Modifiable risk factors and 5-year and lifetime risks of cardiovascular disease among 0.5 million hypertensive patients in primary care

Background Despite extensive research on modifiable risk factors and cardiovascular diseases (CVDs) in the general population, the impact of joint risk factor control on short-term and lifetime CVD risks among patients with hypertension remains incompletely understood, especially in real-world primary care settings. Purpose We aimed to quantify the association between modifiable-risk-factor profiles and 5-year and lifetime CVD risks in a large population-based cohort of hypertensive patients in Chinese primary care settings. Methods We included 554,738 patients with hypertension (mean age 59.5 years [SD 11.0], 47.6% women) and no evidence of CVD at baseline, based on data from community health service centers in an urban primary care setting. Seven modifiable risk factors, including smoking, physical activity, diet, body mass index, blood pressure, plasma glucose, and blood lipids, were assessed. Participants’ joint risk factor control was evaluated by the accumulated number of risk factors at favorable level or total cardiovascular health (CVH) score calculated by the adapted Life's Essential 8 algorithm. The primary outcome was total CVD, a composite of non-fatal myocardial infarction, stroke and CVD death. Patients were followed up until incident CVD, death, end of follow-up, or October 1, 2023, via linked electronic health records and vital records. The Fine-Gray models were used to estimate the 5-year and lifetime CVD risks, treating non-CVD death as competing events. Absolute risk differences (ARDs), hazard ratios (HRs) and related 95% confidence intervals (CIs) for CVD risks associated with favorable modifiable-risk-factor profiles were calculated. Results During a mean follow-up of 2.9 years (1.6 million person-years), we observed 16,073 incident cases of CVD among the hypertensive patients. The 5-year and lifetime CVD risks declined progressively with an increasing number of modifiable risk factors in control. Compared with participants who had 0-1 modifiable risk factor at favorable level, participants with ≥5 modifiable risk factors at favorable level had a lower 5-year CVD risk (adjusted HR, 0.61 [95% CI, 0.56-0.66]; adjusted ARD, -1.93% [95% CI, -2.30% to -1.56%]) and lifetime CVD risk (adjusted HR, 0.60 [95% CI, 0.55-0.65]; adjusted ARD, -14.39% [95% CI, -17.75% to -11.03%]). Similar patterns were observed using the total CVH scores. Conclusion Joint optimization of lifestyle and metabolic factors may substantially reduce both short-term and lifetime CVD risks, highlighting the importance of comprehensive risk management strategies in primary care for hypertensive patients.