Impact of hypertension diagnosis on morbidity and mortality: a retrospective cohort study in primary care

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Abstract

Background

Hypertension is responsible for a huge burden of disease. The aim of this study was to evaluate the impact of newly diagnosed hypertension on the occurrence of kidney or cardiovascular events (K/CVEs) and on mortality among community dwellers.

Methods

Retrospective cohort study, conducted from January, 2007, to December, 2018. All patients (age > 18) newly diagnosed with hypertension and no previous K/CVEs in 2007 and 2008, in the primary care centers of Madrid (Spain) ( n = 71,770), were enrolled. The control group ( n = 72,946) included patients without hypertension, matched by center, sex and age. The occurrence of kidney or CV events, including mortality from these causes and total mortality were evaluated using Cox regression and multistate models. Data were collected from three sources: personal data from administrative records, clinical data from medical records, and mortality data from regional and national databases.

Results

The median follow-up was 138.61 months (IQR: 124.68–143.97 months). There were 32,896 K/CVEs (including 3,669 deaths from these causes) and 12,999 deaths from other causes. Adjusted for sex, smoking, diabetes and socioeconomic status, K/CVEs HR was 4.36 (95% CI: 3.80–5.00) for diagnoses before 45 years of age, 2.45(95% CI: 2.28- 2.63) for diagnosis between 45 to 54 years, and HR decreased to 1.86 (95% CI: 1.64–210) for diagnoses over age 85. Total mortality risk was only higher for hypertension diagnosed before 55 years of age (HR: 2.47, 95% CI: 1.90–3.19 for ages 18 to 44; and HR: 1.14, 95% CI: 1.02–1.28 for ages 45 to 54).

Conclusion

The diagnosis of hypertension in the community environment, in patients without evidence of previous kidney or CV disease, is associated with a large increase in the risk of K/CVEs, but especially in individuals diagnosed before the age of 55. This diagnosis is only associated with an increase in kidney or cardiovascular mortality or overall mortality when it occurs before age 55.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-023-02036-2.

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Most cited references 41

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Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

José Huerta (2021)

Summary Background Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. Methods We used data from 1990 to 2019 on people aged 30–79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. Findings The number of people aged 30–79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306–359) million women and 317 (292–344) million men in 1990 to 626 (584–668) million women and 652 (604–698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55–62) of women and 49% (46–52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43–51) of women and 38% (35–41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20–27) for women and 18% (16–21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. Interpretation Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. Funding WHO.

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Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015

Mohammad Forouzanfar, Patrick T Liu, Gregory A Roth … (2017)

Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions.

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Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people

Eleni Rapsomaniki, Adam Timmis, Julie George … (2014)

Summary Background The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared. In this study, we aimed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease. Methods We used linked electronic health records from 1997 to 2010 in the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme to assemble a cohort of 1·25 million patients, 30 years of age or older and initially free from cardiovascular disease, a fifth of whom received blood pressure-lowering treatments. We studied the heterogeneity in the age-specific associations of clinically measured blood pressure with 12 acute and chronic cardiovascular diseases, and estimated the lifetime risks (up to 95 years of age) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30, 60, and 80 years. This study is registered at ClinicalTrials.gov, number NCT01164371. Findings During 5·2 years median follow-up, we recorded 83 098 initial cardiovascular disease presentations. In each age group, the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90–114 mm Hg and diastolic blood pressure of 60–74 mm Hg, with no evidence of a J-shaped increased risk at lower blood pressures. The effect of high blood pressure varied by cardiovascular disease endpoint, from strongly positive to no effect. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage (hazard ratio 1·44 [95% CI 1·32–1·58]), subarachnoid haemorrhage (1·43 [1·25–1·63]), and stable angina (1·41 [1·36–1·46]), and weakest for abdominal aortic aneurysm (1·08 [1·00–1·17]). Compared with diastolic blood pressure, raised systolic blood pressure had a greater effect on angina, myocardial infarction, and peripheral arterial disease, whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure. Pulse pressure associations were inverse for abdominal aortic aneurysm (HR per 10 mm Hg 0·91 [95% CI 0·86–0·98]) and strongest for peripheral arterial disease (1·23 [1·20–1·27]). People with hypertension (blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3% (95% CI 62·9–63·8) compared with 46·1% (45·5–46·8) for those with normal blood pressure, and developed cardiovascular disease 5·0 years earlier (95% CI 4·8–5·2). Stable and unstable angina accounted for most (43%) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years, whereas heart failure and stable angina accounted for the largest proportion (19% each) of years of life lost from index age 80 years. Interpretation The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them. Funding Medical Research Council, National Institute for Health Research, and Wellcome Trust.

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Author and article information

Contributors

Jesus Martín-Fernández:

ORCID: http://orcid.org/0000-0001-9545-1549

jmfernandez@salud.madrid.org

Tamara Alonso-Safont:

ORCID: http://orcid.org/0000-0003-3837-0085

mtamara.alonso@salud.madrid.org

Elena Polentinos-Castro:

ORCID: http://orcid.org/0000-0001-9460-2966

elena.polentinos@salud.madrid.org

Maria Dolores Esteban-Vasallo:

ORCID: http://orcid.org/0000-0003-0610-9528

maria.estebanv@salud.madrid.org

Gloria Ariza-Cardiel:

ORCID: http://orcid.org/0000-0002-4635-9604

mariagloria.ariza@salud.madrid.org

Mª Isabel González-Anglada:

ORCID: http://orcid.org/0000-0002-5510-5323

mganglada@salud.madrid.org

Luis Sánchez-Perruca:

ORCID: http://orcid.org/0000-0001-5915-4184

luis.sanchez@salud.madrid.org

Gemma Rodríguez-Martínez: grodriguezm@salud.madrid.org

Rafael Rotaeche-del-Campo:

ORCID: http://orcid.org/0000-0001-5594-3768

RAFAELJESUSMARIA.ROTAECHEDELCAMPO@osakidetza.eus

Amaia Bilbao-González:

ORCID: http://orcid.org/0000-0002-2202-0753

AMAIA.BILBAOGONZALEZ@osakidetza.eus

Journal

Journal ID (nlm-ta): BMC Prim Care

Journal ID (iso-abbrev): BMC Prim Care

Title: BMC Primary Care

Publisher: BioMed Central (London )

ISSN (Electronic): 2731-4553

Publication date (Electronic): 23 March 2023

Publication date PMC-release: 23 March 2023

Publication date Collection: 2023

Volume: 24

Electronic Location Identifier: 79

Affiliations

[1 ]GRID grid.410361.1, ISNI 0000 0004 0407 4306, Oeste Family and Community Care Teaching Unit, , Primary Care Assistance Management, Madrid Health Service, ; Madrid, Spain

[2 ]GRID grid.28479.30, ISNI 0000 0001 2206 5938, Department of Medical Specialties and Public Health, Faculty of Health Sciences, , Rey Juan Carlos University, ; Madrid, Spain

[3 ]Health Services Research Network in Chronic Diseases, REDISSEC- ISCIII, Madrid, Spain

[4 ]GRID grid.413448.e, ISNI 0000 0000 9314 1427, Research Network On Chronicity, , Primary Care and Health Promotion-RICAPPS (RICORS), ISCIII, ; Madrid, Spain

[5 ]GRID grid.410526.4, ISNI 0000 0001 0277 7938, Gregorio Marañón Health Research Institute (IISGM), ; Madrid, Spain

[6 ]GRID grid.410361.1, ISNI 0000 0004 0407 4306, Technical Directorate of Health Information Systems, , Primary Care Assistance Management, Madrid Health Service, ; Madrid, Spain

[7 ]GRID grid.410361.1, ISNI 0000 0004 0407 4306, Research Unit, Primary Care Assistance Management, Madrid Health Service, ; Madrid, Spain

[8 ]GRID grid.436087.e, Health Reports and Studies Service, General Directorate of Public Health, Ministry of Health, ; Madrid, Spain

[9 ]GRID grid.411171.3, ISNI 0000 0004 0425 3881, Internal Medicine Service, Alcorcón Foundation University Hospital, ; Madrid, Spain

[10 ]GRID grid.410361.1, ISNI 0000 0004 0407 4306, Don Luis Infant Health Center, Primary Care Assistance Management, Madrid Health Service, ; Madrid, Spain

[11 ]GRID grid.426049.d, ISNI 0000 0004 1793 9479, Alza Health Center, Osakidetza, OSI Donostia, Research Group in AP IIS Biodonostia, ; San Sebastián, Spain

[12 ]GRID grid.414269.c, ISNI 0000 0001 0667 6181, Osakidetza, Basque Health Service, , Basurto University Hospital, Research and Innovation Unit, ; Bilbao, Spain

[13 ]GRID grid.424267.1, Kronikgune Health Services Research Institute, ; Barakaldo, Spain

[14 ]GRID grid.14724.34, ISNI 0000 0001 0941 7046, Department of Medicine, Faculty of Health Sciences, , University of Deusto, ; Bilbao, Spain

Author information

Jesus Martín-Fernández http://orcid.org/0000-0001-9545-1549

Tamara Alonso-Safont http://orcid.org/0000-0003-3837-0085

Elena Polentinos-Castro http://orcid.org/0000-0001-9460-2966

Maria Dolores Esteban-Vasallo http://orcid.org/0000-0003-0610-9528

Gloria Ariza-Cardiel http://orcid.org/0000-0002-4635-9604

Mª Isabel González-Anglada http://orcid.org/0000-0002-5510-5323

Luis Sánchez-Perruca http://orcid.org/0000-0001-5915-4184

Rafael Rotaeche-del-Campo http://orcid.org/0000-0001-5594-3768

Amaia Bilbao-González http://orcid.org/0000-0002-2202-0753

Article

Publisher ID: 2036

DOI: 10.1186/s12875-023-02036-2

PMC ID: 10037862

PubMed ID: 36959558

SO-VID: 0f0992ef-fecb-47c1-8abb-1d941de7fe9e

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 2 September 2022

Date accepted : 13 March 2023

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Keywords: hypertension,survival,cardiovascular disease,primary health care

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Keywords: hypertension, survival, cardiovascular disease, primary health care

Impact of hypertension diagnosis on morbidity and mortality: a retrospective cohort study in primary care

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Most cited references 41

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015

Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people

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