What are the risk factors for Hypertension (HTN)?

Risk Factors for Hypertension

The most important modifiable risk factors for hypertension are overweight/obesity (present in 40% of hypertensive patients), unhealthy lifestyle habits including high sodium intake, physical inactivity, smoking, and excessive alcohol consumption, while non-modifiable risk factors include age >65 years, male sex, and family history of hypertension. 1

Non-Modifiable Risk Factors

Demographic and Genetic Factors:

• Age >65 years is a major risk factor, with hypertension prevalence increasing substantially with advancing age 1
• Male sex confers higher risk than female sex, though this difference diminishes after menopause 1
• Family history of hypertension significantly increases risk, though genetic variants collectively account for only about 3.5% of blood pressure variability 1, 2
• Early-onset menopause increases cardiovascular and hypertension risk in women 1
• Ethnicity plays a role, with certain populations showing higher prevalence 1

Modifiable Lifestyle Risk Factors

Obesity and Body Weight:

• Overweight/obesity affects 40% of hypertensive patients and may be responsible for up to 78% of hypertension cases in men and 65% in women 1, 2
• The relationship between body mass index and blood pressure is continuous and almost linear, with no threshold 2
• Increased waist circumference is an independent risk factor 1

Dietary Factors:

• High sodium intake is positively associated with blood pressure and accounts for much of the age-related increase in blood pressure 2
• Excessive sodium consumption is independently associated with increased risk of stroke and cardiovascular disease beyond its blood pressure effects 2
• Insufficient intake of potassium, calcium, magnesium, protein, fiber, and fish fats are associated with high blood pressure 2
• Eating fruits and vegetables fewer than five times per day increases hypertension risk 3

Physical Activity:

• Physical inactivity/low fitness level is a major modifiable risk factor present in a large proportion of hypertensive patients 1
• Engaging in less than 150 minutes per week of moderate-to-vigorous physical activity significantly increases hypertension risk 3
• Regular exercise can reduce blood pressure by approximately 5 mmHg, which translates to 9% reduction in coronary heart disease mortality and 14% reduction in stroke mortality 4

Substance Use:

• Smoking/tobacco exposure is present in 15.5% of U.S. adults with hypertension 1
• Excessive alcohol consumption (high alcohol intake) contributes to hypertension development 1, 2

Metabolic and Comorbid Conditions

Metabolic Risk Factors:

• Diabetes mellitus affects 15-20% of hypertensive patients, and conversely, 71% of U.S. adults with diagnosed diabetes have hypertension 1
• Dyslipidemia (elevated LDL-cholesterol and triglycerides) is present in 30% of hypertensive patients 1
• Metabolic syndrome affects 40% of hypertensive patients 1
• Hyperuricemia (elevated serum uric acid) is present in 25% of hypertensive patients 1

Renal Disease:

• Chronic kidney disease (eGFR <60 mL/min/1.73 m²) affects 15.8% of hypertensive patients, and conversely, 86% of patients with CKD have hypertension 1

Other Medical Conditions:

• Chronic inflammatory diseases increase cardiovascular risk in hypertensive patients 1
• Chronic obstructive pulmonary disease (COPD) is associated with increased hypertension risk 1
• Obstructive sleep apnea is a secondary cause that presents with snoring and hypersomnolence 2
• Psychiatric disorders and psychosocial stressors increase hypertension risk 1

Cardiovascular Risk Factors

Cardiac Indicators:

• Heart rate >80 beats/min is considered a risk factor 1
• Left ventricular hypertrophy detected on ECG indicates hypertension-mediated organ damage 1

Secondary Causes (10% of Cases)

Endocrine Disorders:

• Primary aldosteronism presents with hypokalemia, muscle cramps, and weakness 2
• Pheochromocytoma causes blood pressure lability, episodic pallor, and dizziness 2
• Cushing's syndrome presents with central obesity, facial rounding, and easy bruisability 1, 2
• Hyperthyroidism causes weight loss, palpitations, and heat intolerance 2

Drug-Induced Hypertension:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) elevate blood pressure 2
• Cocaine and amphetamines cause hypertension 2
• Corticosteroids and calcineurin inhibitors raise blood pressure 2

Clinical Implications

Risk Factor Clustering:

• More than 50% of hypertensive patients have additional cardiovascular risk factors, with multiple risk factors present proportionally increasing the risk of coronary, cerebrovascular, and renal diseases 1
• Among U.S. adults with hypertension, 41.7% have a 10-year coronary heart disease risk >20% 1

Common Pitfall: Poor diet, physical inactivity, and excess alcohol consumption, alone or in combination, are the underlying cause of a large proportion of hypertension, yet these modifiable factors are often inadequately addressed in clinical practice 2. Being overweight or obese, consuming fruits and vegetables less often, being inactive, and having diabetes contribute to the largest attributable fractions for hypertension in the population 3.