Skip to main content
SpringerLink
Log in

Association Between Pre-hypertension and Cardiovascular Outcomes: A Systematic Review and Meta-analysis of Prospective Studies

  • Prevention of Hypertension: Public Health Challenges (NK Hollenberg, Section Editor)
  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

Background

The quantitative associations between prehypertension or its separate blood pressure (BP) ranges and the risk of main cardiovascular diseases (CVDs) have not been reliably documented.

Methods

We performed a comprehensive search of PubMed (1966 to June 2012) and the Cochrane Library (1988 to June 2012) without language restrictions. Prospective studies were included if they reported multivariate-adjusted risk ratios (RRs) and corresponding 95 % confidence intervals (CIs) of desirable outcomes, including fatal or non-fatal incident stroke, coronary heart disease, myocardial infarction (MI) or total CVD events, with respect to prehypertension or its separate BP ranges (low range: 120–129/80–84 mmHg; high range: 130–139/85–89 mmHg) at baseline with normal BP (<120/80 mmHg) as reference. Pooled RRs were estimated using a random-effects model or a fixed-effects model.

Results

Twenty-nine articles met our inclusion criteria, with 1,010,858 participants. Both low-range and high-range prehypertension were associated with a greater risk of developing or dying of total CVD (low-range: RR: 1.24; 95 % CI: 1.10 to 1.39; high range: RR: 1.56; 95 % CI: 1.36 to 1.78), stroke (low-range: RR: 1.35; 95 % CI: 1.10 to 1.66; high-range: RR: 1.95; 95 % CI: 1.69 to 2.24) and myocardial infarction (MI) (low range: RR: 1.43; 95 % CI: 1.10 to 1.86; high range: RR: 1.99; 95 % CI: 1.59 to 2.50). The whole range prehypertension had a 1.44-fold (95 % CI: 1.35 to 1.53), 1.73-fold (95 % CI: 1.61 to 1.85), and 1.79-fold (95 % CI: 1.45 to 2.22) risk of total CVD, stroke, and MI, respectively. There was no evidence of publication bias.

Conclusions

Prehypertensive patients have a greater risk of incident stroke, MI and total CVD events. The impact was markedly different between the low and high prehypertension ranges.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. World Health Organisation. The global burden of disease: 2004 update. Geneva: World Health Organisation; 2008.

    Google Scholar 

  2. Lawes CM, Rodgers A, Bennett DA, Asia Pacific Cohort Studies Collaboration, et al. Blood pressure and cardiovascular diseases in the Asia-Pacific region. J Hypertens. 2003;21:707–16.

    Article  PubMed  CAS  Google Scholar 

  3. Lawes CM, Vander Hoorn S, Rodgers A, International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet. 2008;371:1513–8.

    Article  PubMed  Google Scholar 

  4. He J, Gu D, Chen J, et al. Premature deaths attributable to blood pressure in China: a prospective cohort study. Lancet. 2009;374(9703):1765–72.

    Article  PubMed  Google Scholar 

  5. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217–23.

    PubMed  Google Scholar 

  6. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. 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  PubMed  Google Scholar 

  7. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–52.

    Article  PubMed  CAS  Google Scholar 

  8. Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin RB, Murray CJ, et al. Distribution of major health risks: findings from the Global Burden of Disease Study. PLoS Med. 2004;1:e27.

    Article  PubMed  Google Scholar 

  9. Guo X, Zou L, Zhang X, et al. Prehypertension: a meta-analysis of the epidemiology, risk factors, and predictors of progression. Tex Heart Inst J. 2011;38(6):643–52.

    PubMed  Google Scholar 

  10. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874–9.

    Article  PubMed  CAS  Google Scholar 

  11. De Marco M, de Simone G, Roman MJ, et al. Cardiovascular and metabolic predictors of progression of prehypertension into hypertension: the Strong Heart Study. Hypertension. 2009;54(5):974–80.

    Article  PubMed  Google Scholar 

  12. Zheng L, Sun Z, Zhang X, et al. Predictors of progression from prehypertension to hypertension among rural Chinese adults: results from Liaoning Province. Eur J Cardiovasc Prev Rehabil. 2010;17(2):217–22.

    Article  PubMed  Google Scholar 

  13. Qureshi AI, Suri MF, Kirmani JF, Divani AA, Mohammad Y. Is prehypertension a risk factor for cardiovascular diseases? Stroke. 2005;36(9):1859–63.

    Article  PubMed  Google Scholar 

  14. Hsia J, Margolis KL, Eaton CB, et al. Prehypertension and cardiovascular disease risk in the Women’s Health Initiative. Circulation. 2007;115(7):855–60.

    Article  PubMed  Google Scholar 

  15. Gu D, Chen J, Wu X, et al. Prehypertension and risk of cardiovascular disease in Chinese adults. J Hypertens. 2009;27(4):721–9.

    Article  PubMed  CAS  Google Scholar 

  16. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epide-miology (MOOSE) group. JAMA. 2000;283:2008–12.

    Article  PubMed  CAS  Google Scholar 

  17. Guo X, Zhang X, Zheng L, Guo L, Li Z, Yu S, et al. Prehypertension is not associated with all-cause mortality: a systematic review and meta-analysis of prospective studies. PLoS One. 2013;8(4):e61796.

    Google Scholar 

  18. Harris RP, Helfand M, Woolf SH, Third US Preventive Services Task Force, et al. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20(3 Suppl):21–35.

    Article  PubMed  CAS  Google Scholar 

  19. Smith GL, Lichtman JH, Bracken MB, et al. Renal impairment and outcomes in heart failure: systematic review and meta-analysis. J Am Coll Cardiol. 2006;47(10):1987–96.

    Article  PubMed  Google Scholar 

  20. Lee M, Saver JL, Chang KH, Liao HW, Chang SC, Ovbiagele B. Impact of microalbuminuria on incident stroke: a meta-analysis. Stroke. 2010;41(11):2625–31.

    Article  PubMed  Google Scholar 

  21. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration, 2008.

  22. Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345(18):1291–7.

    Article  PubMed  CAS  Google Scholar 

  23. Wu G, Wu Z, Liu J, et al. Impact of high-normal blood pressure on risk of cardiocerebrovascular disease in 11 provinces in China. Zhonghua Yi Xue Za Zhi. 2002;82(16):1083–5.

    PubMed  Google Scholar 

  24. Arima H, Tanizaki Y, Kiyohara Y, et al. Validity of the JNC VI recommendations for the management of hypertension in a general population of Japanese elderly: the Hisayama study. Arch Intern Med. 2003;163(3):361–6.

    Article  PubMed  Google Scholar 

  25. Asayama K, Ohkubo T, Kikuya M, et al. Prediction of stroke by self-measurement of blood pressure at home versus casual screening blood pressure measurement in relation to the Joint National Committee 7 classification: the Ohasama study. Stroke. 2004;35(10):2356–61.

    Article  PubMed  Google Scholar 

  26. Mainous 3rd AG, Everett CJ, Liszka H, King DE, Egan BM. Prehypertension and mortality in a nationally representative cohort. Am J Cardiol. 2004;94(12):1496–500.

    Article  PubMed  Google Scholar 

  27. Liszka HA, Mainous 3rd AG, King DE, Everett CJ, Egan BM. Prehypertension and cardiovascular morbidity. Ann Fam Med. 2005;3(4):294–9.

    Article  PubMed  Google Scholar 

  28. Kshirsagar AV, Carpenter M, Bang H, Wyatt SB, Colindres RE. Blood pressure usually considered normal is associated with an elevated risk of cardiovascular disease. Am J Med. 2006;119(2):133–41.

    Article  PubMed  Google Scholar 

  29. Terry PD, Abramson JL, Neaton JD, MRFIT Research Group. Blood pressure and risk of death from external causes among men screened for the Multiple Risk Factor Intervention Trial. Am J Epidemiol. 2007;165(3):294–301.

    Article  PubMed  Google Scholar 

  30. Wang W, Lee ET, Fabsitz RR, et al. A longitudinal study of hypertension risk factors and their relation to cardiovascular disease: the Strong Heart Study. Hypertension. 2006;47(3):403–9.

    Article  PubMed  CAS  Google Scholar 

  31. Chien KL, Hsu HC, Sung FC, Su TC, Chen MF, Lee YT. Incidence of hypertension and risk of cardiovascular events among ethnic Chinese: report from a community-based cohort study in Taiwan. J Hypertens. 2007;25(7):1355–61.

    Article  PubMed  CAS  Google Scholar 

  32. Onat A, Yazici M, Can G, Kaya Z, Bulur S, Hergenç G. Predictive value of prehypertension for metabolic syndrome, diabetes, and coronary heart disease among Turks. Am J Hypertens. 2008;21(8):890–5.

    Article  PubMed  Google Scholar 

  33. Gu Q, Burt VL, Paulose-Ram R, Yoon S, Gillum RF. High blood pressure and cardiovascular disease mortality risk among U.S. adults: the third National Health and Nutrition Examination Survey mortality follow-up study. Ann Epidemiol. 2008;18(4):302–9.

    Article  PubMed  Google Scholar 

  34. Zhang Y, Galloway JM, Welty TK, et al. Incidence and risk factors for stroke in American Indians: the Strong Heart Study. Circulation. 2008;118(15):1577–84.

    Article  PubMed  Google Scholar 

  35. Kokubo Y, Kamide K, Okamura T, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease in a Japanese urban cohort: the Suita study. Hypertension. 2008;52(4):652–9.

    Article  PubMed  CAS  Google Scholar 

  36. Lee J, Heng D, Ma S, Chew SK, Hughes K, Tai ES. Influence of pre-hypertension on all-cause and cardiovascular mortality: the Singapore Cardiovascular Cohort Study. Int J Cardiol. 2009;135(3):331–7.

    Article  PubMed  Google Scholar 

  37. Ikeda A, Iso H, Yamagishi K, Inoue M, Tsugane S. Blood pressure and the risk of stroke, cardiovascular disease, and all-cause mortality among Japanese: the JPHC Study. Am J Hypertens. 2009;22(3):273–80.

    Article  PubMed  Google Scholar 

  38. Lorenzo C, Aung K, Stern MP, Haffner SM. Pulse pressure, prehypertension, and mortality: the San Antonio heart study. Am J Hypertens. 2009;22(11):1219–26.

    Article  PubMed  Google Scholar 

  39. Hozawa A, Kuriyama S, Kakizaki M, Ohmori-Matsuda K, Ohkubo T, Tsuji I. Attributable risk fraction of prehypertension on cardiovascular disease mortality in the Japanese population: the Ohsaki Study. Am J Hypertens. 2009;22(3):267–72.

    Article  PubMed  Google Scholar 

  40. Pednekar MS, Gupta R, Gupta PC. Association of blood pressure and cardiovascular mortality in India: Mumbai cohort study. Am J Hypertens. 2009;22(10):1076–84.

    Article  PubMed  Google Scholar 

  41. Dorjgochoo T, Shu XO, Zhang X, et al. Relation of blood pressure components and categories and all-cause, stroke and coronary heart disease mortality in urban Chinese women: a population-based prospective study. J Hypertens. 2009;27(3):468–75.

    Article  PubMed  CAS  Google Scholar 

  42. Tanaka F, Makita S, Onoda T, et al. Prehypertension subtype with elevated C-reactive protein: risk of ischemic stroke in a general Japanese population. Am J Hypertens. 2010;23(10):1108–13.

    Article  PubMed  CAS  Google Scholar 

  43. Ishikawa Y, Ishikawa J, Ishikawa S, et al. Prehypertension and the risk for cardiovascular disease in the Japanese general population: the Jichi Medical School Cohort Study. J Hypertens. 2010;28(8):1630–7.

    Article  PubMed  CAS  Google Scholar 

  44. Kim NH, Cho HJ, et al. Combined effect of high-normal blood pressure and low HDL cholesterol on mortality in an elderly Korean population: the South-West Seoul (SWS) study. Am J Hypertens. 2011;24(8):918–23.

    Article  PubMed  Google Scholar 

  45. Hadaegh F, Mohebi R, Khalili D, Hasheminia M, Sheikholeslami F, Azizi F. High normal blood pressure is an independent risk factor for cardiovascular disease among middle-aged but not in elderly populations: 9-year results of a population-based study. J Hum Hypertens. 2013;27(1):18–23.

    Article  PubMed  CAS  Google Scholar 

  46. Fukuhara M, Arima H, Ninomiya T, et al. Impact of lower range of prehypertension on cardiovascular events in a general population: the Hisayama Study. J Hypertens. 2012;30(5):893–900.

    Article  PubMed  CAS  Google Scholar 

  47. Erbel R, Lehmann N, Möhlenkamp S, et al. Subclinical coronary atherosclerosis predicts cardiovascular risk in different stages of hypertension: result of the Heinz Nixdorf Recall Study. Hypertension. 2012;59(1):44–53.

    Article  PubMed  CAS  Google Scholar 

  48. Wang Y, Wang QJ. The prevalence of prehypertension and hypertension among US adults according to the new joint national committee guidelines: new challenges of the old problem. Arch Intern Med. 2004;164:2126–34.

    Article  PubMed  Google Scholar 

  49. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):e21–e181.

    Article  PubMed  Google Scholar 

  50. Huang Y, Wang S, Cai X, Mai W, Hu Y, Tang H, et al. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Med. 2013;11:177. doi:10.1186/1741-7015-11-177.

    Article  PubMed  Google Scholar 

  51. Bowman TS, Sesso HD, Glynn RJ, Gaziano JM. JNC 7 category and risk of cardiovascular death in men: are there differences by age? Am J Geriatr Cardiol. 2005;14(3):126–31.

    Article  PubMed  Google Scholar 

  52. Arima H, Murakami Y, Lam TH, et al. Effects of prehypertension and hypertension subtype on cardiovascular disease in the Asia-Pacific Region. Hypertension. 2012;59(6):1118–23.

    Article  PubMed  CAS  Google Scholar 

  53. Writing Group Members, Lloyd-Jones D, Adams RJ, et al. Heart disease and stroke statistics: 2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215.

    Article  PubMed  Google Scholar 

  54. Lee M, Saver JL, Chang B, Chang KH, Hao Q, Ovbiagele B. Presence of baseline prehypertension and risk of incident stroke: a meta-analysis. Neurology. 2011;77(14):1330–7.

    Article  PubMed  CAS  Google Scholar 

  55. Sipahi I, Swaminathan A, Natesan V, Debanne SM, Simon DI, Fang JC. Effect of antihypertensive therapy on incident stroke in cohorts with prehypertensive blood pressure levels: a meta-analysis of randomized controlled trials. Stroke. 2012;43(2):432–40.

    Article  PubMed  CAS  Google Scholar 

  56. Butler J, Kalogeropoulos AP, Georgiopoulou VV, et al. Systolic blood pressure and incident heart failure in the elderly. The cardiovascular health study and the health, ageing and body composition study. Heart. 2011;97(16):1304–11.

    Article  PubMed  Google Scholar 

  57. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997; 157:2413–46.

    Google Scholar 

  58. 1999 World Health Organization-International Society of Hypertension guidelines for the management of hypertension, Guidelines Subcommittee. J Hypertens. 1999; 17:151–83.

    Google Scholar 

  59. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105–87.

    Article  PubMed  CAS  Google Scholar 

  60. European Society of Hypertension-European Society of Cardiology Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21:1011–53.

    Article  Google Scholar 

  61. Ogihara T, Kikuchi K, Matsuoka H, et al. The Japanese society of hypertension guidelines for the management of hypertension (JSH 2009). Hypertens Res. 2009;32:3–107.

    PubMed  CAS  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Xiaofan Guo, Xiaoyu Zhang, Liang Guo, Zhao Li, Liqiang Zheng, Shasha Yu, Hongmei Yang, Xinghu Zhou, Xingang Zhang, Zhaoqing Sun, Jue Li, and Yingxian Sun declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, People’s Republic of China

    Xiaofan Guo, Liang Guo, Zhao Li, Shasha Yu, Hongmei Yang, Xinghu Zhou, Xingang Zhang & Yingxian Sun

  2. Shenyang Eye Research Institute, The Fourth People’ Hospital, Shenyang, People’s Republic of China

    Xiaoyu Zhang

  3. Department of Clinical Epidemiology, Library, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China

    Liqiang Zheng

  4. Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China

    Zhaoqing Sun

  5. Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, People’s Republic of China

    Jue Li

Authors
  1. Xiaofan Guo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xiaoyu Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Liang Guo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Zhao Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Liqiang Zheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Shasha Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hongmei Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Xinghu Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Xingang Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Zhaoqing Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Jue Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Yingxian Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yingxian Sun.

Additional information

All the authors take responsibility for all aspects of the reliability and freedom from bias of the data presented, and for their discussed interpretation.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Guo, X., Zhang, X., Guo, L. et al. Association Between Pre-hypertension and Cardiovascular Outcomes: A Systematic Review and Meta-analysis of Prospective Studies. Curr Hypertens Rep 15, 703–716 (2013). https://doi.org/10.1007/s11906-013-0403-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11906-013-0403-y

Keywords

Search

Navigation