) | |||||
| Multi-Ethnic Study of Atherosclerosis | ≥90 | 1.07 (0.52–2.19) | |||||
| Systolic blood pressure, HFpEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.27 (1.03–1.58) | ||||||
| 130–139 | 1.53 (1.18–1.98) | ||||||
| ≥140 | 2.25 (1.51–3.36) | ||||||
| Diastolic blood pressure, HFpEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.74 (0.57–0.95) | ||||||
| 80–89 | 0.59 (0.42–0.83) | ||||||
| ≥90 | 0.61 (0.26–1.41) | ||||||
| Systolic blood pressure, HFbEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.21 (0.74–1.97) | ||||||
| 130–139 | 1.39 (0.78–2.45) | ||||||
| ≥140 | 2.02 (0.94–4.34) | ||||||
| Diastolic blood pressure, HFbEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.88 (0.51–1.52) | ||||||
| 80–89 | 0.90 (0.43–1.86) | ||||||
| ≥90 | 1.29 (0.30–5.58) | ||||||
| Itoga NK, 2021, USA | Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) | 1994–2002, 4.4 years of follow-up | 33 357 men and women, age ≥55 years: 866 HF cases | Systolic blood pressure | <120 mmHg | 1.44 (1.14–1.83) | Age, sex, race, BMI, ethnicity, smoking status, randomized blood pressure medication group, history of ECG changes, MI or stroke, coronary vascularization, other atherosclerotic disease, baseline aspirin use, diabetes mellitus, CHD, baseline antihypertensive medication use |
| 120–129 | 1.00 | ||||||
| 130–139 | 1.16 (0.95–1.41) | ||||||
| 140–149 | 1.14 (0.92–1.42) | ||||||
| 150–159 | 1.29 (1.02–1.64) | ||||||
| ≥160 | 1.96 (1.58–2.43) | ||||||
| Diastolic blood pressure | <60 mmHg | 1.42 (1.06–1.91) | |||||
| 60–69 | 1.13 (0.95–1.36) | ||||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.10 (0.95–1.28) | ||||||
| 90–99 | 1.22 (0.99–1.52) | ||||||
| ≥100 | 1.88 (1.36–2.59) |
ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BMI, body mass index; CHD, coronary heart disease; CRP, C-reactive protein; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; FEV, forced expiratory volume; HDL, high-density lipoprotein; HF, heart failure; HFbEF, heart failure with borderline ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LDL, low-density lipoprotein; LV, left ventricular; LVH, left ventricular hypertrophy; MI, myocardial infarction; NA, not available; TIA, transient ischaemic attack; USA, United States of America; VHD, valvular heart disease.
Prospective studies of blood pressure and heart failure
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | Relative risk (95% confidence interval) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Gottdiener J, 2000, USA | Cardiovascular Health Study | 1989–1990–1994–1995, 6.3 years of follow-up | 5625 men and women, age 65–100 years: 597 HF cases | Systolic blood pressure | Per 20 mmHg | 1.09 (1.01–1.18) | Age, sex, CHD, stroke or TIA, diabetes, FEV, creatinine, CRP, ankle-arm index, ECG atrial fibrillation, ECG left ventricular mass, major ST-T segment abnormality, minor ST-T segment abnormality, internal carotid, abnormal LV ejection fraction |
| Haider AW, 2003, USA | Framingham Heart Study | 1968–1973–1994, 17.4 years of follow-up | 2040 men and women, age 50–79 years: 234 HF cases | Systolic blood pressure | 87–125 mmHg | 1.00 | Age, sex, smoking, left ventricular hypertrophy, BMI, diabetes mellitus, HDL cholesterol, heart rate |
| 126–141 | 1.48 (0.99–2.21) | ||||||
| Diastolic blood pressure | ≥142 | 3.07 (2.10–4.49) | |||||
| 49–74 mmHg | 1.00 | ||||||
| 75–82 | 1.33 (0.94–1.87) | ||||||
| ≥83 | 1.67 (1.18–2.37) | ||||||
| Ingelsson E, 2006, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1990–1995–2002, 9.1 years of follow-up | 951 men, age 70 years: 70 HF cases | Office measurement: | Antihypertensive treatment, prior acute myocardial infarction, diabetes, smoking, BMI, serum cholesterol | ||
| Diastolic blood pressure | Per 10 mmHg | 1.16 (0.91–1.49) | |||||
| Mosley WJ, 2007, USA | Chicago Heart Association Detection Project Study | 1967–1973–2002, 33 years of follow-up | 36 314 men and women, mean age 39 years: 599 HF cases | Systolic blood pressure, | Per 18.5 mmHg | 1.32 (1.28–1.36) | Age, sex, pulse pressure, BMI, smoking, total cholesterol |
| Diastolic blood pressure | Per 11.6mmHg | 1.34 (1.29–1.39) | |||||
| Butler J, 2008, USA | Health ABC | 1997–1998–NA, 6.5 years of follow-up | 2935 men and women, mean age 73.6 years: 258 HF cases | Systolic blood pressure | Per 1 mmHg | 1.02 (1.01–1.02) | Age, CHD, smoking status, creatinine, heart rate, albumin, glucose, VHD, left ventricular hypertrophy |
| Nichols GA, 2009, USA | Kaiser Permanente Northwest medical records | 1997–1998–2005, 6.5 years of follow-up | 10 113 men and women, age ≥50 years: 809 HF cases | Systolic blood pressure | Per 5 mmHg | 1.02 (1.01–1.04) | Age, sex, fasting glucose, BMI, CVD diagnosis, total cholesterol, smoking, eGFR, ACE/ARB inhibitor use, beta-blocker use, statin use, hydrochlorothiazide use, diabetes |
| Diastolic blood pressure | Per 5 mmHg | 0.96 (0.93–0.99) | |||||
| Bibbins-Domingo B, 2009, USA | The CARDIA study | 1985–1986–NA, 20 years of follow-up | 5115 Black men and women, age 18–30 years: 27 HF cases | Systolic blood pressure | Per 10.9 mmHg | 1.7 (1.4–2.0) | Age, sex, diabetes, BMI, cholesterol, alcohol, LVH, smoking |
| Diastolic blood pressure | Per 10.0 mmHg | 1.8 (1.52.2) | |||||
| Britton KA, 2009, USA | Physicians' Health Study 1 | 1982–2008, 20.7 years of follow-up | 18 876 men, mean age 53.8 years: 1098 HF cases | Systolic blood pressure | Not treated: | Age, smoking, BMI, alcohol, diabetes, atrial fibrillation, physical activity, egg intake, breakfast cereal intake | |
| <120 mmHg | 1.00 | ||||||
| 120–129 | 1.10 (0.89–1.37) | ||||||
| 130–139 | 1.35 (1.09–1.68) | ||||||
| Treated: | |||||||
| <130 | 1.71 (1.22–2.40) | ||||||
| 130–139 | 2.30 (1.79–2.95) | ||||||
| 140–149 | 1.66 (1.32–2.09) | ||||||
| 150–159 | 2.02 (1.51–2.71) | ||||||
| ≥160 | 2.46 (1.67–3.63) | ||||||
| Conen D, 2010, USA | Established Populations for Epidemiologic Studies in the Elderly (EPESE) | 1982–1983–1992, 4.3 years of follow-up | 4655 men and women, age 65 years: 642 HF cases | Systolic blood pressure | <120 mmHg | 1.00 | Age, sex, diabetes mellitus, CHD, valvular heart disease, atrial fibrillation, antihypertensive drug use, mutual adjustment between systolic and diastolic blood pressure |
| 120–139 | 1.17 (0.91–1.52) | ||||||
| 140–159 | 1.02 (0.77–1.35) | ||||||
| ≥160 | 1.61 (1.17–2.20) | ||||||
| Diastolic blood pressure | <70 mmHg | 1.46 (1.20–1.76) | |||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.11 (0.90–1.38) | ||||||
| ≥90 | 1.09 (0.78–1.51) | ||||||
| Fedorowski A, 2011, Sweden | Malmö Preventive Project | 1974–1992 - 2006, 24 years follow-up | 32 669 men and women, mean age: 26–61 years: 1293 HF cases | Systolic blood pressure | Per 10 mmHg | 1.17 (1.14–1.20) | Age, gender, antihypertensive treatment, hypertension, cholesterol, diabetes, BMI, smoking |
| Diastolic blood pressure | 71.9 mmHg | 1.00 | |||||
| 80.0 | 1.23 (0.99–1.50) | ||||||
| 87.5 | 1.52 (1.24–1.85) | ||||||
| 100.0 | 2.05 (1.65–2.54) | ||||||
| Butler J, 2011, USA | Cardiovascular Health Study | 1989–1990/1992–1992–NA | 4408 men and women, mean age 72.8 years: 493 HF cases | Systolic blood pressure, all | <120 mmHg | 1.00 | Age, sex, cohort, race/ethnicity, BMI, CHD, smoking, diabetes, electrocardiographic left ventricular hypertrophy, heart rate, fasting glucose, creatinine, albumin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride levels |
| 120–139 | 1.63 (1.23–2.16) | ||||||
| 140–159 | 2.21 (1.65–2.96) | ||||||
| Health ABC Study | 1997–1998–NA, 10 years of follow-up | ≥160 | 2.60 (1.85–3.64) | ||||
| Systolic blood pressure, men | <120 mmHg | 1.00 | |||||
| 120–139 | 1.25 (0.88–1.77) | ||||||
| 140–159 | 1.84 (1.28–2.64) | ||||||
| ≥160 | 2.11 (1.38–3.23) | ||||||
| Systolic blood pressure, women | <120 mmHg | 1.00 | |||||
| 120–139 | 2.51 (1.55–4.06) | ||||||
| 140–159 | 3.09 (1.87–5.11) | ||||||
| ≥160 | 3.74 (2.15–6.50) | ||||||
| Systolic blood pressure, Whites | <120 mmHg | 1.00 | |||||
| 120–139 | 1.62 (1.20–2.19) | ||||||
| 140–159 | 2.17 (1.59–2.97) | ||||||
| ≥160 | 2.59 (1.81–3.72) | ||||||
| Systolic blood pressure, Blacks | <120 mmHg | 1.00 | |||||
| 120–139 | 1.68 (0.73–3.87) | ||||||
| 140–159 | 2.49 (1.07–5.78) | ||||||
| ≥160 | 2.69 (1.05–6.91) | ||||||
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Systolic blood pressure | Per 10 mmHg | 1.15 (1.11–1.20) | Age, sex, foreign-born, waist circumference, use of blood pressure-lowering medications, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Ho JE, 2013, USA | Framingham Heart Study | 1981–2008, 8 years of follow-up | 6340 men and women, age mean age 60.7 years: 512 HF cases | Systolic blood pressure, HFpEF | 19.79 mmHg | 1.17 (1.03–1.34) | Age, sex |
| Diastolic blood pressure, HFpEF | Per 10.07 mmHg | 0.92 (0.80–1.05) | |||||
| Systolic blood pressure, HFrEF | 19.79 mmHg | 1.30 (1.16–1.46) | |||||
| Diastolic blood pressure, HFrEF | Per 10.07 mmHg | 0.97 (0.86–1.10) | |||||
| Rapsomaniki E, 2014, UK | CALIBER | 1997–2010–NA, 5.2 years of follow-up | 1 937 360 men and women, age 30–100 years: 10 437 HF cases | Systolic blood pressure, all | Per 20 mmHg | 1.27 (1.23–1.32) | Age, age group, interaction between blood pressure and age, sex, primary care practice |
| Diastolic blood pressure, all | Per 10 mmHg | 1.23 (1.19–1.28) | |||||
| Systolic blood pressure, men | Per 20 mmHg | 1.30 (1.23–1.37) | |||||
| Diastolic blood pressure, men | Per 10 mmHg | 1.25 (1.18–1.32) | |||||
| Systolic blood pressure, women | Per 20 mmHg | 1.26 (1.20–1.31) | |||||
| Diastolic blood pressure, women | Per 10 mmHg | 1.22 (1.17–1.28) | |||||
| Chirinos JA, 2015, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 8.5 years of follow-up | 6124 men and women, age 45–84 years: 135 HF cases | Systolic blood pressure | 21.4 mmHg | 1.28 (1.00–1.62) | Ethnicity, antihypertensive medication use, eGFR, total cholesterol, HDL cholesterol, smoking status |
| Diastolic blood pressure | 10.3 mmHg | 0.77 (0.60–0.99) | |||||
| Randolph C, 2016, USA | Jackson Heart Study | 2000–2011, 8 years of follow-up | 5280 Black men and women, median age 56 years: 340 HF cases | Systolic blood pressure | Per 10 mmHg | 1.10 (1.06–1.16) | Age, diabetes, BMI, LVH, high cholesterol |
| Diastolic blood pressure | Per 10 mmHg | 0.92 (0.81–1.04) | |||||
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK | 1982–2002–2010 | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Systolic blood pressure, men | Per 21 mmHg | 1.09 (1.05–1.14) | BMI, antihypertensive medication use, total cholesterol, diabetes, daily smoking |
| Systolic blood pressure, women | Per 21 mmHg | 1.19 (1.14–1.24) | |||||
| DanMONICA | 1982–1984, 1986–1987, 1991–1992–2010, 2005–2011 | ||||||
| Moli-sani | |||||||
| Northern Sweden MONICA | 1986–2011, 12.7 years of follow-up (across cohorts) | ||||||
| Choi YJ, 2019, Korea | Korea National Health Insurance Research Database | 2002–2003–2013, 6.7 years of follow-up | 290 600 men and women, age ≥40 years: 5248 HF cases | Systolic blood pressure | <90 mmHg | 2.70 (1.36–5.37) | Age, sex, BMI, income levels, diabetes, dyslipidaemia, malignancy, chronic renal disease, chronic liver disease, chronic pulmonary disease, rheumatic disease, smoking, statin use |
| 90–99 | 1.00 | ||||||
| 100–109 | 1.31 (0.89–1.93) | ||||||
| 110–119 | 1.43 (0.99–2.06) | ||||||
| 120–129 | 1.60 (1.11–2.29) | ||||||
| 130–139 | 1.99 (1.38–2.86) | ||||||
| 140–149 | 2.47 (1.71–3.57) | ||||||
| 150–159 | 2.89 (1.98–4.21) | ||||||
| ≥160 | 4.16 (2.86–6.06) | ||||||
| Diastolic blood pressure | <40 mmHg | 5.80 (0.79–42.50) | |||||
| 40–49 | 0.49 (0.07–3.60) | ||||||
| 50–59 | 1.00 | ||||||
| 60–69 | 1.13 (0.78–1.61) | ||||||
| 70–79 | 1.20 (0.85–1.70) | ||||||
| 80–89 | 1.32 (0.93–1.87) | ||||||
| 90–99 | 2.00 (1.40–2.85) | ||||||
| ≥100 | 2.55 (1.76–3.68) | ||||||
| Sillars A, 2020, UK | UK Biobank | 2007–2010–NA, 8.2 years of follow-up | 33 595 men and women, age 40–60 years: 1812 HF cases | Systolic blood pressure, men | ≤125 mmHg | 1.00 | Age, diabetes, BMI, pulse pressure, women, sleep duration, smoking, physical activity |
| >125 to 138 | 0.88 (0.69–1.12) | ||||||
| >138 to 152 | 1.14 (0.92–1.41) | ||||||
| >152 | 1.23 (1.00–1.51) | ||||||
| Diastolic blood pressure, men | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.83 (0.69–1.00) | ||||||
| >82 to 89 | 0.85 (0.71–1.02) | ||||||
| >89 | 0.91 (0.76–1.08) | ||||||
| Systolic blood pressure, women | ≤125 mmHg | 1.00 | |||||
| >125 to 138 | 1.16 (0.88–1.53) | ||||||
| >138 to 152 | 1.45 (1.12–1.88) | ||||||
| >152 | 1.53 (1.18–1.99) | ||||||
| Diastolic blood pressure, women | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.86 (0.68–1.09) | ||||||
| >82 to 89 | 1.06 (0.84–1.33) | ||||||
| >89 | 1.16 (0.92–1.47) | ||||||
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Systolic blood pressure | Per 10 mmHg | 1.12 (0.98–1.27) | BMI, smoking, sedentary lifestyle, glucose, cholesterol |
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1913 | 1963–1994, 21 years of follow-up | 855 men, age 50 years: 80 HF cases | Systolic blood pressure, <median | Per 10 mmHg | 1.09 (0.75–1.59) | Age |
| Systolic blood pressure, ≥median | Per 10 mmHg | 1.10 (0.97–1.24) | |||||
| Diastolic blood pressure | Per 5 mmHg | 1.09 (1.00–1.18) | |||||
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 797 men, age 50 years: 42 HF cases | Diastolic blood pressure | Per 5 mmHg | 1.18 (1.03–1.35) | Age |
| Cordola Hsu AR, 2021, USA | Women's Health Initiative | 1993–1998–NA, 11.28 years of follow-up | 19 412 women, age 50–79 years: 455 HF cases | Systolic blood pressure | Per 17.58 mmHg | 1.47 (1.32–1.64) | Age, race/ethnicity, income, diabetes, ever smoking, total healthy eating index score, recreational physical activity, total cholesterol |
| Diastolic blood pressure | Per 9.25 mmHg | 0.94 (0.84–1.05) | |||||
| Lind L, 2021, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–2014, ∼40 years of follow-up | 2322 men, age 50 years: 405 HF cases | Systolic blood pressure | Per 10 mmHg | 1.35 (1.23–1.48) | Triglycerides, HDL cholesterol, LDL cholesterol, BMI, diabetes, smoking |
| Cohen LH, 2021, USA | Atherosclerosis Risk in Communities | NA–NA, 12 years of follow-up | 23 861 men and women, mean age 61.8 years: 3666 HF cases | Systolic blood pressure, HFrEF | <120 mmHg | 1.00 | Study cohort, birth year, race/ethnicity, sex, smoking status, use of lipid-lowering medications, antihypertensive medications, anti-diabetic medications, BMI, HDL cholesterol |
| 120–129 | 1.17 (0.90–1.52) | ||||||
| 130–139 | 1.44 (1.03–2.01) | ||||||
| Cardiovascular Health Study | ≥140 | 1.74 (1.15–2.65) | |||||
| Diastolic blood pressure, HFrEF | <70 mmHg70–79 | 1.000.96 (0.72–1.29) | |||||
| Health ABC Study | 80–89 | 0.91 (0.62–1.34) | |||||
| Multi-Ethnic Study of Atherosclerosis | ≥90 | 1.07 (0.52–2.19) | |||||
| Systolic blood pressure, HFpEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.27 (1.03–1.58) | ||||||
| 130–139 | 1.53 (1.18–1.98) | ||||||
| ≥140 | 2.25 (1.51–3.36) | ||||||
| Diastolic blood pressure, HFpEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.74 (0.57–0.95) | ||||||
| 80–89 | 0.59 (0.42–0.83) | ||||||
| ≥90 | 0.61 (0.26–1.41) | ||||||
| Systolic blood pressure, HFbEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.21 (0.74–1.97) | ||||||
| 130–139 | 1.39 (0.78–2.45) | ||||||
| ≥140 | 2.02 (0.94–4.34) | ||||||
| Diastolic blood pressure, HFbEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.88 (0.51–1.52) | ||||||
| 80–89 | 0.90 (0.43–1.86) | ||||||
| ≥90 | 1.29 (0.30–5.58) | ||||||
| Itoga NK, 2021, USA | Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) | 1994–2002, 4.4 years of follow-up | 33 357 men and women, age ≥55 years: 866 HF cases | Systolic blood pressure | <120 mmHg | 1.44 (1.14–1.83) | Age, sex, race, BMI, ethnicity, smoking status, randomized blood pressure medication group, history of ECG changes, MI or stroke, coronary vascularization, other atherosclerotic disease, baseline aspirin use, diabetes mellitus, CHD, baseline antihypertensive medication use |
| 120–129 | 1.00 | ||||||
| 130–139 | 1.16 (0.95–1.41) | ||||||
| 140–149 | 1.14 (0.92–1.42) | ||||||
| 150–159 | 1.29 (1.02–1.64) | ||||||
| ≥160 | 1.96 (1.58–2.43) | ||||||
| Diastolic blood pressure | <60 mmHg | 1.42 (1.06–1.91) | |||||
| 60–69 | 1.13 (0.95–1.36) | ||||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.10 (0.95–1.28) | ||||||
| 90–99 | 1.22 (0.99–1.52) | ||||||
| ≥100 | 1.88 (1.36–2.59) |
| First author, publication year, country | Study name or description | Study period | Number of participants, number of cases | Exposure, subgroup | Comparison | Relative risk (95% confidence interval) | Adjustment for confounders |
|---|---|---|---|---|---|---|---|
| Gottdiener J, 2000, USA | Cardiovascular Health Study | 1989–1990–1994–1995, 6.3 years of follow-up | 5625 men and women, age 65–100 years: 597 HF cases | Systolic blood pressure | Per 20 mmHg | 1.09 (1.01–1.18) | Age, sex, CHD, stroke or TIA, diabetes, FEV, creatinine, CRP, ankle-arm index, ECG atrial fibrillation, ECG left ventricular mass, major ST-T segment abnormality, minor ST-T segment abnormality, internal carotid, abnormal LV ejection fraction |
| Haider AW, 2003, USA | Framingham Heart Study | 1968–1973–1994, 17.4 years of follow-up | 2040 men and women, age 50–79 years: 234 HF cases | Systolic blood pressure | 87–125 mmHg | 1.00 | Age, sex, smoking, left ventricular hypertrophy, BMI, diabetes mellitus, HDL cholesterol, heart rate |
| 126–141 | 1.48 (0.99–2.21) | ||||||
| Diastolic blood pressure | ≥142 | 3.07 (2.10–4.49) | |||||
| 49–74 mmHg | 1.00 | ||||||
| 75–82 | 1.33 (0.94–1.87) | ||||||
| ≥83 | 1.67 (1.18–2.37) | ||||||
| Ingelsson E, 2006, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1990–1995–2002, 9.1 years of follow-up | 951 men, age 70 years: 70 HF cases | Office measurement: | Antihypertensive treatment, prior acute myocardial infarction, diabetes, smoking, BMI, serum cholesterol | ||
| Diastolic blood pressure | Per 10 mmHg | 1.16 (0.91–1.49) | |||||
| Mosley WJ, 2007, USA | Chicago Heart Association Detection Project Study | 1967–1973–2002, 33 years of follow-up | 36 314 men and women, mean age 39 years: 599 HF cases | Systolic blood pressure, | Per 18.5 mmHg | 1.32 (1.28–1.36) | Age, sex, pulse pressure, BMI, smoking, total cholesterol |
| Diastolic blood pressure | Per 11.6mmHg | 1.34 (1.29–1.39) | |||||
| Butler J, 2008, USA | Health ABC | 1997–1998–NA, 6.5 years of follow-up | 2935 men and women, mean age 73.6 years: 258 HF cases | Systolic blood pressure | Per 1 mmHg | 1.02 (1.01–1.02) | Age, CHD, smoking status, creatinine, heart rate, albumin, glucose, VHD, left ventricular hypertrophy |
| Nichols GA, 2009, USA | Kaiser Permanente Northwest medical records | 1997–1998–2005, 6.5 years of follow-up | 10 113 men and women, age ≥50 years: 809 HF cases | Systolic blood pressure | Per 5 mmHg | 1.02 (1.01–1.04) | Age, sex, fasting glucose, BMI, CVD diagnosis, total cholesterol, smoking, eGFR, ACE/ARB inhibitor use, beta-blocker use, statin use, hydrochlorothiazide use, diabetes |
| Diastolic blood pressure | Per 5 mmHg | 0.96 (0.93–0.99) | |||||
| Bibbins-Domingo B, 2009, USA | The CARDIA study | 1985–1986–NA, 20 years of follow-up | 5115 Black men and women, age 18–30 years: 27 HF cases | Systolic blood pressure | Per 10.9 mmHg | 1.7 (1.4–2.0) | Age, sex, diabetes, BMI, cholesterol, alcohol, LVH, smoking |
| Diastolic blood pressure | Per 10.0 mmHg | 1.8 (1.52.2) | |||||
| Britton KA, 2009, USA | Physicians' Health Study 1 | 1982–2008, 20.7 years of follow-up | 18 876 men, mean age 53.8 years: 1098 HF cases | Systolic blood pressure | Not treated: | Age, smoking, BMI, alcohol, diabetes, atrial fibrillation, physical activity, egg intake, breakfast cereal intake | |
| <120 mmHg | 1.00 | ||||||
| 120–129 | 1.10 (0.89–1.37) | ||||||
| 130–139 | 1.35 (1.09–1.68) | ||||||
| Treated: | |||||||
| <130 | 1.71 (1.22–2.40) | ||||||
| 130–139 | 2.30 (1.79–2.95) | ||||||
| 140–149 | 1.66 (1.32–2.09) | ||||||
| 150–159 | 2.02 (1.51–2.71) | ||||||
| ≥160 | 2.46 (1.67–3.63) | ||||||
| Conen D, 2010, USA | Established Populations for Epidemiologic Studies in the Elderly (EPESE) | 1982–1983–1992, 4.3 years of follow-up | 4655 men and women, age 65 years: 642 HF cases | Systolic blood pressure | <120 mmHg | 1.00 | Age, sex, diabetes mellitus, CHD, valvular heart disease, atrial fibrillation, antihypertensive drug use, mutual adjustment between systolic and diastolic blood pressure |
| 120–139 | 1.17 (0.91–1.52) | ||||||
| 140–159 | 1.02 (0.77–1.35) | ||||||
| ≥160 | 1.61 (1.17–2.20) | ||||||
| Diastolic blood pressure | <70 mmHg | 1.46 (1.20–1.76) | |||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.11 (0.90–1.38) | ||||||
| ≥90 | 1.09 (0.78–1.51) | ||||||
| Fedorowski A, 2011, Sweden | Malmö Preventive Project | 1974–1992 - 2006, 24 years follow-up | 32 669 men and women, mean age: 26–61 years: 1293 HF cases | Systolic blood pressure | Per 10 mmHg | 1.17 (1.14–1.20) | Age, gender, antihypertensive treatment, hypertension, cholesterol, diabetes, BMI, smoking |
| Diastolic blood pressure | 71.9 mmHg | 1.00 | |||||
| 80.0 | 1.23 (0.99–1.50) | ||||||
| 87.5 | 1.52 (1.24–1.85) | ||||||
| 100.0 | 2.05 (1.65–2.54) | ||||||
| Butler J, 2011, USA | Cardiovascular Health Study | 1989–1990/1992–1992–NA | 4408 men and women, mean age 72.8 years: 493 HF cases | Systolic blood pressure, all | <120 mmHg | 1.00 | Age, sex, cohort, race/ethnicity, BMI, CHD, smoking, diabetes, electrocardiographic left ventricular hypertrophy, heart rate, fasting glucose, creatinine, albumin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride levels |
| 120–139 | 1.63 (1.23–2.16) | ||||||
| 140–159 | 2.21 (1.65–2.96) | ||||||
| Health ABC Study | 1997–1998–NA, 10 years of follow-up | ≥160 | 2.60 (1.85–3.64) | ||||
| Systolic blood pressure, men | <120 mmHg | 1.00 | |||||
| 120–139 | 1.25 (0.88–1.77) | ||||||
| 140–159 | 1.84 (1.28–2.64) | ||||||
| ≥160 | 2.11 (1.38–3.23) | ||||||
| Systolic blood pressure, women | <120 mmHg | 1.00 | |||||
| 120–139 | 2.51 (1.55–4.06) | ||||||
| 140–159 | 3.09 (1.87–5.11) | ||||||
| ≥160 | 3.74 (2.15–6.50) | ||||||
| Systolic blood pressure, Whites | <120 mmHg | 1.00 | |||||
| 120–139 | 1.62 (1.20–2.19) | ||||||
| 140–159 | 2.17 (1.59–2.97) | ||||||
| ≥160 | 2.59 (1.81–3.72) | ||||||
| Systolic blood pressure, Blacks | <120 mmHg | 1.00 | |||||
| 120–139 | 1.68 (0.73–3.87) | ||||||
| 140–159 | 2.49 (1.07–5.78) | ||||||
| ≥160 | 2.69 (1.05–6.91) | ||||||
| Borne Y, 2012, Sweden | Malmo Diet and Cancer Study | 1991–1996–2008, 15 years of follow-up | 26 559 men and women, mean age 58 years: 764 HF cases | Systolic blood pressure | Per 10 mmHg | 1.15 (1.11–1.20) | Age, sex, foreign-born, waist circumference, use of blood pressure-lowering medications, leukocyte count, use of lipid-lowering medications, diabetes mellitus, smoking, alcohol, physical activity, marital status, education |
| Ho JE, 2013, USA | Framingham Heart Study | 1981–2008, 8 years of follow-up | 6340 men and women, age mean age 60.7 years: 512 HF cases | Systolic blood pressure, HFpEF | 19.79 mmHg | 1.17 (1.03–1.34) | Age, sex |
| Diastolic blood pressure, HFpEF | Per 10.07 mmHg | 0.92 (0.80–1.05) | |||||
| Systolic blood pressure, HFrEF | 19.79 mmHg | 1.30 (1.16–1.46) | |||||
| Diastolic blood pressure, HFrEF | Per 10.07 mmHg | 0.97 (0.86–1.10) | |||||
| Rapsomaniki E, 2014, UK | CALIBER | 1997–2010–NA, 5.2 years of follow-up | 1 937 360 men and women, age 30–100 years: 10 437 HF cases | Systolic blood pressure, all | Per 20 mmHg | 1.27 (1.23–1.32) | Age, age group, interaction between blood pressure and age, sex, primary care practice |
| Diastolic blood pressure, all | Per 10 mmHg | 1.23 (1.19–1.28) | |||||
| Systolic blood pressure, men | Per 20 mmHg | 1.30 (1.23–1.37) | |||||
| Diastolic blood pressure, men | Per 10 mmHg | 1.25 (1.18–1.32) | |||||
| Systolic blood pressure, women | Per 20 mmHg | 1.26 (1.20–1.31) | |||||
| Diastolic blood pressure, women | Per 10 mmHg | 1.22 (1.17–1.28) | |||||
| Chirinos JA, 2015, USA | Multi-Ethnic Study of Atherosclerosis | 2000–2002–NA, 8.5 years of follow-up | 6124 men and women, age 45–84 years: 135 HF cases | Systolic blood pressure | 21.4 mmHg | 1.28 (1.00–1.62) | Ethnicity, antihypertensive medication use, eGFR, total cholesterol, HDL cholesterol, smoking status |
| Diastolic blood pressure | 10.3 mmHg | 0.77 (0.60–0.99) | |||||
| Randolph C, 2016, USA | Jackson Heart Study | 2000–2011, 8 years of follow-up | 5280 Black men and women, median age 56 years: 340 HF cases | Systolic blood pressure | Per 10 mmHg | 1.10 (1.06–1.16) | Age, diabetes, BMI, LVH, high cholesterol |
| Diastolic blood pressure | Per 10 mmHg | 0.92 (0.81–1.04) | |||||
| Magnussen C, 2019, Finland, Denmark, Italy, Northern Sweden | FINRISK | 1982–2002–2010 | 78 657 men and women, age 24.1–98.7 years: 5170 HF cases | Systolic blood pressure, men | Per 21 mmHg | 1.09 (1.05–1.14) | BMI, antihypertensive medication use, total cholesterol, diabetes, daily smoking |
| Systolic blood pressure, women | Per 21 mmHg | 1.19 (1.14–1.24) | |||||
| DanMONICA | 1982–1984, 1986–1987, 1991–1992–2010, 2005–2011 | ||||||
| Moli-sani | |||||||
| Northern Sweden MONICA | 1986–2011, 12.7 years of follow-up (across cohorts) | ||||||
| Choi YJ, 2019, Korea | Korea National Health Insurance Research Database | 2002–2003–2013, 6.7 years of follow-up | 290 600 men and women, age ≥40 years: 5248 HF cases | Systolic blood pressure | <90 mmHg | 2.70 (1.36–5.37) | Age, sex, BMI, income levels, diabetes, dyslipidaemia, malignancy, chronic renal disease, chronic liver disease, chronic pulmonary disease, rheumatic disease, smoking, statin use |
| 90–99 | 1.00 | ||||||
| 100–109 | 1.31 (0.89–1.93) | ||||||
| 110–119 | 1.43 (0.99–2.06) | ||||||
| 120–129 | 1.60 (1.11–2.29) | ||||||
| 130–139 | 1.99 (1.38–2.86) | ||||||
| 140–149 | 2.47 (1.71–3.57) | ||||||
| 150–159 | 2.89 (1.98–4.21) | ||||||
| ≥160 | 4.16 (2.86–6.06) | ||||||
| Diastolic blood pressure | <40 mmHg | 5.80 (0.79–42.50) | |||||
| 40–49 | 0.49 (0.07–3.60) | ||||||
| 50–59 | 1.00 | ||||||
| 60–69 | 1.13 (0.78–1.61) | ||||||
| 70–79 | 1.20 (0.85–1.70) | ||||||
| 80–89 | 1.32 (0.93–1.87) | ||||||
| 90–99 | 2.00 (1.40–2.85) | ||||||
| ≥100 | 2.55 (1.76–3.68) | ||||||
| Sillars A, 2020, UK | UK Biobank | 2007–2010–NA, 8.2 years of follow-up | 33 595 men and women, age 40–60 years: 1812 HF cases | Systolic blood pressure, men | ≤125 mmHg | 1.00 | Age, diabetes, BMI, pulse pressure, women, sleep duration, smoking, physical activity |
| >125 to 138 | 0.88 (0.69–1.12) | ||||||
| >138 to 152 | 1.14 (0.92–1.41) | ||||||
| >152 | 1.23 (1.00–1.51) | ||||||
| Diastolic blood pressure, men | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.83 (0.69–1.00) | ||||||
| >82 to 89 | 0.85 (0.71–1.02) | ||||||
| >89 | 0.91 (0.76–1.08) | ||||||
| Systolic blood pressure, women | ≤125 mmHg | 1.00 | |||||
| >125 to 138 | 1.16 (0.88–1.53) | ||||||
| >138 to 152 | 1.45 (1.12–1.88) | ||||||
| >152 | 1.53 (1.18–1.99) | ||||||
| Diastolic blood pressure, women | ≤75 mmHg | 1.00 | |||||
| >75 to 82 | 0.86 (0.68–1.09) | ||||||
| >82 to 89 | 1.06 (0.84–1.33) | ||||||
| >89 | 1.16 (0.92–1.47) | ||||||
| Chen X, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 535 men, age 50 years: 92 HF cases | Systolic blood pressure | Per 10 mmHg | 1.12 (0.98–1.27) | BMI, smoking, sedentary lifestyle, glucose, cholesterol |
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1913 | 1963–1994, 21 years of follow-up | 855 men, age 50 years: 80 HF cases | Systolic blood pressure, <median | Per 10 mmHg | 1.09 (0.75–1.59) | Age |
| Systolic blood pressure, ≥median | Per 10 mmHg | 1.10 (0.97–1.24) | |||||
| Diastolic blood pressure | Per 5 mmHg | 1.09 (1.00–1.18) | |||||
| Ergatoudes C, 2020, Sweden | Study of Men Born in 1943 | 1993–2014, 21 years of follow-up | 797 men, age 50 years: 42 HF cases | Diastolic blood pressure | Per 5 mmHg | 1.18 (1.03–1.35) | Age |
| Cordola Hsu AR, 2021, USA | Women's Health Initiative | 1993–1998–NA, 11.28 years of follow-up | 19 412 women, age 50–79 years: 455 HF cases | Systolic blood pressure | Per 17.58 mmHg | 1.47 (1.32–1.64) | Age, race/ethnicity, income, diabetes, ever smoking, total healthy eating index score, recreational physical activity, total cholesterol |
| Diastolic blood pressure | Per 9.25 mmHg | 0.94 (0.84–1.05) | |||||
| Lind L, 2021, Sweden | Uppsala Longitudinal Study of Adult Men (ULSAM) | 1970–1974–2014, ∼40 years of follow-up | 2322 men, age 50 years: 405 HF cases | Systolic blood pressure | Per 10 mmHg | 1.35 (1.23–1.48) | Triglycerides, HDL cholesterol, LDL cholesterol, BMI, diabetes, smoking |
| Cohen LH, 2021, USA | Atherosclerosis Risk in Communities | NA–NA, 12 years of follow-up | 23 861 men and women, mean age 61.8 years: 3666 HF cases | Systolic blood pressure, HFrEF | <120 mmHg | 1.00 | Study cohort, birth year, race/ethnicity, sex, smoking status, use of lipid-lowering medications, antihypertensive medications, anti-diabetic medications, BMI, HDL cholesterol |
| 120–129 | 1.17 (0.90–1.52) | ||||||
| 130–139 | 1.44 (1.03–2.01) | ||||||
| Cardiovascular Health Study | ≥140 | 1.74 (1.15–2.65) | |||||
| Diastolic blood pressure, HFrEF | <70 mmHg70–79 | 1.000.96 (0.72–1.29) | |||||
| Health ABC Study | 80–89 | 0.91 (0.62–1.34) | |||||
| Multi-Ethnic Study of Atherosclerosis | ≥90 | 1.07 (0.52–2.19) | |||||
| Systolic blood pressure, HFpEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.27 (1.03–1.58) | ||||||
| 130–139 | 1.53 (1.18–1.98) | ||||||
| ≥140 | 2.25 (1.51–3.36) | ||||||
| Diastolic blood pressure, HFpEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.74 (0.57–0.95) | ||||||
| 80–89 | 0.59 (0.42–0.83) | ||||||
| ≥90 | 0.61 (0.26–1.41) | ||||||
| Systolic blood pressure, HFbEF | <120 mmHg | 1.00 | |||||
| 120–129 | 1.21 (0.74–1.97) | ||||||
| 130–139 | 1.39 (0.78–2.45) | ||||||
| ≥140 | 2.02 (0.94–4.34) | ||||||
| Diastolic blood pressure, HFbEF | <70 mmHg | 1.00 | |||||
| 70–79 | 0.88 (0.51–1.52) | ||||||
| 80–89 | 0.90 (0.43–1.86) | ||||||
| ≥90 | 1.29 (0.30–5.58) | ||||||
| Itoga NK, 2021, USA | Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) | 1994–2002, 4.4 years of follow-up | 33 357 men and women, age ≥55 years: 866 HF cases | Systolic blood pressure | <120 mmHg | 1.44 (1.14–1.83) | Age, sex, race, BMI, ethnicity, smoking status, randomized blood pressure medication group, history of ECG changes, MI or stroke, coronary vascularization, other atherosclerotic disease, baseline aspirin use, diabetes mellitus, CHD, baseline antihypertensive medication use |
| 120–129 | 1.00 | ||||||
| 130–139 | 1.16 (0.95–1.41) | ||||||
| 140–149 | 1.14 (0.92–1.42) | ||||||
| 150–159 | 1.29 (1.02–1.64) | ||||||
| ≥160 | 1.96 (1.58–2.43) | ||||||
| Diastolic blood pressure | <60 mmHg | 1.42 (1.06–1.91) | |||||
| 60–69 | 1.13 (0.95–1.36) | ||||||
| 70–79 | 1.00 | ||||||
| 80–89 | 1.10 (0.95–1.28) | ||||||
| 90–99 | 1.22 (0.99–1.52) | ||||||
| ≥100 | 1.88 (1.36–2.59) |
ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BMI, body mass index; CHD, coronary heart disease; CRP, C-reactive protein; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; FEV, forced expiratory volume; HDL, high-density lipoprotein; HF, heart failure; HFbEF, heart failure with borderline ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LDL, low-density lipoprotein; LV, left ventricular; LVH, left ventricular hypertrophy; MI, myocardial infarction; NA, not available; TIA, transient ischaemic attack; USA, United States of America; VHD, valvular heart disease.
Quality assessment of included studies
The quality of studies included in the meta-analysis was assessed using a modified version of the Newcastle Ottawa quality assessment scale for cohort studies.70 Studies were assessed under three main categories and each category with sub-probing questions: selection (selection of the non-exposed cohort, ascertainment of exposure, and demonstration that outcome of interest was not present at the start of study), comparability (control for confounders), and assessment of outcome (outcome assessment, long enough follow-up period for cases to accrue, and adequacy of follow-up). The point regarding representativeness was excluded because it is not an indicator of study quality, and with regard to confounders, we gave 0.25 points for each confounder adjusted for up to a total of 2 points, rather than giving 1 point for each of two confounders, because studies could receive a full score with adjustment for only age and sex and still be prone to confounding. Lastly, we gave 1 point for studies that either validated heart failure diagnoses or had confirmation of either self-reported or registry-based linkages by independent experts. Studies that only used registry linkage were given 0.5 points and studies using only self-report received 0 points on this criterion.
Certainty of evidence
We used the World Cancer Research Fund criteria to assess the likelihood of causality using a defined set of criteria including the significance and robustness of an association, number of studies included, heterogeneity, quality of the studies, biologically plausible dose–response relationship, and strong and plausible supporting experimental evidence.71
Statistical analysis
Random effects models that take into account heterogeneity within and between studies were used to estimate summary RRs (95% CIs) for the association between hypertension or blood pressure and the risk of heart failure.72 The method of Greenland and Longnecker was used for the linear dose–response analysis of blood pressure and heart failure risk and study-specific slopes (linear trends) and 95% CIs were estimated across categories of blood pressure.73 When studies reported means or medians of systolic or diastolic blood pressure per category, these values were used directly, and when studies reported ranges of blood pressure, we calculated the mean of the upper and lower ranges. When the lowest or highest category was open-ended or had extreme lower or higher values, we used the width of the adjacent category to estimate a lower or higher cut-off value for the category. For the linear dose–response analysis, the RRs for at least three categories of blood pressure, as well as the number of cases and number of participants, or person-years per category, or a risk estimate on a continuous scale, were required for the studies to be included. For studies reporting the total number of cases, but not per category, these were estimated based on a previously described method.74 Fractional polynomial models were used for the non-linear dose–response analysis of blood pressure and heart failure.75 The best-fitting second-order fractional polynomial regression model, defined as the one with the lowest deviance, was determined. A likelihood ratio test was used to assess the difference between the non-linear and linear models to test for non-linearity.75
Heterogeneity between studies was evaluated with Q and I2 statistics.76 I2 ranges from a low of 0% to a high of 100% and is the percentage of variation across studies that are due to heterogeneity rather than due to chance. Subgroup and meta-regression analyses were conducted, stratified by study characteristics including duration of follow-up, sex, geographical location, ethnicity, number of cases, heart failure subtype, study quality, and adjustment for confounding factors, to investigate the potential sources of heterogeneity. In a sensitivity analysis, we excluded three publications38,43,47 that used the ACC/AHA definition of hypertension to clarify whether this impacted the results. Publication bias was assessed with Egger’s test77 and by inspection of the funnel plots. Sensitivity analyses excluding one study at a time from the analysis were conducted to assess whether the observed summary estimates were robust to the influence of each included study. All statistical analyses were performed with STATA version 15.0 (Stata Corp LP, College Station, TX, USA).
Ethical considerations
No ethical approval was necessary because the project used already published studies.
Results
Characteristics of included studies
The literature search retrieved a total of 64 445 records including 23 734 records from PubMed and 40 709 from Embase and two records32,54 that were identified by hand searching (Figure 1). The first part of the screening based on inspection of abstract and title excluded 64 111 records (duplicates between databases were among these), leaving 334 potentially relevant articles. Further inspection of these studies led to the final inclusion of 60 publications with data from 47 studies,2,6,13,15–68,78–80 with a total of >20 million participants and >170 000 heart failure cases (Figure 1 and Tables 1 and 2). The age of the participants in the included studies ranged between 18 and 100 years. Forty-one studies included both men and women, five studies included only men, and one study included only women. Twenty-three studies were from North America, 18 studies were from Europe, three studies were from Asia, and three studies were international. The mean (median) study quality as measured by the Newcastle-Ottawa scale was 6.5 (6.4) out of 8 for the studies included in the analysis of hypertension, 6 (6.1) for the studies on systolic blood pressure, and 6.3 (6.2) for the studies on diastolic blood pressure (see Supplementary material online, Tables S3–S5).
Flow-chart of study selection.
Hypertension and heart failure
Forty-three cohort studies (37 risk estimates and 36 publications)2,6,15–48 were included in the analysis of the association between hypertension and the risk of heart failure, including 166 798 cases and 20 359 997 participants. Two papers reported results for four studies combined.6,37 A few articles were only included in subgroup analyses stratified by sex,79 ethnicity,78 or subtype of heart failure80 as they overlapped with other articles that were used for the main analysis.34,35,46 Among the studies, 20 studies were from the USA, 20 studies were from Europe, and 3 studies were from Asia. The summary RR of heart failure in people with hypertension vs. without hypertension was 1.71 (95% CI: 1.53–1.90, I2 = 98.4%, Pheterogeneity < 0.0001) (Figure 2). When individual studies were excluded one at a time, the summary RRs ranged from 1.67 (1.50–1.86) when the study by Voulgari et al.30 was excluded to 1.73 (1.58–1.89) when the study by Uijl et al.41 was excluded (see Supplementary material online, Figure S1). There was no evidence of publication bias with Egger’s test (P = 0.39) or by inspection of the funnel plot (see Supplementary material online, Figure S2).
Hypertension and heart failure.
Systolic blood pressure and heart failure
Twenty-four cohort studies (21 risk estimates and 21 publications)6,13,28,31,42,49,52–57,59–64,66,68,81 were included in the analysis of systolic blood pressure and heart failure with 31 639 cases and 2 557 298 participants. Twelve studies were from the North America, 11 studies were from Europe, and one study was from Asia. Nineteen studies had both men and women included, four studies included only men, and one study included only women. The summary RR per 20 mmHg increment in systolic blood pressure was 1.28 (95% CI: 1.22–1.35, I2 = 90.3%, Pheterogeneity < 0.0001) (Figure 3A). The summary RRs ranged from 1.27 (95% CI: 1.21–1.33) when the study by Bibbins-Domingo et al.55 was excluded to 1.30 (95% CI: 1.23–1.36) when the study by Gottdiener et al.49 was excluded (see Supplementary material online, Figure S3). Egger’s test was not significant (P = 0.30), but there was some asymmetry in the funnel plot when inspected visually (see Supplementary material online, Figure S4). The asymmetry was driven mainly by one outlying study,55 which, when excluded from the analysis, did not substantially alter the results (summary RR = 1.27, 95% CI: 1.21–1.33, I2 = 89.3%). Eight cohort studies were included in the non-linear dose–response analysis.13,50,56–58,61,63,68 There was evidence of a non-linear association between systolic blood pressure and heart failure (Pnon-linearity < 0.0001) with a steeper increase in risk from around 150 mmHg and above than below (Figure 3B and Supplementary material online, Table S6).
Systolic blood pressure and heart failure, linear (A) and nonlinear (B) dose-response analyses. Diastolic blood pressure and heart failure, linear (C) and nonlinear (D) dose-response analyses.
Diastolic blood pressure and heart failure
Sixteen cohort studies (15 publications and 16 risk estimates)13,50–52,54,55,57,59–64,67,68 were included in the analysis of diastolic blood pressure and risk of heart failure including 23 127 cases and 2 419 295 participants. Nine studies were from North America, six from Europe, and one from Asia. Twelve studies included both men and women, three included only men, and one included only women. The summary RR per 10 mmHg increment in diastolic blood pressure was 1.12 (95% CI: 1.04–1.21, I2 = 92.6%, Pheterogeneity < 0.0001) (Figure 3C). The summary RRs ranged from 1.09 (95% CI: 1.01–1.18) when the study by Bibbins-Domingo et al.55 was excluded to 1.14 (95% CI: 1.05–1.23) when the study by Chirinos et al.59 was excluded (see Supplementary material online, Figure S5). There was no evidence of publication bias with Eggers’s test (P = 0.19) or by inspection of the funnel plot (see Supplementary material online, Figure S6). Seven cohort studies were included in the non-linear dose–response analysis.13,50,57,61,63,67,68 There was evidence of a non-linear association between diastolic blood pressure and heart failure, with some indication of a threshold level around 100 mmHg and steeper increases at higher levels than at lower levels (Figure 3D and Supplementary material online, Table S6).
Subgroup and sensitivity analyses
Tables 3 and 4 show the results of the subgroup analyses. The positive associations between hypertension and systolic blood pressure and heart failure persisted across all the subgroups that were considered including sex, duration of follow-up, geographical location, ethnicity, number of cases, subtype of heart failure, study quality, and adjustment for a range of confounding factors (Tables 3 and 4). High heterogeneity was observed within each subgroup analysis. The only subgroup analyses with significant between-subgroup heterogeneity were the subgroups of hypertension and heart failure stratified by ethnicity (P = 0.04), adjustment for smoking (P = 0.01), and adjustment for body mass index (BMI) or obesity (P = 0.04), and the associations were stronger among Asians and Hispanics when compared with Whites and Blacks, in studies without adjustment for smoking or BMI when compared with studies with such adjustment. For systolic blood pressure, there was heterogeneity between subgroups in strata of studies with and without adjustment for alcohol consumption (P = 0.04), with a stronger association among studies with such adjustment. The positive association between diastolic blood pressure and heart failure was less consistent, and there was significant heterogeneity between subgroups stratified by duration of follow-up (P = 0.04), number of cases (P < 0.0001), and adjustment for alcohol (P < 0.0001), with a stronger association in studies with ≥10 vs. <10 years of follow-up, in studies with ≥1000 vs. fewer cases, and in the one study with adjustment for alcohol consumption.
Subgroup analyses of hypertension and heart failure
| Hypertension and heart failure | ||||||
|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | ||
| All studies | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | ||
| Sex | ||||||
| Men | 12 | 1.71 (1.35–2.16) | 98.9 | <0.0001 | 0.80/0.79c | |
| Women | 10 | 1.78 (1.37–2.32) | 99.0 | <0.0001 | ||
| Men, women | 23 | 1.66 (1.53–1.80) | 88.2 | <0.0001 | ||
| Follow-up | ||||||
| <10 years | 15 | 1.81 (1.49–2.19) | 99.4 | <0.0001 | 0.37 | |
| ≥10 years | 22 | 1.64 (1.53–1.76) | 75.2 | <0.0001 | ||
| Geographic location | ||||||
| Europe | 14 | 1.61 (1.39–1.86) | 96.7 | <0.0001 | 0.58 | |
| America | 19 | 1.79 (1.57–2.04) | 92.0 | <0.0001 | ||
| Asia | 3 | 1.62 (1.13–2.31) | 99.7 | <0.0001 | ||
| International | 1 | 1.65 (1.33–2.05) | ||||
| Ethnicity | ||||||
| Caucasian | 4 | 1.98 (1.50–2.61) | 87.3 | <0.0001 | 0.04 | |
| African American | 6 | 1.98 (1.70–2.30) | 12.9 | 0.33 | ||
| Asian | 2 | 5.04 (1.86–13.69) | 19.3 | 0.27 | ||
| Hispanic | 2 | 4.10 (2.23–7.53) | 0 | 0.39 | ||
| Number of cases | ||||||
| Cases, <250 | 5 | 1.93 (1.23–3.05) | 80.9 | <0.0001 | 0.35 | |
| Cases, 250 to <500 | 9 | 1.66 (1.47–1.87) | 26.9 | 0.21 | ||
| Cases, 500 to <1000 | 8 | 1.88 (1.62–2.18) | 78.4 | <0.0001 | ||
| Cases, ≥1000 | 15 | 1.61 (1.37–1.89) | 99.4 | <0.0001 | ||
| Outcome subtype | ||||||
| HFpEF | 4 | 1.86 (1.54–2.26) | 47.3 | 0.13 | 0.47 | |
| HFrEF | 4 | 2.01 (1.78–2.27) | 0 | 0.84 | ||
| Study quality | ||||||
| 0 to <3 stars | 0 | 0.94 | ||||
| 3 to <6 stars | 7 | 1.63 (1.11–2.39) | 93.6 | <0.0001 | ||
| 6–8 stars | 30 | 1.71 (1.53–1.92) | 98.6 | <0.0001 | ||
| Adjustment for confounding factorsc | ||||||
| Age | Yes | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | NC |
| No | 0 | |||||
| Alcohol | Yes | 8 | 1.65 (1.33–2.06) | 99.0 | <0.0001 | 0.73 |
| No | 29 | 1.72 (1.52–1.95) | 97.3 | <0.0001 | ||
| Smoking | Yes | 28 | 1.61 (1.43–1.82) | 98.6 | <0.0001 | 0.01 |
| No | 9 | 2.03 (1.63–2.53) | 91.0 | <0.0001 | ||
| BMI or obesity | Yes | 27 | 1.62 (1.44–1.82) | 98.7 | <0.0001 | 0.04 |
| No | 10 | 2.01 (1.50–2.69) | 93.5 | <0.0001 | ||
| Physical activity | Yes | 11 | 1.59 (1.38–1.83) | 97.2 | <0.0001 | 0.34 |
| No | 16 | 1.75 (1.58–1.93) | 95.5 | <0.0001 | ||
| Cholesterol | Yes | 19 | 1.58 (1.42–1.76) | 95.8 | <0.0001 | 0.12 |
| No | 18 | 1.82 (1.61–2.06) | 96.6 | <0.0001 | ||
| Diabetes | Yes | 30 | 1.69 (1.48–1.92) | 98.6 | <0.0001 | 0.73 |
| No | 7 | 1.80 (1.40–2.32) | 86.5 | <0.0001 | ||
| Coronary heart disease | Yes | 14 | 1.60 (1.45–1.77) | 73.3 | <0.0001 | 0.28 |
| No | 23 | 1.78 (1.54–2.05) | 99.0 | <0.0001 | ||
| Valvular heart disease | Yes | 4 | 2.00 (1.37–2.94) | 97.3 | <0.0001 | 0.14 |
| No | 33 | 1.67 (1.49–1.86) | 98.4 | <0.0001 | ||
| Atrial fibrillation | Yes | 5 | 1.53 (0.90–2.60) | 99.3 | <0.0001 | 0.40 |
| No | 32 | 1.73 (1.58–1.89) | 96.5 | <0.0001 | ||
| Left ventricular hypertrophy | Yes | 4 | 1.90 (1.35–2.66) | 90.5 | <0.0001 | 0.58 |
| No | 33 | 1.69 (1.50–1.89) | 98.6 | <0.0001 | ||
| Hypertension and heart failure | ||||||
|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | ||
| All studies | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | ||
| Sex | ||||||
| Men | 12 | 1.71 (1.35–2.16) | 98.9 | <0.0001 | 0.80/0.79c | |
| Women | 10 | 1.78 (1.37–2.32) | 99.0 | <0.0001 | ||
| Men, women | 23 | 1.66 (1.53–1.80) | 88.2 | <0.0001 | ||
| Follow-up | ||||||
| <10 years | 15 | 1.81 (1.49–2.19) | 99.4 | <0.0001 | 0.37 | |
| ≥10 years | 22 | 1.64 (1.53–1.76) | 75.2 | <0.0001 | ||
| Geographic location | ||||||
| Europe | 14 | 1.61 (1.39–1.86) | 96.7 | <0.0001 | 0.58 | |
| America | 19 | 1.79 (1.57–2.04) | 92.0 | <0.0001 | ||
| Asia | 3 | 1.62 (1.13–2.31) | 99.7 | <0.0001 | ||
| International | 1 | 1.65 (1.33–2.05) | ||||
| Ethnicity | ||||||
| Caucasian | 4 | 1.98 (1.50–2.61) | 87.3 | <0.0001 | 0.04 | |
| African American | 6 | 1.98 (1.70–2.30) | 12.9 | 0.33 | ||
| Asian | 2 | 5.04 (1.86–13.69) | 19.3 | 0.27 | ||
| Hispanic | 2 | 4.10 (2.23–7.53) | 0 | 0.39 | ||
| Number of cases | ||||||
| Cases, <250 | 5 | 1.93 (1.23–3.05) | 80.9 | <0.0001 | 0.35 | |
| Cases, 250 to <500 | 9 | 1.66 (1.47–1.87) | 26.9 | 0.21 | ||
| Cases, 500 to <1000 | 8 | 1.88 (1.62–2.18) | 78.4 | <0.0001 | ||
| Cases, ≥1000 | 15 | 1.61 (1.37–1.89) | 99.4 | <0.0001 | ||
| Outcome subtype | ||||||
| HFpEF | 4 | 1.86 (1.54–2.26) | 47.3 | 0.13 | 0.47 | |
| HFrEF | 4 | 2.01 (1.78–2.27) | 0 | 0.84 | ||
| Study quality | ||||||
| 0 to <3 stars | 0 | 0.94 | ||||
| 3 to <6 stars | 7 | 1.63 (1.11–2.39) | 93.6 | <0.0001 | ||
| 6–8 stars | 30 | 1.71 (1.53–1.92) | 98.6 | <0.0001 | ||
| Adjustment for confounding factorsc | ||||||
| Age | Yes | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | NC |
| No | 0 | |||||
| Alcohol | Yes | 8 | 1.65 (1.33–2.06) | 99.0 | <0.0001 | 0.73 |
| No | 29 | 1.72 (1.52–1.95) | 97.3 | <0.0001 | ||
| Smoking | Yes | 28 | 1.61 (1.43–1.82) | 98.6 | <0.0001 | 0.01 |
| No | 9 | 2.03 (1.63–2.53) | 91.0 | <0.0001 | ||
| BMI or obesity | Yes | 27 | 1.62 (1.44–1.82) | 98.7 | <0.0001 | 0.04 |
| No | 10 | 2.01 (1.50–2.69) | 93.5 | <0.0001 | ||
| Physical activity | Yes | 11 | 1.59 (1.38–1.83) | 97.2 | <0.0001 | 0.34 |
| No | 16 | 1.75 (1.58–1.93) | 95.5 | <0.0001 | ||
| Cholesterol | Yes | 19 | 1.58 (1.42–1.76) | 95.8 | <0.0001 | 0.12 |
| No | 18 | 1.82 (1.61–2.06) | 96.6 | <0.0001 | ||
| Diabetes | Yes | 30 | 1.69 (1.48–1.92) | 98.6 | <0.0001 | 0.73 |
| No | 7 | 1.80 (1.40–2.32) | 86.5 | <0.0001 | ||
| Coronary heart disease | Yes | 14 | 1.60 (1.45–1.77) | 73.3 | <0.0001 | 0.28 |
| No | 23 | 1.78 (1.54–2.05) | 99.0 | <0.0001 | ||
| Valvular heart disease | Yes | 4 | 2.00 (1.37–2.94) | 97.3 | <0.0001 | 0.14 |
| No | 33 | 1.67 (1.49–1.86) | 98.4 | <0.0001 | ||
| Atrial fibrillation | Yes | 5 | 1.53 (0.90–2.60) | 99.3 | <0.0001 | 0.40 |
| No | 32 | 1.73 (1.58–1.89) | 96.5 | <0.0001 | ||
| Left ventricular hypertrophy | Yes | 4 | 1.90 (1.35–2.66) | 90.5 | <0.0001 | 0.58 |
| No | 33 | 1.69 (1.50–1.89) | 98.6 | <0.0001 | ||
n denotes the number of risk estimates.
BMI, body mass index; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; NC, not calculable.
aP for heterogeneity within each subgroup.
bP for heterogeneity between subgroups with meta-regression analysis.
cP for heterogeneity between men and women (excluding studies with both genders) with meta-regression analysis.
Subgroup analyses of hypertension and heart failure
| Hypertension and heart failure | ||||||
|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | ||
| All studies | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | ||
| Sex | ||||||
| Men | 12 | 1.71 (1.35–2.16) | 98.9 | <0.0001 | 0.80/0.79c | |
| Women | 10 | 1.78 (1.37–2.32) | 99.0 | <0.0001 | ||
| Men, women | 23 | 1.66 (1.53–1.80) | 88.2 | <0.0001 | ||
| Follow-up | ||||||
| <10 years | 15 | 1.81 (1.49–2.19) | 99.4 | <0.0001 | 0.37 | |
| ≥10 years | 22 | 1.64 (1.53–1.76) | 75.2 | <0.0001 | ||
| Geographic location | ||||||
| Europe | 14 | 1.61 (1.39–1.86) | 96.7 | <0.0001 | 0.58 | |
| America | 19 | 1.79 (1.57–2.04) | 92.0 | <0.0001 | ||
| Asia | 3 | 1.62 (1.13–2.31) | 99.7 | <0.0001 | ||
| International | 1 | 1.65 (1.33–2.05) | ||||
| Ethnicity | ||||||
| Caucasian | 4 | 1.98 (1.50–2.61) | 87.3 | <0.0001 | 0.04 | |
| African American | 6 | 1.98 (1.70–2.30) | 12.9 | 0.33 | ||
| Asian | 2 | 5.04 (1.86–13.69) | 19.3 | 0.27 | ||
| Hispanic | 2 | 4.10 (2.23–7.53) | 0 | 0.39 | ||
| Number of cases | ||||||
| Cases, <250 | 5 | 1.93 (1.23–3.05) | 80.9 | <0.0001 | 0.35 | |
| Cases, 250 to <500 | 9 | 1.66 (1.47–1.87) | 26.9 | 0.21 | ||
| Cases, 500 to <1000 | 8 | 1.88 (1.62–2.18) | 78.4 | <0.0001 | ||
| Cases, ≥1000 | 15 | 1.61 (1.37–1.89) | 99.4 | <0.0001 | ||
| Outcome subtype | ||||||
| HFpEF | 4 | 1.86 (1.54–2.26) | 47.3 | 0.13 | 0.47 | |
| HFrEF | 4 | 2.01 (1.78–2.27) | 0 | 0.84 | ||
| Study quality | ||||||
| 0 to <3 stars | 0 | 0.94 | ||||
| 3 to <6 stars | 7 | 1.63 (1.11–2.39) | 93.6 | <0.0001 | ||
| 6–8 stars | 30 | 1.71 (1.53–1.92) | 98.6 | <0.0001 | ||
| Adjustment for confounding factorsc | ||||||
| Age | Yes | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | NC |
| No | 0 | |||||
| Alcohol | Yes | 8 | 1.65 (1.33–2.06) | 99.0 | <0.0001 | 0.73 |
| No | 29 | 1.72 (1.52–1.95) | 97.3 | <0.0001 | ||
| Smoking | Yes | 28 | 1.61 (1.43–1.82) | 98.6 | <0.0001 | 0.01 |
| No | 9 | 2.03 (1.63–2.53) | 91.0 | <0.0001 | ||
| BMI or obesity | Yes | 27 | 1.62 (1.44–1.82) | 98.7 | <0.0001 | 0.04 |
| No | 10 | 2.01 (1.50–2.69) | 93.5 | <0.0001 | ||
| Physical activity | Yes | 11 | 1.59 (1.38–1.83) | 97.2 | <0.0001 | 0.34 |
| No | 16 | 1.75 (1.58–1.93) | 95.5 | <0.0001 | ||
| Cholesterol | Yes | 19 | 1.58 (1.42–1.76) | 95.8 | <0.0001 | 0.12 |
| No | 18 | 1.82 (1.61–2.06) | 96.6 | <0.0001 | ||
| Diabetes | Yes | 30 | 1.69 (1.48–1.92) | 98.6 | <0.0001 | 0.73 |
| No | 7 | 1.80 (1.40–2.32) | 86.5 | <0.0001 | ||
| Coronary heart disease | Yes | 14 | 1.60 (1.45–1.77) | 73.3 | <0.0001 | 0.28 |
| No | 23 | 1.78 (1.54–2.05) | 99.0 | <0.0001 | ||
| Valvular heart disease | Yes | 4 | 2.00 (1.37–2.94) | 97.3 | <0.0001 | 0.14 |
| No | 33 | 1.67 (1.49–1.86) | 98.4 | <0.0001 | ||
| Atrial fibrillation | Yes | 5 | 1.53 (0.90–2.60) | 99.3 | <0.0001 | 0.40 |
| No | 32 | 1.73 (1.58–1.89) | 96.5 | <0.0001 | ||
| Left ventricular hypertrophy | Yes | 4 | 1.90 (1.35–2.66) | 90.5 | <0.0001 | 0.58 |
| No | 33 | 1.69 (1.50–1.89) | 98.6 | <0.0001 | ||
| Hypertension and heart failure | ||||||
|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | ||
| All studies | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | ||
| Sex | ||||||
| Men | 12 | 1.71 (1.35–2.16) | 98.9 | <0.0001 | 0.80/0.79c | |
| Women | 10 | 1.78 (1.37–2.32) | 99.0 | <0.0001 | ||
| Men, women | 23 | 1.66 (1.53–1.80) | 88.2 | <0.0001 | ||
| Follow-up | ||||||
| <10 years | 15 | 1.81 (1.49–2.19) | 99.4 | <0.0001 | 0.37 | |
| ≥10 years | 22 | 1.64 (1.53–1.76) | 75.2 | <0.0001 | ||
| Geographic location | ||||||
| Europe | 14 | 1.61 (1.39–1.86) | 96.7 | <0.0001 | 0.58 | |
| America | 19 | 1.79 (1.57–2.04) | 92.0 | <0.0001 | ||
| Asia | 3 | 1.62 (1.13–2.31) | 99.7 | <0.0001 | ||
| International | 1 | 1.65 (1.33–2.05) | ||||
| Ethnicity | ||||||
| Caucasian | 4 | 1.98 (1.50–2.61) | 87.3 | <0.0001 | 0.04 | |
| African American | 6 | 1.98 (1.70–2.30) | 12.9 | 0.33 | ||
| Asian | 2 | 5.04 (1.86–13.69) | 19.3 | 0.27 | ||
| Hispanic | 2 | 4.10 (2.23–7.53) | 0 | 0.39 | ||
| Number of cases | ||||||
| Cases, <250 | 5 | 1.93 (1.23–3.05) | 80.9 | <0.0001 | 0.35 | |
| Cases, 250 to <500 | 9 | 1.66 (1.47–1.87) | 26.9 | 0.21 | ||
| Cases, 500 to <1000 | 8 | 1.88 (1.62–2.18) | 78.4 | <0.0001 | ||
| Cases, ≥1000 | 15 | 1.61 (1.37–1.89) | 99.4 | <0.0001 | ||
| Outcome subtype | ||||||
| HFpEF | 4 | 1.86 (1.54–2.26) | 47.3 | 0.13 | 0.47 | |
| HFrEF | 4 | 2.01 (1.78–2.27) | 0 | 0.84 | ||
| Study quality | ||||||
| 0 to <3 stars | 0 | 0.94 | ||||
| 3 to <6 stars | 7 | 1.63 (1.11–2.39) | 93.6 | <0.0001 | ||
| 6–8 stars | 30 | 1.71 (1.53–1.92) | 98.6 | <0.0001 | ||
| Adjustment for confounding factorsc | ||||||
| Age | Yes | 37 | 1.71 (1.53–1.90) | 98.4 | <0.0001 | NC |
| No | 0 | |||||
| Alcohol | Yes | 8 | 1.65 (1.33–2.06) | 99.0 | <0.0001 | 0.73 |
| No | 29 | 1.72 (1.52–1.95) | 97.3 | <0.0001 | ||
| Smoking | Yes | 28 | 1.61 (1.43–1.82) | 98.6 | <0.0001 | 0.01 |
| No | 9 | 2.03 (1.63–2.53) | 91.0 | <0.0001 | ||
| BMI or obesity | Yes | 27 | 1.62 (1.44–1.82) | 98.7 | <0.0001 | 0.04 |
| No | 10 | 2.01 (1.50–2.69) | 93.5 | <0.0001 | ||
| Physical activity | Yes | 11 | 1.59 (1.38–1.83) | 97.2 | <0.0001 | 0.34 |
| No | 16 | 1.75 (1.58–1.93) | 95.5 | <0.0001 | ||
| Cholesterol | Yes | 19 | 1.58 (1.42–1.76) | 95.8 | <0.0001 | 0.12 |
| No | 18 | 1.82 (1.61–2.06) | 96.6 | <0.0001 | ||
| Diabetes | Yes | 30 | 1.69 (1.48–1.92) | 98.6 | <0.0001 | 0.73 |
| No | 7 | 1.80 (1.40–2.32) | 86.5 | <0.0001 | ||
| Coronary heart disease | Yes | 14 | 1.60 (1.45–1.77) | 73.3 | <0.0001 | 0.28 |
| No | 23 | 1.78 (1.54–2.05) | 99.0 | <0.0001 | ||
| Valvular heart disease | Yes | 4 | 2.00 (1.37–2.94) | 97.3 | <0.0001 | 0.14 |
| No | 33 | 1.67 (1.49–1.86) | 98.4 | <0.0001 | ||
| Atrial fibrillation | Yes | 5 | 1.53 (0.90–2.60) | 99.3 | <0.0001 | 0.40 |
| No | 32 | 1.73 (1.58–1.89) | 96.5 | <0.0001 | ||
| Left ventricular hypertrophy | Yes | 4 | 1.90 (1.35–2.66) | 90.5 | <0.0001 | 0.58 |
| No | 33 | 1.69 (1.50–1.89) | 98.6 | <0.0001 | ||
n denotes the number of risk estimates.
BMI, body mass index; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; NC, not calculable.
aP for heterogeneity within each subgroup.
bP for heterogeneity between subgroups with meta-regression analysis.
cP for heterogeneity between men and women (excluding studies with both genders) with meta-regression analysis.
Subgroup analyses of systolic and diastolic blood pressure and heart failure
| Systolic blood pressure (per 20 mmHg) | Diastolic blood pressure (per 10 mmHg) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | n | RR (95% CI) | I2 (%) | Pha | Phb | ||
| All studies | 21 | 1.28 (1.22–1.35) | 90.3 | <0.0001 | 16 | 1.12 (1.04–1.21) | 92.6 | <0.0001 | 0.04 | ||
| Sex | |||||||||||
| Men | 8 | 1.28 (1.16–1.41) | 88.3 | <0.0001 | 0.90/0.92c | 4 | 1.15 (1.05–1.25) | 6.3 | 0.36 | 0.94/0.03c | |
| Women | 5 | 1.28 (1.18–1.39) | 83.2 | <0.0001 | 2 | 0.96 (0.90–1.03) | 0 | 0.61 | |||
| Men, women | 12 | 1.27 (1.18–1.37) | 90.5 | <0.0001 | 12 | 1.14 (1.04–1.24) | 94.0 | <0.0001 | |||
| Follow-up | |||||||||||
| <10 years | 11 | 1.22 (1.14–1.30) | 88.1 | <0.0001 | 0.05 | 9 | 1.02 (0.92–1.12) | 92.5 | <0.0001 | 0.04 | |
| ≥10 years | 10 | 1.38 (1.26–1.51) | 92.6 | <0.0001 | 7 | 1.28 (1.15–1.42) | 84.9 | <0.0001 | |||
| Geographic location | |||||||||||
| Europe | 8 | 1.26 (1.18–1.35) | 85.4 | <0.0001 | 0.46 | 6 | 1.21 (1.13–1.29) | 55.6 | 0.05 | 0.76 | |
| America | 12 | 1.28 (1.19–1.39) | 89.1 | <0.0001 | 9 | 1.06 (0.92–1.23) | 95.6 | <0.0001 | |||
| Asia | 1 | 1.47 (1.40–1.54) | 1 | 1.19 (1.13–1.27) | |||||||
| Ethnicity | |||||||||||
| White | 1 | 1.33 (1.21–1.46) | 0.71 | 0 | NC | ||||||
| Black | 3 | 1.61 (1.05–2.47) | 90.4 | <0.0001 | 2 | 1.28 (0.66–2.47) | 97.0 | <0.0001 | |||
| Number of cases | |||||||||||
| <250 | 4 | 1.47 (1.08–2.01) | 83.0 | <0.0001 | 0.36 | 6 | 1.25 (1.00–1.55) | 83.7 | <0.0001 | <0.0001 | |
| 250 to <500 | 4 | 1.36 (1.24–1.50) | 72.4 | 0.01 | 2 | 0.93 (0.85–1.01) | 0 | 0.85 | |||
| 500 to <1000 | 7 | 1.20 (1.10–1.30) | 90.1 | <0.0001 | 4 | 1.03 (0.84–1.25) | 97.6 | <0.0001 | |||
| ≥1000 | 6 | 1.30 (1.18–1.43) | 95.2 | <0.0001 | 4 | 1.20 (1.13–1.28) | 72.1 | 0.01 | |||
| Outcome subtype | |||||||||||
| HFrEF | 2 | 1.33 (1.20–1.48) | 0 | 0.40 | 0.19 | 2 | 0.97 (0.88–1.08) | 0 | 0.98 | 0.39 | |
| HFpEF | 2 | 1.35 (1.00–1.84) | 82.2 | <0.0001 | 2 | 0.85 (0.72–1.01) | 57.9 | 0.12 | |||
| HFbEFd | 1 | 1.52 (0.98–2.37) | 1 | 0.98 (0.69–1.41) | |||||||
| Study quality | |||||||||||
| 0 to <3 stars | 0 | 0.19 | 0 | 0.67 | |||||||
| 3 to <6 stars | 7 | 1.21 (1.14–1.28) | 77.9 | <0.0001 | 6 | 1.16 (1.06–1.26) | 86.6 | <0.0001 | |||
| 6–8 stars | 14 | 1.32 (1.24–1.42) | 89.8 | <0.0001 | 10 | 1.10 (0.98–1.24) | 92.3 | <0.0001 | |||
| Adjustment for confounding factorsc | |||||||||||
| Age | Yes | 20 | 1.28 (1.22–1.35) | 90.8 | <0.0001 | 0.91 | 15 | 1.14 (1.05–1.23) | 92.7 | <0.0001 | NC |
| No | 1 | 1.26 (1.00–1.57) | 1 | 0.78 (0.61–0.99) | |||||||
| Alcohol | Yes | 3 | 1.59 (1.29–1.97) | 88.4 | <0.0001 | 0.04 | 1 | 1.80 (1.49–2.18) | <0.0001 | ||
| No | 18 | 1.25 (1.19–1.32) | 90.2 | <0.0001 | 15 | 1.09 (1.01–1.18) | 92.4 | <0.0001 | |||
| Smoking | Yes | 16 | 1.31 (1.23–1.40) | 92.4 | <0.0001 | 0.29 | 11 | 1.13 (1.02–1.25) | 93.9 | <0.0001 | 0.55 |
| No | 5 | 1.22 (1.16–1.28) | 46.7 | 0.11 | 5 | 1.10 (0.93–1.29) | 90.2 | <0.0001 | |||
| BMI or obesity | Yes | 13 | 1.31 (1.22–1.40) | 93.0 | <0.0001 | 0.52 | 10 | 1.16 (1.05–1.29) | 94.1 | <0.0001 | 0.40 |
| No | 8 | 1.25 (1.16–1.34) | 78.7 | <0.0001 | 6 | 1.05 (0.89–1.23) | 90.2 | <0.0001 | |||
| Physical activity | Yes | 4 | 1.36 (1.22–1.52) | 83.7 | <0.0001 | 0.35 | 2 | 0.98 (0.89–1.06) | 0 | 0.33 | 0.05 |
| No | 17 | 1.26 (1.19–1.34) | 91.1 | <0.0001 | 14 | 1.14 (1.05–1.24) | 93.0 | <0.0001 | |||
| Cholesterol | Yes | 12 | 1.30 (1.20–1.4) | 91.9 | <0.0001 | 0.73 | 9 | 1.13 (0.98–1.29) | 94.8 | <0.0001 | 0.76 |
| No | 9 | 1.27 (1.19–1.36) | 84.8 | <0.0001 | 7 | 1.11 (1.01–1.22) | 87.3 | <0.0001 | |||
| Diabetes | Yes | 14 | 1.29 (1.19–1.39) | 92.4 | <0.0001 | 0.98 | 11 | 1.10 (0.99–1.22) | 91.4 | <0.0001 | 0.12 |
| No | 7 | 1.30 (1.26–1.35) | 29.3 | 0.21 | 5 | 1.21 (1.12–1.31) | 79.5 | 0.001 | |||
| Coronary heart disease | Yes | 5 | 1.19 (1.10–1.29) | 81.2 | <0.0001 | 0.17 | 4 | 1.07 (0.92–1.25) | 92.6 | <0.0001 | NC |
| No | 16 | 1.32 (1.24–1.41) | 91.8 | <0.0001 | 12 | 1.14 (1.03–1.26) | 93.2 | <0.0001 | |||
| Valvular heart disease | Yes | 2 | 1.22 (1.01–1.48) | 87.2 | 0.005 | 0.61 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 19 | 1.29 (1.22–1.36) | 90.9 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Atrial fibrillation | Yes | 3 | 1.21 (1.01–1.44) | 91.6 | <0.0001 | 0.40 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 18 | 1.30 (1.23–1.37) | 90.4 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Left ventricular heart disease | Yes | 3 | 1.52 (1.18–1.94) | 90.5 | <0.0001 | 0.21 | 3 | 1.31 (0.85–2.01) | 94.4 | <0.0001 | 0.67 |
| No | 18 | 1.27 (1.20–1.33) | 90.7 | <0.0001 | 13 | 1.09 (1.01–1.18) | 92.9 | <0.0001 | |||
| Systolic blood pressure (per 20 mmHg) | Diastolic blood pressure (per 10 mmHg) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | n | RR (95% CI) | I2 (%) | Pha | Phb | ||
| All studies | 21 | 1.28 (1.22–1.35) | 90.3 | <0.0001 | 16 | 1.12 (1.04–1.21) | 92.6 | <0.0001 | 0.04 | ||
| Sex | |||||||||||
| Men | 8 | 1.28 (1.16–1.41) | 88.3 | <0.0001 | 0.90/0.92c | 4 | 1.15 (1.05–1.25) | 6.3 | 0.36 | 0.94/0.03c | |
| Women | 5 | 1.28 (1.18–1.39) | 83.2 | <0.0001 | 2 | 0.96 (0.90–1.03) | 0 | 0.61 | |||
| Men, women | 12 | 1.27 (1.18–1.37) | 90.5 | <0.0001 | 12 | 1.14 (1.04–1.24) | 94.0 | <0.0001 | |||
| Follow-up | |||||||||||
| <10 years | 11 | 1.22 (1.14–1.30) | 88.1 | <0.0001 | 0.05 | 9 | 1.02 (0.92–1.12) | 92.5 | <0.0001 | 0.04 | |
| ≥10 years | 10 | 1.38 (1.26–1.51) | 92.6 | <0.0001 | 7 | 1.28 (1.15–1.42) | 84.9 | <0.0001 | |||
| Geographic location | |||||||||||
| Europe | 8 | 1.26 (1.18–1.35) | 85.4 | <0.0001 | 0.46 | 6 | 1.21 (1.13–1.29) | 55.6 | 0.05 | 0.76 | |
| America | 12 | 1.28 (1.19–1.39) | 89.1 | <0.0001 | 9 | 1.06 (0.92–1.23) | 95.6 | <0.0001 | |||
| Asia | 1 | 1.47 (1.40–1.54) | 1 | 1.19 (1.13–1.27) | |||||||
| Ethnicity | |||||||||||
| White | 1 | 1.33 (1.21–1.46) | 0.71 | 0 | NC | ||||||
| Black | 3 | 1.61 (1.05–2.47) | 90.4 | <0.0001 | 2 | 1.28 (0.66–2.47) | 97.0 | <0.0001 | |||
| Number of cases | |||||||||||
| <250 | 4 | 1.47 (1.08–2.01) | 83.0 | <0.0001 | 0.36 | 6 | 1.25 (1.00–1.55) | 83.7 | <0.0001 | <0.0001 | |
| 250 to <500 | 4 | 1.36 (1.24–1.50) | 72.4 | 0.01 | 2 | 0.93 (0.85–1.01) | 0 | 0.85 | |||
| 500 to <1000 | 7 | 1.20 (1.10–1.30) | 90.1 | <0.0001 | 4 | 1.03 (0.84–1.25) | 97.6 | <0.0001 | |||
| ≥1000 | 6 | 1.30 (1.18–1.43) | 95.2 | <0.0001 | 4 | 1.20 (1.13–1.28) | 72.1 | 0.01 | |||
| Outcome subtype | |||||||||||
| HFrEF | 2 | 1.33 (1.20–1.48) | 0 | 0.40 | 0.19 | 2 | 0.97 (0.88–1.08) | 0 | 0.98 | 0.39 | |
| HFpEF | 2 | 1.35 (1.00–1.84) | 82.2 | <0.0001 | 2 | 0.85 (0.72–1.01) | 57.9 | 0.12 | |||
| HFbEFd | 1 | 1.52 (0.98–2.37) | 1 | 0.98 (0.69–1.41) | |||||||
| Study quality | |||||||||||
| 0 to <3 stars | 0 | 0.19 | 0 | 0.67 | |||||||
| 3 to <6 stars | 7 | 1.21 (1.14–1.28) | 77.9 | <0.0001 | 6 | 1.16 (1.06–1.26) | 86.6 | <0.0001 | |||
| 6–8 stars | 14 | 1.32 (1.24–1.42) | 89.8 | <0.0001 | 10 | 1.10 (0.98–1.24) | 92.3 | <0.0001 | |||
| Adjustment for confounding factorsc | |||||||||||
| Age | Yes | 20 | 1.28 (1.22–1.35) | 90.8 | <0.0001 | 0.91 | 15 | 1.14 (1.05–1.23) | 92.7 | <0.0001 | NC |
| No | 1 | 1.26 (1.00–1.57) | 1 | 0.78 (0.61–0.99) | |||||||
| Alcohol | Yes | 3 | 1.59 (1.29–1.97) | 88.4 | <0.0001 | 0.04 | 1 | 1.80 (1.49–2.18) | <0.0001 | ||
| No | 18 | 1.25 (1.19–1.32) | 90.2 | <0.0001 | 15 | 1.09 (1.01–1.18) | 92.4 | <0.0001 | |||
| Smoking | Yes | 16 | 1.31 (1.23–1.40) | 92.4 | <0.0001 | 0.29 | 11 | 1.13 (1.02–1.25) | 93.9 | <0.0001 | 0.55 |
| No | 5 | 1.22 (1.16–1.28) | 46.7 | 0.11 | 5 | 1.10 (0.93–1.29) | 90.2 | <0.0001 | |||
| BMI or obesity | Yes | 13 | 1.31 (1.22–1.40) | 93.0 | <0.0001 | 0.52 | 10 | 1.16 (1.05–1.29) | 94.1 | <0.0001 | 0.40 |
| No | 8 | 1.25 (1.16–1.34) | 78.7 | <0.0001 | 6 | 1.05 (0.89–1.23) | 90.2 | <0.0001 | |||
| Physical activity | Yes | 4 | 1.36 (1.22–1.52) | 83.7 | <0.0001 | 0.35 | 2 | 0.98 (0.89–1.06) | 0 | 0.33 | 0.05 |
| No | 17 | 1.26 (1.19–1.34) | 91.1 | <0.0001 | 14 | 1.14 (1.05–1.24) | 93.0 | <0.0001 | |||
| Cholesterol | Yes | 12 | 1.30 (1.20–1.4) | 91.9 | <0.0001 | 0.73 | 9 | 1.13 (0.98–1.29) | 94.8 | <0.0001 | 0.76 |
| No | 9 | 1.27 (1.19–1.36) | 84.8 | <0.0001 | 7 | 1.11 (1.01–1.22) | 87.3 | <0.0001 | |||
| Diabetes | Yes | 14 | 1.29 (1.19–1.39) | 92.4 | <0.0001 | 0.98 | 11 | 1.10 (0.99–1.22) | 91.4 | <0.0001 | 0.12 |
| No | 7 | 1.30 (1.26–1.35) | 29.3 | 0.21 | 5 | 1.21 (1.12–1.31) | 79.5 | 0.001 | |||
| Coronary heart disease | Yes | 5 | 1.19 (1.10–1.29) | 81.2 | <0.0001 | 0.17 | 4 | 1.07 (0.92–1.25) | 92.6 | <0.0001 | NC |
| No | 16 | 1.32 (1.24–1.41) | 91.8 | <0.0001 | 12 | 1.14 (1.03–1.26) | 93.2 | <0.0001 | |||
| Valvular heart disease | Yes | 2 | 1.22 (1.01–1.48) | 87.2 | 0.005 | 0.61 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 19 | 1.29 (1.22–1.36) | 90.9 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Atrial fibrillation | Yes | 3 | 1.21 (1.01–1.44) | 91.6 | <0.0001 | 0.40 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 18 | 1.30 (1.23–1.37) | 90.4 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Left ventricular heart disease | Yes | 3 | 1.52 (1.18–1.94) | 90.5 | <0.0001 | 0.21 | 3 | 1.31 (0.85–2.01) | 94.4 | <0.0001 | 0.67 |
| No | 18 | 1.27 (1.20–1.33) | 90.7 | <0.0001 | 13 | 1.09 (1.01–1.18) | 92.9 | <0.0001 | |||
n denotes the number of risk estimates.
BMI, body mass index; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFbEF, heart failure with borderline ejection fraction; NC, not calculable.
aP for heterogeneity within each subgroup.
bP for heterogeneity between subgroups with meta-regression analysis.
cP for heterogeneity between men and women (excluding studies with both genders) with meta-regression analysis.
dHeart failure with borderline ejection fraction is the same as heart failure with midrange ejection fraction and is defined as ejection fraction between 41 and 49%.
Subgroup analyses of systolic and diastolic blood pressure and heart failure
| Systolic blood pressure (per 20 mmHg) | Diastolic blood pressure (per 10 mmHg) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | n | RR (95% CI) | I2 (%) | Pha | Phb | ||
| All studies | 21 | 1.28 (1.22–1.35) | 90.3 | <0.0001 | 16 | 1.12 (1.04–1.21) | 92.6 | <0.0001 | 0.04 | ||
| Sex | |||||||||||
| Men | 8 | 1.28 (1.16–1.41) | 88.3 | <0.0001 | 0.90/0.92c | 4 | 1.15 (1.05–1.25) | 6.3 | 0.36 | 0.94/0.03c | |
| Women | 5 | 1.28 (1.18–1.39) | 83.2 | <0.0001 | 2 | 0.96 (0.90–1.03) | 0 | 0.61 | |||
| Men, women | 12 | 1.27 (1.18–1.37) | 90.5 | <0.0001 | 12 | 1.14 (1.04–1.24) | 94.0 | <0.0001 | |||
| Follow-up | |||||||||||
| <10 years | 11 | 1.22 (1.14–1.30) | 88.1 | <0.0001 | 0.05 | 9 | 1.02 (0.92–1.12) | 92.5 | <0.0001 | 0.04 | |
| ≥10 years | 10 | 1.38 (1.26–1.51) | 92.6 | <0.0001 | 7 | 1.28 (1.15–1.42) | 84.9 | <0.0001 | |||
| Geographic location | |||||||||||
| Europe | 8 | 1.26 (1.18–1.35) | 85.4 | <0.0001 | 0.46 | 6 | 1.21 (1.13–1.29) | 55.6 | 0.05 | 0.76 | |
| America | 12 | 1.28 (1.19–1.39) | 89.1 | <0.0001 | 9 | 1.06 (0.92–1.23) | 95.6 | <0.0001 | |||
| Asia | 1 | 1.47 (1.40–1.54) | 1 | 1.19 (1.13–1.27) | |||||||
| Ethnicity | |||||||||||
| White | 1 | 1.33 (1.21–1.46) | 0.71 | 0 | NC | ||||||
| Black | 3 | 1.61 (1.05–2.47) | 90.4 | <0.0001 | 2 | 1.28 (0.66–2.47) | 97.0 | <0.0001 | |||
| Number of cases | |||||||||||
| <250 | 4 | 1.47 (1.08–2.01) | 83.0 | <0.0001 | 0.36 | 6 | 1.25 (1.00–1.55) | 83.7 | <0.0001 | <0.0001 | |
| 250 to <500 | 4 | 1.36 (1.24–1.50) | 72.4 | 0.01 | 2 | 0.93 (0.85–1.01) | 0 | 0.85 | |||
| 500 to <1000 | 7 | 1.20 (1.10–1.30) | 90.1 | <0.0001 | 4 | 1.03 (0.84–1.25) | 97.6 | <0.0001 | |||
| ≥1000 | 6 | 1.30 (1.18–1.43) | 95.2 | <0.0001 | 4 | 1.20 (1.13–1.28) | 72.1 | 0.01 | |||
| Outcome subtype | |||||||||||
| HFrEF | 2 | 1.33 (1.20–1.48) | 0 | 0.40 | 0.19 | 2 | 0.97 (0.88–1.08) | 0 | 0.98 | 0.39 | |
| HFpEF | 2 | 1.35 (1.00–1.84) | 82.2 | <0.0001 | 2 | 0.85 (0.72–1.01) | 57.9 | 0.12 | |||
| HFbEFd | 1 | 1.52 (0.98–2.37) | 1 | 0.98 (0.69–1.41) | |||||||
| Study quality | |||||||||||
| 0 to <3 stars | 0 | 0.19 | 0 | 0.67 | |||||||
| 3 to <6 stars | 7 | 1.21 (1.14–1.28) | 77.9 | <0.0001 | 6 | 1.16 (1.06–1.26) | 86.6 | <0.0001 | |||
| 6–8 stars | 14 | 1.32 (1.24–1.42) | 89.8 | <0.0001 | 10 | 1.10 (0.98–1.24) | 92.3 | <0.0001 | |||
| Adjustment for confounding factorsc | |||||||||||
| Age | Yes | 20 | 1.28 (1.22–1.35) | 90.8 | <0.0001 | 0.91 | 15 | 1.14 (1.05–1.23) | 92.7 | <0.0001 | NC |
| No | 1 | 1.26 (1.00–1.57) | 1 | 0.78 (0.61–0.99) | |||||||
| Alcohol | Yes | 3 | 1.59 (1.29–1.97) | 88.4 | <0.0001 | 0.04 | 1 | 1.80 (1.49–2.18) | <0.0001 | ||
| No | 18 | 1.25 (1.19–1.32) | 90.2 | <0.0001 | 15 | 1.09 (1.01–1.18) | 92.4 | <0.0001 | |||
| Smoking | Yes | 16 | 1.31 (1.23–1.40) | 92.4 | <0.0001 | 0.29 | 11 | 1.13 (1.02–1.25) | 93.9 | <0.0001 | 0.55 |
| No | 5 | 1.22 (1.16–1.28) | 46.7 | 0.11 | 5 | 1.10 (0.93–1.29) | 90.2 | <0.0001 | |||
| BMI or obesity | Yes | 13 | 1.31 (1.22–1.40) | 93.0 | <0.0001 | 0.52 | 10 | 1.16 (1.05–1.29) | 94.1 | <0.0001 | 0.40 |
| No | 8 | 1.25 (1.16–1.34) | 78.7 | <0.0001 | 6 | 1.05 (0.89–1.23) | 90.2 | <0.0001 | |||
| Physical activity | Yes | 4 | 1.36 (1.22–1.52) | 83.7 | <0.0001 | 0.35 | 2 | 0.98 (0.89–1.06) | 0 | 0.33 | 0.05 |
| No | 17 | 1.26 (1.19–1.34) | 91.1 | <0.0001 | 14 | 1.14 (1.05–1.24) | 93.0 | <0.0001 | |||
| Cholesterol | Yes | 12 | 1.30 (1.20–1.4) | 91.9 | <0.0001 | 0.73 | 9 | 1.13 (0.98–1.29) | 94.8 | <0.0001 | 0.76 |
| No | 9 | 1.27 (1.19–1.36) | 84.8 | <0.0001 | 7 | 1.11 (1.01–1.22) | 87.3 | <0.0001 | |||
| Diabetes | Yes | 14 | 1.29 (1.19–1.39) | 92.4 | <0.0001 | 0.98 | 11 | 1.10 (0.99–1.22) | 91.4 | <0.0001 | 0.12 |
| No | 7 | 1.30 (1.26–1.35) | 29.3 | 0.21 | 5 | 1.21 (1.12–1.31) | 79.5 | 0.001 | |||
| Coronary heart disease | Yes | 5 | 1.19 (1.10–1.29) | 81.2 | <0.0001 | 0.17 | 4 | 1.07 (0.92–1.25) | 92.6 | <0.0001 | NC |
| No | 16 | 1.32 (1.24–1.41) | 91.8 | <0.0001 | 12 | 1.14 (1.03–1.26) | 93.2 | <0.0001 | |||
| Valvular heart disease | Yes | 2 | 1.22 (1.01–1.48) | 87.2 | 0.005 | 0.61 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 19 | 1.29 (1.22–1.36) | 90.9 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Atrial fibrillation | Yes | 3 | 1.21 (1.01–1.44) | 91.6 | <0.0001 | 0.40 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 18 | 1.30 (1.23–1.37) | 90.4 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Left ventricular heart disease | Yes | 3 | 1.52 (1.18–1.94) | 90.5 | <0.0001 | 0.21 | 3 | 1.31 (0.85–2.01) | 94.4 | <0.0001 | 0.67 |
| No | 18 | 1.27 (1.20–1.33) | 90.7 | <0.0001 | 13 | 1.09 (1.01–1.18) | 92.9 | <0.0001 | |||
| Systolic blood pressure (per 20 mmHg) | Diastolic blood pressure (per 10 mmHg) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| n | RR (95%CI) | I2 (%) | Pha | Phb | n | RR (95% CI) | I2 (%) | Pha | Phb | ||
| All studies | 21 | 1.28 (1.22–1.35) | 90.3 | <0.0001 | 16 | 1.12 (1.04–1.21) | 92.6 | <0.0001 | 0.04 | ||
| Sex | |||||||||||
| Men | 8 | 1.28 (1.16–1.41) | 88.3 | <0.0001 | 0.90/0.92c | 4 | 1.15 (1.05–1.25) | 6.3 | 0.36 | 0.94/0.03c | |
| Women | 5 | 1.28 (1.18–1.39) | 83.2 | <0.0001 | 2 | 0.96 (0.90–1.03) | 0 | 0.61 | |||
| Men, women | 12 | 1.27 (1.18–1.37) | 90.5 | <0.0001 | 12 | 1.14 (1.04–1.24) | 94.0 | <0.0001 | |||
| Follow-up | |||||||||||
| <10 years | 11 | 1.22 (1.14–1.30) | 88.1 | <0.0001 | 0.05 | 9 | 1.02 (0.92–1.12) | 92.5 | <0.0001 | 0.04 | |
| ≥10 years | 10 | 1.38 (1.26–1.51) | 92.6 | <0.0001 | 7 | 1.28 (1.15–1.42) | 84.9 | <0.0001 | |||
| Geographic location | |||||||||||
| Europe | 8 | 1.26 (1.18–1.35) | 85.4 | <0.0001 | 0.46 | 6 | 1.21 (1.13–1.29) | 55.6 | 0.05 | 0.76 | |
| America | 12 | 1.28 (1.19–1.39) | 89.1 | <0.0001 | 9 | 1.06 (0.92–1.23) | 95.6 | <0.0001 | |||
| Asia | 1 | 1.47 (1.40–1.54) | 1 | 1.19 (1.13–1.27) | |||||||
| Ethnicity | |||||||||||
| White | 1 | 1.33 (1.21–1.46) | 0.71 | 0 | NC | ||||||
| Black | 3 | 1.61 (1.05–2.47) | 90.4 | <0.0001 | 2 | 1.28 (0.66–2.47) | 97.0 | <0.0001 | |||
| Number of cases | |||||||||||
| <250 | 4 | 1.47 (1.08–2.01) | 83.0 | <0.0001 | 0.36 | 6 | 1.25 (1.00–1.55) | 83.7 | <0.0001 | <0.0001 | |
| 250 to <500 | 4 | 1.36 (1.24–1.50) | 72.4 | 0.01 | 2 | 0.93 (0.85–1.01) | 0 | 0.85 | |||
| 500 to <1000 | 7 | 1.20 (1.10–1.30) | 90.1 | <0.0001 | 4 | 1.03 (0.84–1.25) | 97.6 | <0.0001 | |||
| ≥1000 | 6 | 1.30 (1.18–1.43) | 95.2 | <0.0001 | 4 | 1.20 (1.13–1.28) | 72.1 | 0.01 | |||
| Outcome subtype | |||||||||||
| HFrEF | 2 | 1.33 (1.20–1.48) | 0 | 0.40 | 0.19 | 2 | 0.97 (0.88–1.08) | 0 | 0.98 | 0.39 | |
| HFpEF | 2 | 1.35 (1.00–1.84) | 82.2 | <0.0001 | 2 | 0.85 (0.72–1.01) | 57.9 | 0.12 | |||
| HFbEFd | 1 | 1.52 (0.98–2.37) | 1 | 0.98 (0.69–1.41) | |||||||
| Study quality | |||||||||||
| 0 to <3 stars | 0 | 0.19 | 0 | 0.67 | |||||||
| 3 to <6 stars | 7 | 1.21 (1.14–1.28) | 77.9 | <0.0001 | 6 | 1.16 (1.06–1.26) | 86.6 | <0.0001 | |||
| 6–8 stars | 14 | 1.32 (1.24–1.42) | 89.8 | <0.0001 | 10 | 1.10 (0.98–1.24) | 92.3 | <0.0001 | |||
| Adjustment for confounding factorsc | |||||||||||
| Age | Yes | 20 | 1.28 (1.22–1.35) | 90.8 | <0.0001 | 0.91 | 15 | 1.14 (1.05–1.23) | 92.7 | <0.0001 | NC |
| No | 1 | 1.26 (1.00–1.57) | 1 | 0.78 (0.61–0.99) | |||||||
| Alcohol | Yes | 3 | 1.59 (1.29–1.97) | 88.4 | <0.0001 | 0.04 | 1 | 1.80 (1.49–2.18) | <0.0001 | ||
| No | 18 | 1.25 (1.19–1.32) | 90.2 | <0.0001 | 15 | 1.09 (1.01–1.18) | 92.4 | <0.0001 | |||
| Smoking | Yes | 16 | 1.31 (1.23–1.40) | 92.4 | <0.0001 | 0.29 | 11 | 1.13 (1.02–1.25) | 93.9 | <0.0001 | 0.55 |
| No | 5 | 1.22 (1.16–1.28) | 46.7 | 0.11 | 5 | 1.10 (0.93–1.29) | 90.2 | <0.0001 | |||
| BMI or obesity | Yes | 13 | 1.31 (1.22–1.40) | 93.0 | <0.0001 | 0.52 | 10 | 1.16 (1.05–1.29) | 94.1 | <0.0001 | 0.40 |
| No | 8 | 1.25 (1.16–1.34) | 78.7 | <0.0001 | 6 | 1.05 (0.89–1.23) | 90.2 | <0.0001 | |||
| Physical activity | Yes | 4 | 1.36 (1.22–1.52) | 83.7 | <0.0001 | 0.35 | 2 | 0.98 (0.89–1.06) | 0 | 0.33 | 0.05 |
| No | 17 | 1.26 (1.19–1.34) | 91.1 | <0.0001 | 14 | 1.14 (1.05–1.24) | 93.0 | <0.0001 | |||
| Cholesterol | Yes | 12 | 1.30 (1.20–1.4) | 91.9 | <0.0001 | 0.73 | 9 | 1.13 (0.98–1.29) | 94.8 | <0.0001 | 0.76 |
| No | 9 | 1.27 (1.19–1.36) | 84.8 | <0.0001 | 7 | 1.11 (1.01–1.22) | 87.3 | <0.0001 | |||
| Diabetes | Yes | 14 | 1.29 (1.19–1.39) | 92.4 | <0.0001 | 0.98 | 11 | 1.10 (0.99–1.22) | 91.4 | <0.0001 | 0.12 |
| No | 7 | 1.30 (1.26–1.35) | 29.3 | 0.21 | 5 | 1.21 (1.12–1.31) | 79.5 | 0.001 | |||
| Coronary heart disease | Yes | 5 | 1.19 (1.10–1.29) | 81.2 | <0.0001 | 0.17 | 4 | 1.07 (0.92–1.25) | 92.6 | <0.0001 | NC |
| No | 16 | 1.32 (1.24–1.41) | 91.8 | <0.0001 | 12 | 1.14 (1.03–1.26) | 93.2 | <0.0001 | |||
| Valvular heart disease | Yes | 2 | 1.22 (1.01–1.48) | 87.2 | 0.005 | 0.61 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 19 | 1.29 (1.22–1.36) | 90.9 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Atrial fibrillation | Yes | 3 | 1.21 (1.01–1.44) | 91.6 | <0.0001 | 0.40 | 1 | 0.91 (0.81–1.02) | NC | ||
| No | 18 | 1.30 (1.23–1.37) | 90.4 | <0.0001 | 15 | 1.14 (1.05–1.23) | 92.4 | <0.0001 | |||
| Left ventricular heart disease | Yes | 3 | 1.52 (1.18–1.94) | 90.5 | <0.0001 | 0.21 | 3 | 1.31 (0.85–2.01) | 94.4 | <0.0001 | 0.67 |
| No | 18 | 1.27 (1.20–1.33) | 90.7 | <0.0001 | 13 | 1.09 (1.01–1.18) | 92.9 | <0.0001 | |||
n denotes the number of risk estimates.
BMI, body mass index; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFbEF, heart failure with borderline ejection fraction; NC, not calculable.
aP for heterogeneity within each subgroup.
bP for heterogeneity between subgroups with meta-regression analysis.
cP for heterogeneity between men and women (excluding studies with both genders) with meta-regression analysis.
dHeart failure with borderline ejection fraction is the same as heart failure with midrange ejection fraction and is defined as ejection fraction between 41 and 49%.
Exclusion of three publications38,43,47 that used the ACC/AHA definition of hypertension (≥130 mmHg systolic blood pressure or ≥80 mmHg diastolic blood pressure) from the overall analysis did not substantially alter the summary estimate (summary RR = 1.70, 95% CI: 1.52–1.91, I2 = 96.9%, Pheterogeneity < 0.0001).
Evidence grading
Using the World Cancer Research Fund criteria (see Supplementary material online, Table S7) to evaluate the likelihood of causality, we concluded that there was convincing evidence that hypertension and elevated systolic blood pressure increase the risk of heart failure and probable evidence that diastolic blood pressure increases heart failure risk (see Supplementary material online, Tables S8 and S9). This was based on (i) highly robust and statistically significant associations for hypertension and systolic blood pressure, (ii) a large number of studies, which were (iii) consistent with regard to the direction of the association, although there was extreme heterogeneity due to differences in the strength of the association between studies, (iv) moderately high-quality studies that reduce the potential that biases could explain the association, and (v) there was for systolic and diastolic blood pressure evidence of a clear dose–response relationship, and (vi) there is also strong evidence supporting the biological plausibility of the findings, and in addition, the findings are supported by (vii) a Mendelian randomization (MR) study and (viii) randomized clinical trials on blood pressure lowering showing a clear reduction in heart failure risk with the use of blood pressure-lowering medications and evidence of a dose–response relationship between greater reductions in blood pressure and lower heart failure risk (see Discussion for details and references). Given that the number of studies was somewhat lower and results less consistent for diastolic blood pressure, we graded this association probable.
Discussion
In this meta-analysis of 47 cohort studies on hypertension status and blood pressure and heart failure risk, there was a 71% increase in the RR of heart failure among people with hypertension compared with those without hypertension, and there was a 28% and 12% increase in the RR of heart failure per 20 mmHg increment in systolic blood pressure and per 10 mmHg increment in diastolic blood pressure, respectively. The associations between systolic and diastolic blood pressure and heart failure risk appeared to be non-linear, and there was a steeper increase in risk at higher levels of blood pressure than at lower levels; however, the non-linearity was most pronounced for diastolic blood pressure. The associations between hypertension and systolic blood pressure and heart failure were in general consistent across subgroup analyses, and with a few exceptions, there was little evidence of heterogeneity between subgroups. The summary estimates were robust to the influence of individual studies. The association between diastolic blood pressure and heart failure was less consistent across subgroups. Using the World Cancer Research Fund criteria to evaluate the strength of evidence, we concluded that there was convincing evidence that hypertension and high systolic blood pressure increase heart failure risk and probable evidence that high diastolic blood pressure increases heart failure risk.
The findings of this meta-analysis are consistent with a pooled analysis of 61 prospective studies on blood pressure and mortality from heart failure, which found a HR of 0.53 (95% CI: 0.48–0.59) for a 20 mmHg lower systolic blood pressure,82 a pooled analysis of four cohort studies of elderly participants, which found a 74% increase in risk of heart failure with reduced ejection fraction and a 125% increase in risk of heart failure with preserved ejection fraction when comparing ≥140 vs. <120 mmHg of systolic blood pressure (although no association was observed for diastolic blood pressure), and a pooled analysis of six studies of younger participants, which found a systolic blood pressure (>140 mmHg) to be associated with a 51–74% increase in heart failure risk; however, diastolic blood pressure was only associated with increased heart failure risk in the youngest participants.83 The results are also consistent with a pooled analysis of three cohort studies, which found HRs in the range of 1.43–3.02 from older to younger age for participants with hypertension compared with those without hypertension.84 The current findings are also further supported by a recent MR study, which reported an OR of heart failure of 1.38 (95% CI: 1.25–1.53) per 10 mmHg increment in genetically predicted systolic blood pressure,85 while the current analysis showed a 28% increase in risk per 20 mmHg in systolic blood pressure, which is directionally similar but weaker than what was observed in the MR study. It is possible that the difference in the strength of the association could partly be due to (i) some of the observational cohort studies included in the current analysis having adjusted for potentially intermediate factors, (ii) regression dilution bias where measurement of blood pressure only at baseline does not take into account changes in blood pressure during follow-up, (iii) the impact of lifelong elevated blood pressure, which may be better assessed in the MR studies and which could have a stronger adverse impact on heart failure than blood pressure measured in middle age, or (iv) a combination of some or all these. The findings are also consistent with a meta-analysis of randomized trials that reported a 37% reduction in heart failure risk among subjects randomized to blood pressure-lowering drugs.86 Of note, there was a dose-dependent reduction in heart failure risk with greater blood pressure lowering,86 which is consistent with our finding of a dose–response relationship between higher systolic and diastolic blood pressure and heart failure risk.
Several mechanisms could explain the association between high blood pressure or hypertension and increased risk of heart failure. Hypertension is associated with both structural changes, including left atrial enlargement, left ventricular hypertrophy, and myocardial fibrosis, and functional changes, including left ventricular systolic and diastolic dysfunction, that are driven by both haemodynamic and non-haemodynamic factors. High blood pressure increases the left ventricular afterload and peripheral vascular resistance, which over time can lead to left ventricular structural remodelling,79,87 and it is associated with endothelial dysfunction, ischaemia, inflammation, and resulting apoptosis and fibrosis.88,89 Hyperplasia of fibroblasts and hypertrophy of the vascular smooth muscle layer, accompanied by expansion of interstitial collagen, result in changes in the density of intramyocardial capillaries and arteriolar thickening, which contributes to ischaemia.90 These structural changes lead to physical stress and upregulation of hypertrophy-related genes, leading to left ventricular hypertrophy and left ventricular diastolic dysfunction, which can progress to heart failure.90 Although ventricular hypertrophy initially is a compensatory mechanism in response to chronic pressure overload that preserves the cardiac output and delays cardiac failure, the remodelled left ventricle is likely to decompensate, and increased left ventricular stiffness and the presence of diastolic dysfunction can lead to heart failure.91 It has also been hypothesized that hypertensive patients can progress from concentric left ventricular hypertrophy to left ventricular dilatation to systolic dysfunction, leading to heart failure.92 In epidemiological studies, higher blood pressure has been strongly associated with increased risk of left ventricular hypertrophy,93 which increases the risk of coronary heart disease94 and atrial fibrillation94 (conditions that are strongly associated with increased risk of heart failure,34,37,49) and heart failure.95
Systematic review and meta-analysis have both strengths and limitations. Inclusion of cohort studies ensured that hypertension status or blood pressure was assessed before the occurrence of heart failure, avoiding the potential for recall bias and reducing the potential for selection bias and reverse causation to have impacted the results. With a total of over 20 million participants and more than 166 000 cases included in the analysis of hypertension, there was sufficient statistical power to detect even a modest association between hypertension and heart failure. Further strengths include the high study quality of the included studies, as well as the detailed subgroup and sensitivity analyses, which showed that the observed associations were robust in different strata and to the influence of any individual studies. The current meta-analysis also has some limitations, including potential confounding, errors in the exposure and outcome assessment, reverse causation, heterogeneity between studies, and differences in the definition of hypertension. Although only cohort studies with adjusted RR estimates were included in the meta-analysis, residual confounding cannot be completely excluded; however, some studies may also have over-adjusted by including mediating factors on the pathway from elevated blood pressure to heart failure in the multivariable models, such as coronary heart disease and atrial fibrillation. However, the observed associations persisted across a range of subgroup analyses by adjustment for various confounding factors including age, alcohol, smoking, BMI, physical activity, serum cholesterol, and diabetes and by adjustment for potential intermediate factors such as coronary heart disease, valvular heart disease, atrial fibrillation, and left ventricular hypertrophy, and there was little indication of between subgroup heterogeneity in these analyses. While blood pressure was measured in the included studies, hypertension status was additionally based on medical history of elevated blood pressure or treatment with blood pressure-lowering medications in many studies. Changes in blood pressure or hypertension status during follow-up were not usually assessed as most of the included studies only had a baseline assessment; however, any changes in exposure status would most likely have led to regression dilution bias and, if anything, underestimation of the observed associations. The outcome was assessed by linkages of medical records and/or death records across studies, and any inaccuracies in such records would most likely lead to underestimation of the observed association as the analysis was based on cohort studies. Reverse causation could potentially have influenced the results; however, the vast majority of studies excluded participants with prevalent heart failure (only two studies did not exclude prevalent cases in both the analysis of hypertension and systolic blood pressure, while all studies on diastolic blood pressure made such exclusions). It is possible that some patients with heart failure could have been asymptomatic; however, reverse causation would have the most impact in the early follow-up of the studies, and the observed associations persisted among studies with longer follow-up (10+ years), suggesting this is a less likely explanation. Although there was high heterogeneity in the analyses as measured by I2, the heterogeneity in the analyses of hypertension and systolic blood pressure was driven by differences in the strength of the association rather than differences in the direction of the observed association, as all the included studies reported RRs above 1. This is less problematic than when there is heterogeneity with regard to the direction of the observed associations as observed in the analysis of diastolic blood pressure and heart failure, where studies showed a mix of positive, null, and inverse associations. Although publication bias can affect meta-analyses of published studies, there was no indication of publication bias across the analyses; however, given that fewer studies reported on diastolic pressure, it is possible that some degree of selective reporting could have influenced those results, and any further studies should clarify the association between diastolic blood pressure and heart failure. Differences in the definition of hypertension could have affected the results as the ACC/AHA defines hypertension at a lower cut-off of blood pressure10 than what has been used traditionally as cut-off values.9 The majority of studies used the traditional cut-off values, registry diagnosis of hypertension, self-report of hypertension status, or antihypertensive medication use to define hypertension status, and the exclusion of three studies that used the lower cut-off point did not substantially alter the overall summary estimate. However, a more appropriate approach to test whether there are differences in results between the two definitions would be to compare analyses using the two different definitions within the same data set, and this could be a point for any future studies to address. Lastly, we cannot completely exclude the possibility that some studies may have been missed by the literature search; however, the screening was done in duplicate, and we consider it less likely that studies were missed in the screening process. Given a large number of studies and participants and cases included in the analyses, any missed studies would have to be extremely large to substantially alter the results of our study, and we therefore consider this less likely.
The current systematic review and meta-analysis provide strong support for the role of high blood pressure in the development of heart failure and, combined with other evidence, support a causal relationship between high blood pressure and heart failure risk. Some of the main determinants for elevated blood pressure include high BMI, low physical activity, smoking, dietary factors like high intakes of salt and low intakes of fruit and vegetables, and medication use96 and could be targets for interventions to reduce blood pressure for the primary prevention of heart failure. Given the epidemic of obesity and inactivity globally and the relationship between obesity and low physical activity and increased heart failure risk,7,8 policies to reduce adiposity and increase physical activity are likely to be important for preventing not only heart failure but also a range of other cardiovascular and chronic diseases. Because the majority of the studies considered were from Europe, America, and Asia, more research is needed to confirm these relationships in other geographic locations; however, given the current consistency of the associations across regions, we think it is likely that the current findings are widely applicable.
Conclusion
In this meta-analysis of 47 cohort studies, there was a 71% increase in the RR of heart failure for persons with compared with without hypertension and a 28% and 12% increase in the RR of heart failure per 20 mmHg increment in systolic blood pressure and per 10 mmHg increment in diastolic blood pressure, respectively. These findings provide strong evidence that hypertension and elevated systolic and diastolic blood pressure increase the risk of heart failure. These findings provide support for targeted interventions to reduce the blood pressure level in the general population.
Supplementary material
Supplementary material is available at European Journal of Preventive Cardiology.
Funding
D.A. was funded by the Helse Sør-Øst RHF (grant 2017076).
Data availability
The data sets used and/or analysed during the current study available from the corresponding author on reasonable request.
Authors’ contributions
D.A. contributed to the conception or design of the work. P.K.B., L.J., S.J., D.A., and A.S. contributed to the acquisition, analysis, or interpretation of data for the work. P.K.B., D.A., and A.S. drafted the manuscript. P.K.B., L.J., S.J., D.A., and A.S. critically revised the manuscript. All gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.
Ethical approval and consent to participate
Ethical approval and consent to participate were not needed for this study as it used already published data.
Registration and protocol
A protocol was developed for the study that was submitted to the administration at the Norwegian University of Science and Technology, but this was not registered in a public registry.
References
Author notes
Conflict of interest: none declared.
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