The study, published in Nature Mental Health by an interdisciplinary team led by Yiling Zhou and Douwe Postmus of the University of Groningen’s University Medical Center, together with colleagues in nephrology, psychiatry and endocrinology, is among the first to map the long-term cardiorenal illness trajectories of newly treated hypertensive patients according to ADHD status. Rather than asking a single question such as whether ADHD raises the risk of one event, the team used multistate modeling to trace how patients move through a sequence of health states: from apparently healthy hypertensive treatment, to the onset of complications such as heart failure hospitalization or chronic kidney disease, and ultimately, in some cases, to cardiorenal death.

This trajectory-based approach matters because hypertension is rarely a one-act story. Standard cardiovascular risk tools typically estimate the probability of a first event, but clinicians and patients also care deeply about what happens afterward: whether a person who survives a stroke or develops kidney disease faces elevated risk of dying from a cardiorenal cause. By modeling the entire pathway, the researchers could distinguish between transitions, asking, for example, not only whether adults with ADHD were more likely to develop heart failure, but whether, once heart failure appeared, they were more likely to die from it.

The scale of the analysis lends its findings unusual statistical weight. The cohort included 706,414 adults aged 18 to 90 who initiated antihypertensive medications between 2007 and 2021, with no prior cardiovascular disease or chronic kidney disease recorded. Just over half, 52.2 percent, were women. Within this population, 10,689 individuals had a documented ADHD diagnosis. The data came from Dutch national registers held by Statistics Netherlands, linking medication dispensing, hospital records and cause of death at the level of individual citizens, an infrastructure that permits follow-up across nearly the entire population rather than a select insured sample.

The headline results are stark. After adjusting for age, sex, comorbidities, medication class, lifestyle-related factors and other covariates, adults with ADHD had a 46 percent higher rate of hospitalization for heart failure after starting antihypertensive treatment, with a hazard ratio of 1.46 and a 95 percent confidence interval of 1.12 to 1.90. Their adjusted rate of stroke was 19 percent higher, with a hazard ratio of 1.19. These are not marginal signals confined to subgroups; they persisted across a large, unselected nationwide population followed for years after treatment initiation.

Perhaps more troubling are the findings on what happens after complications emerge. Once hospitalized for heart failure, adults with ADHD showed a 79 percent higher adjusted rate of subsequent cardiorenal death compared with adults without ADHD, a hazard ratio of 1.79. After the onset of chronic kidney disease, their rate of cardiorenal death was more than two and a half times higher, with a hazard ratio of 2.57. Put together, the ten-year trajectories that pass through heart failure or kidney disease and end in cardiorenal death were consistently more common among patients with ADHD than among otherwise comparable hypertensive patients without the diagnosis.

Why should ADHD, a neurodevelopmental condition most often associated with inattention, impulsivity and hyperactivity, shape the course of cardiovascular and kidney disease so profoundly? The study was not designed to isolate mechanisms, but the authors and related literature point to several converging explanations. One candidate is medication adherence. A companion multinational cohort study cited by the team found that adults with ADHD are less likely to adhere to antihypertensive treatment, and interruptions in therapy blunt the very protection these drugs are meant to provide. ADHD medications themselves, particularly stimulants, have also been scrutinized for cardiovascular effects, although the new analysis focused on newly treated hypertension and adjusted for a range of factors, leaving the contribution of ADHD pharmacotherapy an open question.

Broader biological and social pathways likely contribute as well. Recent genetically informed research has documented familial co-aggregation and shared heritability between neurodevelopmental conditions and cardiometabolic disease, hinting at shared physiological roots. Adults with ADHD also carry higher burdens of obesity, smoking, sleep problems and other somatic conditions across the lifecourse, and they frequently encounter barriers in healthcare systems, from fragmented follow-up to challenges in self-management of chronic therapy. Heart failure and chronic kidney disease, in particular, demand sustained engagement: daily medication regimens, fluid and dietary vigilance, and prompt recognition of worsening symptoms. Where engagement falters, outcomes deteriorate.

The clinical implications are hard to ignore. Current hypertension guidelines stratify patients by age, blood pressure severity and comorbidity, but ADHD rarely appears in the risk calculators that guide treatment intensity and follow-up schedules. The new findings suggest it should. A newly diagnosed hypertensive patient with ADHD may warrant closer monitoring of blood pressure control, more deliberate selection of antihypertensive agents, proactive screening for early heart and kidney involvement, and targeted support for medication persistence. The researchers emphasize that their results describe elevated risks and trajectories in an observational setting; they do not establish that ADHD causes worse outcomes, and residual confounding cannot be excluded. Still, the consistency of elevated hazard ratios across multiple transitions, from first complication to death, argues that ADHD belongs in the conversation about cardiorenal risk management.

For the study’s authors, the multistate framework is as much a message as the numbers themselves. Illness after hypertension unfolds as a chain of events, and each link in that chain represents a moment where intensified care could change the trajectory. The analysis code has been released publicly, and the underlying microdata remain accessible to accredited researchers through Statistics Netherlands under strict legal safeguards. As populations age and hypertension remains the leading modifiable risk factor for death worldwide, the study adds a new and sobering dimension to the growing evidence that mental health conditions cast long physical shadows, and that treating blood pressure alone may not be enough to equalize the odds for the one in twenty adults living with ADHD.

Subject of Research: Long-term cardiorenal illness trajectories after antihypertensive medication initiation in adults with and without ADHD

Article Title: Long-term cardiorenal illness trajectories after initiation of antihypertensive medications in adults with and without ADHD: a nationwide cohort study

Article References: Long-term cardiorenal illness trajectories after initiation of antihypertensive medications in adults with and without ADHD: a nationwide cohort study. (n.d.). https://doi.org/10.1038/s44220-026-00718-1

Image Credits: AI Generated

DOI: 10.1038/s44220-026-00718-1

Keywords: ADHD, hypertension, antihypertensive medications, heart failure, chronic kidney disease, stroke, cardiorenal death, multistate modeling, nationwide cohort study, medication adherence, cardiovascular risk, epidemiology