European Journal of Cardiovascular Medicine

Background and Global Significance of Hypertension

Hypertension, defined by persistently elevated blood pressure with systolic values ≥140 mmHg or diastolic values ≥90 mmHg, is one of the leading global health concerns due to its role in increasing morbidity and mortality (1). As a major contributor to cardiovascular diseases (CVD), hypertension significantly increases the risk of heart attacks, strokes, chronic kidney disease (CKD), and retinopathy (2). According to the World Health Organization (WHO), hypertension accounts for around 12.8% of all deaths globally, resulting in an estimated 7.5 million deaths annually.

Historically, hypertension was more prevalent in high-income countries (HICs); however, recent decades have seen a marked increase in its prevalence across LMICs. Urbanization and associated lifestyle changes, including increased consumption of processed foods, higher sodium intake, and reduced physical activity, have contributed to rising hypertension rates in these countries (3). This trend underscores the growing need for targeted public health interventions in LMICs, where healthcare systems may not be adequately equipped to manage the burden of hypertension and its complications (4).

The economic impact of hypertension is profound. The condition not only increases healthcare costs but also impacts workforce productivity due to disability and premature mortality (5). Given its asymptomatic nature, hypertension often remains undiagnosed until severe complications arise, which highlights the importance of identifying and addressing its risk factors early (6). A comprehensive understanding of hypertension’s risk factors can inform preventive strategies, helping reduce the disease burden on healthcare systems worldwide (7).

Importance of Identifying Risk Factors

The identification and understanding of risk factors for hypertension are critical for developing targeted prevention and management strategies. Hypertension risk factors are broadly categorized as non-modifiable and modifiable factors. Non-modifiable risk factors include genetic predisposition, age, and sex, which set a baseline risk that cannot be altered. Modifiable risk factors, such as diet, physical inactivity, stress, obesity, and socio-economic factors, offer opportunities for intervention, allowing individuals and healthcare providers to actively manage and reduce hypertension risk (8).

For LMICs, the rising prevalence of hypertension due to lifestyle shifts highlights the need for effective public health interventions that focus on modifiable risk factors (9). Public health programs targeting diet, physical activity, and socio-economic disparities are essential in curbing hypertension prevalence. In HICs, while structured healthcare systems have successfully implemented preventive programs, socio-economic inequalities still affect access to healthcare and resources, limiting the effectiveness of these interventions among disadvantaged populations. Addressing these disparities and focusing on modifiable factors can enhance the effectiveness of hypertension prevention programs globally (10).

Search Strategy

To conduct a comprehensive review, a systematic search of electronic databases, including PubMed, Scopus, Web of Science, and Google Scholar, was performed to locate peer-reviewed studies published between 2000 and 2024. The search terms included “hypertension,” “risk factors,” “genetic predisposition,” “lifestyle,” “diet,” “physical inactivity,” “obesity,” “socio-economic status,” and “psychological stress.” Boolean operators (AND, OR) were used to refine search results and ensure the inclusion of studies that explore a wide range of hypertension-related risk factors (11).

Inclusion and Exclusion Criteria

The inclusion criteria were:

• Peer-reviewed research studies, systematic reviews, and meta-analyses focused on hypertension risk factors.
• Studies involving adults aged 18 and older, examining genetic, lifestyle, dietary, and socio-economic determinants.
• Articles providing quantitative and qualitative data on hypertension prevention and management strategies.

The exclusion criteria included:

• Studies focused solely on pharmacological treatments, without addressing underlying risk factors.
• Research involving pediatric populations, animal studies, and studies with insufficient data or inconclusive results.

Data Extraction and Synthesis

Data extraction followed a standardized process to maintain consistency, capturing details such as study design, population characteristics, identified risk factors, and significant findings. Extracted data were categorized into non-modifiable and modifiable risk factors and synthesized into a structured narrative with tables to clarify key findings (12).

PRISMA Flowchart

The PRISMA flowchart below provides a detailed overview of the study selection process, including identification, screening, eligibility assessment, and inclusion.

PRISMA Flowchart

The PRISMA flowchart in this review illustrates the systematic selection process of studies on hypertension risk factors, ensuring transparency and rigor. Initially, 3,200 studies were identified across major databases using broad search terms like “hypertension” and “risk factors.” After duplicate removal, 2,500 unique studies were screened by title and abstract for relevance. Following a detailed eligibility assessment of 400 full-text studies, 150 were excluded due to insufficient data or unclear results. This led to the inclusion of 250 high-quality studies, providing a robust foundation for evidence-based findings. The PRISMA chart thus validates the reliability of this review’s conclusions.

Non-Modifiable Risk Factors

Genetic Predisposition

Genetic predisposition is a major non-modifiable risk factor for hypertension, with heritability estimates suggesting that genetic factors account for approximately 30-50% of blood pressure variability among individuals (13). Family and twin studies, along with genome-wide association studies (GWAS), have identified several genes involved in blood pressure regulation. These include genes within the renin-angiotensin-aldosterone system (RAAS), such as ACE (angiotensin-converting enzyme) and AGT (angiotensinogen), which play critical roles in maintaining fluid and electrolyte balance, vascular tone, and arterial stiffness (14).

Individuals with specific genetic variants in these genes have an increased susceptibility to hypertension, as these variations influence key pathways involved in blood pressure regulation. Epigenetic modifications, such as DNA methylation and histone acetylation, add another layer of complexity, enabling environmental factors to modulate gene expression and modify hypertension risk over time (15). Understanding these genetic predispositions is crucial, as it can lead to the development of targeted interventions for individuals at higher risk (16).

Age and Sex

Age is one of the most significant non-modifiable risk factors for hypertension. As individuals age, vascular structures naturally lose elasticity, leading to increased arterial stiffness and reduced baroreceptor sensitivity, which in turn elevate blood pressure. Epidemiological studies indicate that hypertension prevalence increases substantially after the age of 40, with risk escalating further with each subsequent decade (17).

Gender also influences hypertension risk. Men tend to have higher hypertension rates in early adulthood, while post-menopausal women experience a sharp increase in blood pressure due to hormonal changes, particularly the reduction in estrogen levels, which affects vascular function. These age- and gender-related dynamics are essential for guiding public health screening and intervention strategies, as they highlight populations at higher risk (18).

Modifiable Risk Factors

Dietary Factors

Dietary habits, particularly sodium intake, are crucial modifiable risk factors for hypertension. High sodium intake, often associated with processed and restaurant foods, is directly linked to increased blood pressure through mechanisms that involve extracellular fluid retention and elevated cardiac output (19). The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes low sodium intake and higher consumption of potassium, calcium, and magnesium, nutrients that benefit vascular health. Studies show that the DASH diet effectively reduces both systolic and diastolic blood pressure, underscoring the importance of dietary modifications in hypertension prevention (20).

Physical Inactivity and Obesity

Physical inactivity is another significant modifiable risk factor for hypertension, as it impairs endothelial function, reduces cardiovascular fitness, and leads to weight gain. Regular aerobic exercise has been shown to lower both systolic and diastolic blood pressure by improving vascular elasticity, reducing systemic vascular resistance, and enhancing overall metabolic health (21). Obesity, frequently resulting from physical inactivity, exacerbates hypertension through mechanisms such as increased sympathetic nervous system activity, insulin resistance, and RAAS activation (22). Research indicates that weight loss of even 5-10% can significantly reduce blood pressure, highlighting the importance of physical activity and weight management in hypertension prevention (23).

Psychological Stress and Socio-Economic Factors

Chronic psychological stress has a well-established link to hypertension, largely due to its effect on the hypothalamic-pituitary-adrenal (HPA) axis, leading to elevated cortisol levels and sympathetic nervous system stimulation, which collectively elevate blood pressure (24). Socio-economic status (SES) is also a critical determinant of hypertension risk, as individuals with lower SES face multiple barriers to healthy lifestyles, including limited access to healthcare, high-stress environments, and fewer opportunities for physical activity and nutritious food choices (25). Addressing socio-economic disparities through public health initiatives is essential to reducing hypertension prevalence, particularly in underserved populations (26).

The results of this review underscore the complex etiology of hypertension, characterized by an interplay of genetic, lifestyle, dietary, and socio-economic factors. While non-modifiable risk factors like age and genetic predisposition establish a baseline risk, modifiable factors such as diet, physical inactivity, and socio-economic status offer potential areas for intervention. The DASH diet and sodium reduction represent effective dietary strategies for reducing hypertension risk, emphasizing the need for dietary modifications in both individual and population-level interventions.

Physical activity enhances cardiovascular health by supporting vascular elasticity, weight management, and reduced systemic vascular resistance, all of which contribute to lower blood pressure. Socio-economic factors further complicate hypertension prevention, as individuals from lower SES backgrounds often have limited access to healthcare, unhealthy dietary options, and high-stress living environments. Addressing these disparities through public health policies that improve healthcare access and promote health literacy can substantially reduce hypertension prevalence and improve health outcomes.

Hypertension continues to be a critical global health challenge, influenced by a combination of genetic, lifestyle, and socio-economic factors. While genetic predisposition and age are unalterable, lifestyle interventions focusing on diet, physical activity, and stress management offer considerable opportunities to mitigate hypertension risk. Public health policies that address socio-economic disparities and promote healthy lifestyle choices are essential for reducing hypertension prevalence and improving cardiovascular health outcomes. Future research should prioritize gene-environment interactions, the long-term impact of lifestyle interventions, and socio-economic factors to develop more personalized and effective hypertension management strategies.

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