Associations of the Timing of First Reported Hypertension and Healthy Lifestyle with Incident Cardiovascular Disease Among Middle-aged and Older Adults

Background Hypertension is a major modifiable risk factor for cardiovascular disease (CVD), but its characterization at a single assessment may overlook differences in the timing of its first report. We examined the associations of timing of first reported hypertension and a healthy lifestyle score with incident CVD among middle-aged and older adults, and whether the score–CVD association differed by hypertension reporting group. Methods We analyzed 9,394 participants free of cardiovascular disease at baseline (2008) in the Health and Retirement Study. Using repeated survey reports through baseline, participants were classified as having no reported hypertension through baseline, first reported hypertension before age 55 years, or first reported hypertension at or after age 55 years. A healthy lifestyle score ranging from 0 to 8 was derived from smoking, alcohol use, physical activity, and depressive symptoms, and categorized as poor, intermediate, or ideal. Incident CVD was defined as first self-reported heart disease or stroke through 2018. Cox proportional hazards models estimated adjusted hazard ratios, with stratified, joint classification, and interaction analyses. Robustness was assessed using landmark, competing-risk, and additional sensitivity analyses. Results During follow-up, 1,921 incident CVD events occurred. Compared with no reported hypertension through baseline, adjusted hazard ratios were 1.63 (95% confidence interval, 1.43–1.86) for first reported hypertension before age 55 years and 1.46 (95% CI, 1.32–1.62) for first reported hypertension at or after age 55 years. An ideal versus poor category was associated with a lower CVD hazard in each hypertension reporting group, with no statistical evidence of multiplicative interaction ( P = 0.395). The joint category combining first reported hypertension before age 55 years and a poor category had the highest estimated CVD hazard (HR, 2.48; 95% CI, 1.98–3.11) compared with participants with no reported hypertension through baseline and an ideal score. Sensitivity analyses showed variation by model and score specification, including attenuation in competing-risk analyses. Conclusions First reported hypertension before or after age 55 years was associated with a higher CVD hazard than no reported hypertension through baseline, whereas a more favorable healthy lifestyle score was associated with a lower hazard. These findings describe observational associations and do not establish hypertension onset timing or incremental clinical predictive value. Clinical trial number Not applicable.