Hypertension Death Risk Falls Sharply With Risk Factor Control

Comprehensive management of multiple modifiable health risk factors may effectively eliminate the elevated risk for premature death in people with hypertension, according to a large cohort study published in Precision Clinical Medicine. The study was supported by institutions including Tulane University, the Harvard T.H. Chan School of Public Health, and Central South University.

The study, led by Jian Zhou, MD, and Lu Qi, MD, PhD, of Tulane University, analyzed data from more than 70,000 adults with hypertension enrolled in the UK Biobank. The researchers assessed the impact of controlling up to eight modifiable risk factors on premature mortality over a median follow-up of 13.7 years. A reference group of 224,069 participants without hypertension was included to benchmark mortality risk.

The eight modifiable risk factors evaluated included systolic/diastolic blood pressure, body mass index (BMI), waist circumference, low-density lipoprotein (LDL) cholesterol, glycated hemoglobin (HbA1c), albuminuria, smoking status, and physical activity.

For all-cause and cancer premature mortality, participants with hypertension with four or more controlled risk factors had no significant excess risk compared to participants without hypertension. For CVD and other-cause premature mortality, five or more controlled factors were needed to eliminate excess risk.

“High blood pressure is not the only risk factor for high mortality risk among patients with hypertension, who are often affected by other metabolic abnormalities and unhealthy lifestyle, all contributing to high mortality risk,” said Dr. Qi. “Therefore, jointly controlling multiple risk factors may lead to additive beneficial impact to minimize mortality risk.”

Only 7.3% of participants with hypertension achieved control of more than or equal to seven risk factors. People with higher risk factor control were more likely to be older, female, White, and have higher education. They also tended to have better diets and were more likely to take cholesterol-lowering medication.

Among people with hypertension, increasing the number of controlled risk factors was consistently associated with lower risks of all-cause, cardiovascular, cancer, and other-cause mortality. For those with greater than or equal to seven controlled risk factors:

• All-cause mortality was reduced by 40%
• Cardiovascular mortality was reduced by 53%
• Cancer mortality was reduced by 39%
• Other-cause mortality was reduced by 29%

These results support current guideline emphasis on multifactorial prevention strategies, the authors said. The findings may also inform the development of future clinical recommendations and public health initiatives.

“Indeed, current clinical guidelines have emphasized multi-factorial prevention strategies,” Dr. Qi said. “Our findings lend further support to such strategies.”

The authors noted several limitations, including reliance on baseline risk factor data without accounting for longitudinal changes, the observational study design, and lack of generalizability to non-European populations.

“Replication of the findings in a diverse population is necessary,” said Dr. Qi. “Given the included risk factors have been consistently related to mortality risk in populations of various demographic backgrounds, similar findings are expected.”

Despite these limitations, the results highlight a significant opportunity for improving hypertension management through a comprehensive approach to health risk reduction.

“Our study provides compelling evidence that effective joint management of health risks can neutralize the elevated mortality risks typically associated with hypertension,” Dr. Qi said.

Source: Zhou J, et al. Precision Clinical Medicine 2025; 8(2): pbaf006. doi: 10.1093/pcmedi/pbaf006