Blood pressure and incidence of twelve cardiovascular diseases

The Problem

High blood pressure is the leading risk factor for the overall global burden of disease and is a major risk factor for all forms of major cardiovascular disease (CVD) events. Prevalence of CVD is rising despite a reduction in CVD mortality. CVD represents a single family of diseases and conditions linked by common risk factors and the direct effect they have on CVD mortality and morbidity, and should be managed as such. However, CVD is commonly studied as a single construct.  An understanding of the contemporary associations of blood pressure across a wide range of incident CVDs across a broad age range and a wider range of blood pressure values would help to refine strategies for primary prevention and inform the design of future clinical trials. 

Our Research

Using linked EHR data from primary care and hospital databases, we analysed data on 1.25m people in the CALIBER database with no previous diagnosis of CVD who had at least one baseline blood pressure measurement to investigate the association between blood pressure and 12 different presentations of CVD.  

Our study found substantial heterogeneity in associations with blood pressure across CVDs and ages. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage, subarachnoid haemorrhage, and stable angina and weakest for abdominal aortic aneurysm. 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.

incidence_forestplot

Our study has important implications for clinical practice. This research showed the high burden of CVDs such as stable and unstable angina, and heart failure in older age (>=80 years). The lifetime burden of blood pressure in relation to different CVDs that we observed in this study can be used to inform decision-making and extend counselling treatments of patients.  Our findings also emphasise unmet need in the form of improved blood pressure management and better management of other CVD risk factors as part of global risk estimation, to reduce risks of CVD. Study findings could help to refine strategies for primary prevention and inform the design of future clinical trials. For example, while heart failure and peripheral arterial disease are observed to be common initial presentations of CVD, they are included less frequently in the primary outcome of blood pressure-lowering trials.

New and existing clinical trials investigating the effectiveness of blood pressure-lowering strategies should include other common initial presentation of CVD presentations as the primary outcome.

We found substantial heterogeneity in associations with blood pressure across CVDs and ages, and identified a continuing failure to meet guideline targets for blood pressure control.  

Themes

Diseases

People 

  • Prof Harry Hemingway
  • Dr Spiros Denaxas
  • Prof Aroon Hingorani 
  • Prof Adam Timmis
  • Dr Julie George
  • Dr Mar Pujades-Rodriguez
  • Dr Anoop D Shah 

Collaborators

  • Dr Eleni Rapsomaniki
  • Prof Ian R White
  • Prof Mark J Caulfield
  • Prof John E Deanfield
  • Prof Liam Smeeth
  • Prof Bryan Williams

Publications

Rapsomaniki E, Timmis A, George J, Pujades-Rodriguez M, Shah AD, Denaxas S et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. The Lancet 2014; 383(9932):1899-1911. doi: 10.1016/S0140-6736(14)60685-1.

Impact in research