Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Special Issue: Current evidence and perspectives for hypertension management in Asia
  • Published:

Associations and attributable burden between risk factors and all-cause and cause-specific mortality at different ages in patients with hypertension

Hypertension Research volume 47, pages 2053–2063 (2024)Cite this article

A Comment to this article was published on 02 August 2024

Abstract

It remains unclear the age-specific associations of risk factors with deaths and mortality burden attributable across age. In a territory-wide retrospective cohort, 1,012,228 adults with hypertension were identified. Comorbidities including diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), heart failure, and cancer, and risk factors including current smoking and suboptimal control of blood pressure (BP), glucose and low-density lipoprotein cholesterol were defined. Associations of comorbidities/risk factors with all-cause and cause-specific mortality across age groups (18–54, 55–64, 65–74, and ≥75 years) were assessed. Population attributable fractions were also quantified. During a median follow-up of 10.7 years, 244,268 (24.1%) patients died, with pneumonia (7.2%), cancer (5.1%), and CVD (4.2%) being the leading causes. Despite increasing deaths with age, relative risk of mortality related to comorbidities/risk factors decreased with age; similar patterns were found for cause-specific mortality. The assessed risk factors accounted for 24.0% (95% CI 22.5%, 25.4%) deaths, with highest proportion in the youngest group (33.5% [28.1%, 38.5%] in 18–54 years vs 19.4% [17.0%, 21.6%] in ≥75 years). For mortality burden, CKD was the overall leading risk factor (12.7% [12.4%, 12.9%]) with higher proportions in older patients (11.1–13.1% in ≥65 years), while diabetes was the leading risk factor in younger patients (15.9–13.5% in 18–54 years). The association of comorbidities or risk factors with mortality is stronger in younger patients with hypertension, despite lower absolute mortality in young patients than in the elderly. Leading risk factors differed across age, highlighting the importance of targeted and precise risk management.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

Data will not be made available to others because the data custodians have not given permission. The syntax is available upon reasonable request.

References

  1. Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 Countries. Circulation. 2016;134:441–50.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Asayama K, Stolarz-Skrzypek K, Yang WY, Hansen TW, Brguljan-Hitij J, Odili AN, et al. What did we learn from the international databases on ambulatory and home blood pressure in relation to cardiovascular outcome? Hypertens Res. 2023;46:934–49.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347–60.

    Article  PubMed  Google Scholar 

  4. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123:933–44.

    Article  PubMed  Google Scholar 

  5. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398–404.

    Article  CAS  PubMed  Google Scholar 

  6. Wang JG, Zhang W, Li Y, Liu L. Hypertension in China: epidemiology and treatment initiatives. Nat Rev Cardiol. 2023;20:531–45.

    Article  PubMed  Google Scholar 

  7. Lauder L, Mahfoud F, Azizi M, Bhatt DL, Ewen S, Kario K, et al. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J. 2023;44:2066–77.

    Article  CAS  PubMed  Google Scholar 

  8. Wang C, Yuan Y, Zheng M, Pan A, Wang M, Zhao M, et al. Association of age of onset of hypertension with cardiovascular diseases and mortality. J Am Coll Cardiol. 2020;75:2921–30.

    Article  PubMed  Google Scholar 

  9. Lacey B, Lewington S, Clarke R, Kong XL, Chen Y, Guo Y, et al. Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0·5 million adults in China: a prospective cohort study. Lancet Glob Health. 2018;6:e641–e9.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Collaboration PS. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–13.

    Article  Google Scholar 

  11. Liu J, Zhao D, Liu J, Qi Y, Sun J, Wang W. Prevalence of diabetes mellitus in outpatients with essential hypertension in China: a cross-sectional study. BMJ Open. 2013;3:e003798.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Song J, Sheng CS, Huang QF, Li LH, Ma CS, Guo XH, et al. Management of hypertension and diabetes mellitus by cardiovascular and endocrine physicians: a China registry. J Hypertens. 2016;34:1648–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Zhang L, Wang F, Wang L, Wang W, Liu B, Liu J, et al. Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet. 2012;379:815–22.

    Article  PubMed  Google Scholar 

  14. Spiegelman D, Hertzmark E, Wand HC. Point and interval estimates of partial population attributable risks in cohort studies: examples and software. Cancer Causes Control. 2007;18:571–9.

    Article  CAS  PubMed  Google Scholar 

  15. Smith JR, Sharrett AR, Pike JR, Gottesman RF, Knopman DS, Lee M, et al. Dementia occurring over a 32-year follow-up attributable to hypertension observed at different ages: Implications for dementia prevention. Alzheimers Dement. 2023;19:3435–47.

    Article  PubMed  Google Scholar 

  16. Lee A. Seamless health care for chronic diseases in a dual health care system: managed care and the role of family physicians. J Manag Med. 1998;12:398–405, 322.

    Article  CAS  PubMed  Google Scholar 

  17. Yu EYT, Wan EYF, Mak IL, Chao DVK, Ko WWK, Leung M, et al. Assessment of hypertension complications and health service use 5 years after implementation of a multicomponent intervention. JAMA Netw Open. 2023;6:e2315064.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wan EY, Fung CS, Yu EY, Fong DY, Chen JY, Lam CL. Association of visit-to-visit variability of systolic blood pressure with cardiovascular disease and mortality in primary care chinese patients with type 2 diabetes-A retrospective population-based cohort study. Diabetes Care. 2017;40:270–9.

    Article  CAS  PubMed  Google Scholar 

  19. Jin Q, Lau ESH, Luk AO, Tam CHT, Ozaki R, Lim CKP et al. Circulating metabolomic markers linking diabetic kidney disease and incident cardiovascular disease in type 2 diabetes: analyses from the Hong Kong Diabetes Biobank. Diabetologia. 2024. https://doi.org/10.1007/s00125-024-06108-5.

  20. Jin Q, Kuen Lam CL, Fai Wan EY. Association of eGFR slope with all-cause mortality, macrovascular and microvascular outcomes in people with type 2 diabetes and early-stage chronic kidney disease. Diabetes Res Clin Pract. 2023;205:110924.

    Article  CAS  PubMed  Google Scholar 

  21. Jin Q, Luk AO, Lau ESH, Tam CHT, Ozaki R, Lim CKP, et al. Nonalbuminuric diabetic kidney disease and risk of all-cause mortality and cardiovascular and kidney outcomes in type 2 diabetes: findings from the hong kong diabetes biobank. Am J Kidney Dis. 2022;80:196–206.e1.

    Article  CAS  PubMed  Google Scholar 

  22. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–12.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75:1334–57.

    Article  CAS  PubMed  Google Scholar 

  24. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45:S83–96.

  25. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014;37 Suppl 1:S81-90.

  26. Ference BA, Ginsberg HN, Graham I, Ray KK, Packard CJ, Bruckert E, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J. 2017;38:2459–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Rubin DB. Multiple imputation for nonresponse in surveys. John Wiley & Sons; Hoboken, New Jersey; 2004.

  28. Mahmoodi BK, Matsushita K, Woodward M, Blankestijn PJ, Cirillo M, Ohkubo T, et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without hypertension: a meta-analysis. Lancet. 2012;380:1649–61.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hallan SI, Matsushita K, Sang Y, Mahmoodi BK, Black C, Ishani A, et al. Age and association of kidney measures with mortality and end-stage renal disease. JAMA. 2012;308:2349–60.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. van Vark LC, Bertrand M, Akkerhuis KM, Brugts JJ, Fox K, Mourad JJ, et al. Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin-angiotensin-aldosterone system inhibitors involving 158,998 patients. Eur Heart J. 2012;33:2088–97.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: a comparative risk assessment. Lancet Diabetes Endocrinol. 2014;2:634–47.

  32. Jacobs E, Hoyer A, Brinks R, Kuss O, Rathmann W. Burden of mortality attributable to diagnosed diabetes: a nationwide analysis based on claims data from 65 million people in Germany. Diabetes Care. 2017;40:1703–9.

    Article  PubMed  Google Scholar 

  33. Sugiyama D, Okamura T, Watanabe M, Higashiyama A, Okuda N, Nakamura Y, et al. Risk of hypercholesterolemia for cardiovascular disease and the population attributable fraction in a 24-year Japanese cohort study. J Atheroscler Thromb. 2015;22:95–107.

    Article  PubMed  Google Scholar 

  34. Gu D, Kelly TN, Wu X, Chen J, Samet JM, Huang J-f, et al. Mortality attributable to smoking in China. N. Engl J Med. 2009;360:150–9.

    Article  CAS  PubMed  Google Scholar 

  35. Ghazi L, Oparil S, Calhoun DA, Lin CP, Dudenbostel T. Distinctive risk factors and phenotype of younger patients with resistant hypertension: age is relevant. Hypertension. 2017;69:827–35.

    Article  CAS  PubMed  Google Scholar 

  36. Aguilar D. Preventing Heart Failure in People With Hypertension: The Time Is Now. JACC Heart Fail. 2023;11:689–90.

  37. Maeda D, Dotare T, Matsue Y, Teramoto K, Sunayama T, Tromp J, et al. Blood pressure in heart failure management and prevention. Hypertens Res 2023;46:817–33.

    Article  PubMed  Google Scholar 

  38. Anker SD, Usman MS, Butler J SGLT2 inhibitors: from antihyperglycemic agents to all-around heart failure therapy. In. Vol 146. Am Heart Assoc2022, 299-302.

  39. Kjeldsen SE, Stenehjem A, Os I, Van de Borne P, Burnier M, Narkiewicz K, et al. Treatment of high blood pressure in elderly and octogenarians: European Society of Hypertension statement on blood pressure targets. Blood Press. 2016;25:333–6.

    Article  PubMed  Google Scholar 

  40. Boshuizen HC, Izaks GJ, van Buuren S, Ligthart GJ. Blood pressure and mortality in elderly people aged 85 and older: community based study. BMJ. 1998;316:1780–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Daw J. Contribution of four comorbid conditions to racial/ethnic disparities in mortality risk. Am J Prevent Med. 2017;52:S95–S102.

    Article  Google Scholar 

  42. Murray CJL, Aravkin AY, Zheng P, Abbafati C, Abbas KM, Abbasi-Kangevari M, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1223–49.

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank the Statistics and Workforce Planning Department at the Hong Kong Hospital Authority for data extraction.

Funding

This study is supported by the start-up fund from the University of Hong Kong. No funding organization had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation of the manuscript.

Author information

Authors and Affiliations

  1. Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China

    Qiao Jin, Jie Mei, Yu Chit Wong, Cindy Lo Kuen Lam & Eric Yuk Fai Wan

  2. Department of Family Medicine, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China

    Cindy Lo Kuen Lam

  3. Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China

    Eric Yuk Fai Wan

  4. Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China

    Eric Yuk Fai Wan

Authors
  1. Qiao Jin
    View author publications

    Search author on:PubMed Google Scholar

  2. Jie Mei
    View author publications

    Search author on:PubMed Google Scholar

  3. Yu Chit Wong
    View author publications

    Search author on:PubMed Google Scholar

  4. Cindy Lo Kuen Lam
    View author publications

    Search author on:PubMed Google Scholar

  5. Eric Yuk Fai Wan
    View author publications

    Search author on:PubMed Google Scholar

Contributions

Study design and conception: QJ, EYFW; data acquisition: QJ, JM; statistical analysis: QJ, JM; data interpretation: QJ, EYFW; manuscript draft: QJ, EYFW; critical revision: QJ, CLKL, EYFW; funding acquisition: CLKL, EYFW; supervision or mentorship: EYFW. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Eric Yuk Fai Wan.

Ethics declarations

Conflict of interest

EYFW has received research grants from the Health Bureau, the Hong Kong Research Grant Council, the Narcotics Division of Security Bureau of the Government of the Hong Kong SAR, and National Natural Science Foundation of China outside the submitted work. CLKL has received research grants from the Health Bureau of the Government of the Hong Kong SAR, the Hong Kong Research Grant Council, the Hong Kong College of Family Physicians, and Kerry Group Kuok Foundation outside the submitted work.

Ethical approval

This study was approved by the Institutional Review Board of The University of Hong Kong (UW 19-329). As all data used in this study have been anonymized and retrieved from the Clinical Management System of the Hong Kong Hospital Authority, no consent to participate from the patient was required.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jin, Q., Mei, J., Wong, Y.C. et al. Associations and attributable burden between risk factors and all-cause and cause-specific mortality at different ages in patients with hypertension. Hypertens Res 47, 2053–2063 (2024). https://doi.org/10.1038/s41440-024-01717-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • Issue date:

  • DOI: https://doi.org/10.1038/s41440-024-01717-4

Keywords

This article is cited by

Search

Advanced search

Quick links