The University of Manchester Research

Genetic analysis of over one million people identifies 535new loci associated with blood pressure traits.DOI:10.1038/s41588-018-0205-x

Document VersionAccepted author manuscript

Link to publication record in Manchester Research Explorer

Citation for published version (APA):Keavney, B., Tomaszewski, M., Morris, A., & et al (2018). Genetic analysis of over one million people identifies 535new loci associated with blood pressure traits. Nature Genetics. https://doi.org/10.1038/s41588-018-0205-x

Published in:Nature Genetics

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Download date:10. Jan. 2020

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Geneticanalysisofoveronemillionpeopleidentifies535novellociforbloodpressure.1

Shorttitle:BloodpressureGWASinonemillionpeople2

EvangelosEvangelou1,2*,HelenRWarren3,4*,DavidMosen-Ansorena1*,BorbalaMifsud3*,Raha3Pazoki1*,HeGao1,5*,GeorgiosNtritsos2*,NikiDimou2*,ClaudiaPCabrera3,4,IbrahimKaraman1,4FuLiangNg3,MarinaEvangelou1,6,KatarzynaWitkowska3,EvanTzanis3,JacklynNHellwege7,5AyushGiri8,DignaRVelez-Edwards8,YanVSun9,10,KellyCho11,12,J.MichaelGaziano11,12,Peter6WFWilson13,PhilipSTsao14,CsabaPKovesdy15,TonuEsko16,17,ReedikMägi16,LiliMilani16,7PeterAlmgren18,ThibaudBoutin19,StéphanieDebette20,21,JunDing22,FrancoGiulianini23,8ElizabethGHolliday24,AnneUJackson25,RuifangLi-Gao26,Wei-YuLin27,Jian'anLuan28,Massimo9Mangino29,30,ChristopherOldmeadow24,BramPrins31,YongQian22,Muralidharan10Sargurupremraj21,NabiShah32,33,PraveenSurendran27,SébastienThériault34,35,Niek11Verweij17,36,37,SaraMWillems28,Jing-HuaZhao28,PhilippeAmouyel38,JohnConnell39,Renéede12Mutsert26,AlexSFDoney32,MartinFarrall40,41,CristinaMenni29,AndrewDMorris42,Raymond13Noordam43,GuillaumeParé34,NeilRPoulter44,DenisCShields45,AliceStanton46,SimonThom44,14GonçaloAbecasis47,NajafAmin48,DanEArking49,KristinLAyers50,CaterinaMBarbieri51,52,15ChiaraBatini53,JoshuaCBis54,TinekaBlake53,MurielleBochud55,MichaelBoehnke25,Eric16Boerwinkle56,DorretIBoomsma57,ErwinPBottinger58,PeterSBraund59,60,MarcoBrumat61,17ArchieCampbell62,63,HarryCampbell64,AravindaChakravarti49,JohnCChambers1,5,65-67,Ganesh18Chauhan68,MarinaCiullo69,70,MassimilianoCocca52,FrancisCollins71,HeatherJCordell72,Gail19Davies73,74,MartinHdeBorst75,EcoJdeGeus57,IanJDeary73,74,JorisDeelen76,FabiolaDelGreco20M77,CumhurYusufDemirkale78,MarcusDörr79,80,GeorgBEhret49,81,RobertoElosua82,Stefan21Enroth83,AMesutErzurumluoglu53,TeresaFerreira84,MattiasFrånberg85-87,OscarHFranco88,22IlariaGandin61,PaoloGasparini61,89,VilmantasGiedraitis90,ChristianGieger91-93,Giorgia23Girotto61,94,AnujGoel40,41,AlanJGow73,95,VilmundurGudnason96,97,XiuqingGuo98,Ulf24Gyllensten83,AndersHamsten85,86,TamaraBHarris99,SarahEHarris62,73,CatharinaA25Hartman100,AkiSHavulinna101,102,AndrewAHicks77,EdithHofer103,104,AlbertHofman88,105,26Jouke-JanHottenga57,JenniferEHuffman19,Shih-JenHwang106,107,ErikIngelsson108,109,Alan27James110,111,RickJansen112,Marjo-RiittaJarvelin5,113-115,RobyJoehanes116,117,ÅsaJohansson83,28AndrewDJohnson117,118,PeterKJoshi64,PekkaJousilahti101,JWouterJukema119,AnttiJula101,29MikaKähönen120,121,SekarKathiresan17,36,122,BernardDKeavney123,124,Kay-TeeKhaw125,Paul30Knekt101,JoanneKnight126,IvanaKolcic127,JaspalSKooner5,66,67,128,SeppoKoskinen101,Kati31Kristiansson101,ZoltanKutalik55,129,MarisLaan130,MartyLarson117,LenoreJLauner99,Benjamin32CLehne1,TerhoLehtimäki131,132,DavidCMLiewald73,74,LiLin81,LarsLind133,CeciliaM33Lindgren40,84,134,YongMeiLiu135,RuthJFLoos28,58,136,LornaMLopez73,137,138,YingchangLu58,34Leo-PekkaLyytikäinen131,132,AnubhaMahajan40,ChrysovalantoMamasoula139,Jaume35Marrugat82,JonathanMarten19,YuriMilaneschi140,AnnaMorgan61,AndrewPMorris40,141,36AlannaCMorrison142,PeterJMunson78,MikeANalls143,144,PriyankaNandakumar49,Christopher37PNelson59,60,TeemuNiiranen101,145,IljaMNolte146,TeresaNutile69,AlbertineJOldehinkel147,38BenAOostra48,PaulFO'Reilly148,ElinOrg16,SandoshPadmanabhan63,149,WalterPalmas150,39AarnoPalotie102,151,152,AlisonPattie74,BrendaWJHPenninx140,MarkusPerola101,102,153,Annette40Peters92,OzrenPolasek127,154,PeterPPramstaller77,155,156,NguyenQuangTri78,OlliT41Raitakari157,158,MeixiaRen159,160,RainerRettig161,KennethRice162,PaulMRidker23,163,JaninaS42Ried92,HarriëtteRiese147,SamuliRipatti102,164,AntoniettaRobino52,LyndaMRose23,JeromeI43Rotter98,IgorRudan165,DanielaRuggiero69,YasamanSaba166,CinziaFSala51,VeikkoSalomaa101,44NileshJSamani59,60,Antti-PekkaSarin102,ReinholdSchmidt103,HelenaSchmidt166,NickShrine53,45DavidSiscovick167,AlbertVSmith96,97,HaroldSnieder146,SiimSõber130,RossellaSorice69,JohnM46Starr73,168,DavidJStott169,DavidPStrachan170,RonaJStrawbridge85,86,JohanSundström133,47MorrisASwertz171,KentDTaylor98,AlexanderTeumer80,172,MartinDTobin53,Maciej48

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Tomaszewski123,124,DanielaToniolo51,MichelaTraglia51,StellaTrompet119,173,Jaakko49Tuomilehto174-177,ChristopheTzourio21,AndréGUitterlinden88,178,AhmadVaez146,179,PeterJvan50derMost146,CorneliaMvanDuijn48,Anne-ClaireVergnaud1,GermaineCVerwoert88,Veronique51Vitart19,UweVölker80,180,PeterVollenweider181,DraganaVuckovic61,182,HughWatkins40,41,52SarahHWild183,GonnekeWillemsen57,JamesFWilson19,64,AlanFWright19,JieYao98,Tatijana53Zemunik184,WeihuaZhang1,66,JohnRAttia24,AdamSButterworth27,185,DanielIChasman23,163,54DavidConen186,187,FrancescoCucca188,189,JohnDanesh27,185,CarolineHayward19,JoannaMM55Howson27,MarkkuLaakso190,EdwardGLakatta191,ClaudiaLangenberg28,OlleMelander18,56DennisOMook-Kanamori26,192,ColinNAPalmer32,LorenzRisch193-195,RobertAScott28,RodneyJ57Scott24,PeterSever128,TimDSpector29,PimvanderHarst196,NicholasJWareham28,Eleftheria58Zeggini31,DanielLevy117,118,PatriciaBMunroe3,ChristopherNewton-Cheh134,197,198,MorrisJ59Brown3,4,AndresMetspalu16,AdrianaMHung199,ChristopherJO’Donnell200,ToddLEdwards760onbehalfoftheMillionVeteranProgram,BruceM.Psaty201,202,IoannaTzoulaki1,2,5*,MichaelR61Barnes3,4*,LouiseVWain53*,PaulElliott1,5,203,204*‡,MarkJCaulfield3,4*‡62

63

*Equalcontribution64

‡Correspondingauthors65

66

1. DepartmentofEpidemiologyandBiostatistics,ImperialCollegeLondon,London,67UK.68

2. DepartmentofHygieneandEpidemiology,UniversityofIoanninaMedical69School,Ioannina,Greece.70

3. WilliamHarveyResearchInstitute,BartsandTheLondonSchoolofMedicineand71Dentistry,QueenMaryUniversityofLondon,London,UK.72

4. NationalInstituteforHealthResearch,BartsCardiovascularBiomedical73ResearchCenter,QueenMaryUniversityofLondon,London,UK.74

5. MRC-PHECentreforEnvironmentandHealth,ImperialCollegeLondon,London75W21PG,UK.76

6. DepartmentofMathematics,ImperialCollegeLondon,UK777. DivisionofEpidemiology,DepartmentofMedicine,InstituteforMedicineand78

PublicHealth,VanderbiltGeneticsInstitute,VanderbiltUniversityMedical79Center,TennesseeValleyHealthcareSystem(626)/VanderbiltUniversity,80Nashville,TN.81

8. VanderbiltGeneticsInstitute,VanderbiltEpidemiologyCenter,Departmentof82ObstetricsandGynecology,VanderbiltUniversityMedicalCenter;Tennessee83ValleyHealthSystemsVA,Nashville,TN.84

9. DepartmentofEpidemiologyandBiomedicalInformatics,EmoryUniversity85RollinsSchoolofPublicHealth,AtlantaGA,USA.86

10. DepartmentofBiomedicalInformatics,EmoryUniversitySchoolofMedicine,87Atlanta,GA.88

11. MassachusettsVeteransEpidemiologyResearchandInformationCenter89(MAVERIC),VABostonHealthcareSystem,150S.HuntingtonAvenue,Boston,90MA02130,USA.91

12. DivisionofAging,DepartmentofMedicine,BrighamandWomen’sHospital,92Boston,MA,DepartmentofMedicine,HarvardMedicalSchool,Boston,MA.93

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13. AtlantaVAMCandEmoryClinicalCardiovascularResearchInstitute,Atlanta,GA,9430233.95

14. VAPaloAltoHealthCareSystem;DivisionofCardiovascularMedicine,Stanford96UniversitySchoolofMedicine.97

15. NephrologySection,MemphisVAMedicalCenter,MemphisTN.9816. EstonianGenomeCenter,UniversityofTartu,Tartu,Estonia.9917. PrograminMedicalandPopulationGenetics,BroadInstituteofHarvardand100

MIT,Cambridge,USA.10118. DepartmentClinicalSciences,Malmö,LundUniversity,Malmö,Sweden.10219. MRCHumanGeneticsUnit,MRCInstituteofGeneticsandMolecularMedicine,103

UniversityofEdinburgh,WesternGeneralHospital,Edinburgh,EH42XU104Scotland,UK105

20. DepartmentofNeurology,BordeauxUniversityHospital,F-33000Bordeaux,106France.107

21. Univ.Bordeaux,Inserm,BordeauxPopulationHealthResearchCenter,UMR1081219,CHUBordeaux,F-33000Bordeaux,France.109

22. LaboratoryofGeneticsandGenomics,NIA/NIH,Baltimore,MD21224,USA.11023. DivisionofPreventiveMedicine,BrighamandWomen'sHospital,Boston,MA,111

USA.11224. HunterMedicalReseachInstituteandFacultyofHealth,UniversityofNewcastle,113

NewLambtonHeights,NewSouthWales,Australia.11425. DepartmentofBiostatisticsandCenterforStatisticalGenetics,Universityof115

Michigan,AnnArbor,MI48109,USA.11626. DepartmentofClinicalEpidemiology,LeidenUniversityMedicalCenter,Leiden,117

theNetherlands.11827. MRC/BHFCardiovascularEpidemiologyUnit,DepartmentofPublicHealthand119

PrimaryCare,UniversityofCambridge,Cambridge,UK.12028. MRCEpidemiologyUnit,UniversityofCambridgeSchoolofClinicalMedicine,121

Cambridge,CB20QQ,UK.12229. DepartmentofTwinResearchandGeneticEpidemiology,KingsCollegeLondon,123

LondonSE17EH,UK.12430. NIHRBiomedicalResearchCentreatGuy’sandStThomas’FoundationTrust,125

LondonSE19RT,UK.12631. WellcomeTrustSangerInstitute,Hinxton,CB101SA,UK.12732. DivisionofMolecularandClinicalMedicine,SchoolofMedicine,Universityof128

Dundee,DD19SY,UK.12933. DepartmentofPharmacy,COMSATSInstituteofInformationTechnology,130

Abbottabad,22060,Pakistan.13134. DepartmentofPathologyandMolecularMedicine,McMasterUniversity,1280132

MainStW,Hamilton,L8S4L8,Canada.13335. InstitutuniversitairedecardiologieetdepneumologiedeQuébec-Université134

Laval,2725CheminSte-Foy,QuebecCity,G1V4G5,Canada.13536. CardiovascularResearchCenterandCenterforHumanGeneticResearch,136

MassachusettsGeneralHospital,Boston,Massachusetts,USA.13737. UniversityofGroningen,UniversityMedicalCenterGroningen,Departmentof138

Cardiology,Groningen,TheNetherlands.13938. UniversityofLille,Inserm,CentreHosp.UnivLille,InstitutPasteurdeLille,140

UMR1167-RID-AGE-Riskfactorsandmoleculardeterminantsofaging-related141diseases,EpidemiologyandPublicHealthDepartment,F-59000Lille,France.142

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39. UniversityofDundee,NinewellsHospital&MedicalSchool,Dundee,DD19SY,143UK.144

40. WellcomeTrustCentreforHumanGenetics,UniversityofOxford,Oxford,UK.14541. DivisionofCardiovascularMedicine,RadcliffeDepartmentofMedicine,146

UniversityofOxford,Oxford,OX39DU,UK.14742. UsherInstituteofPopulationHealthSciencesandInformatics,Universityof148

Edinburgh.14943. DepartmentofInternalMedicine,SectionGerontologyandGeriatrics,Leiden150

UniversityMedicalCenter,Leiden,TheNetherlands.15144. InternationalCentreforCirculatoryHealth,ImperialCollegeLondon,London,152

W21PG,UK.15345. SchoolofMedicine,UniversityCollegeDublin,Ireland.15446. MolecularandCellularTherapeutics,RoyalCollegeofSurgeonsinIreland,Dublin155

2,Ireland.15647. CenterforStatisticalGenetics,Dept.ofBiostatistics,SPHII,1420Washington157

Heights,AnnArbor,MI48109-2029.15848. GeneticEpidemiologyUnit,DepartmentofEpidemiology,ErasmusMC,159

Rotterdam,3000CA,theNetherlands.16049. CenterforComplexDiseaseGenomics,McKusick-NathansInstituteofGenetic161

Medicine,JohnsHopkinsUniversitySchoolofMedicine,Baltimore,MD21205,162USA.163

50. DepartmentofGeneticsandGenomicSciences,IcahnSchoolofMedicineat164MountSinai,NewYork,NY,USA.165

51. DivisionofGeneticsandCellBiology,SanRaffaeleScientificInstitute,20132166Milano,Italy.167

52. InstituteforMaternalandChildHealthIRCCSBurloGarofolo,Viadell'Istria65,168Trieste,34200,Italy.169

53. DepartmentofHealthSciences,UniversityofLeicester,Leicester,UK.17054. CardiovascularHealthResearchUnit,DepartmentofMedicine,Universityof171

Washington,Seattle,WA98101,USA.17255. InstituteofSocialandPreventiveMedicine,UniversityHospitalofLausanne,173

RoutedelaCorniche10,1010Lausanne,Switzerland.17456. HumanGeneticsCenter,SchoolofPublicHealth,TheUniversityofTexasHealth175

ScienceCenteratHoustonandHumanGenomeSequencingCenter,Baylor176CollegeofMedicine,OneBaylorPlaza,Houston,TX,77030,USA.177

57. DepartmentofBiologicalPsychology,VrijeUniversiteitAmsterdam,EMGO+178institute,VUUniversitymedicalcenter,Amsterdam,theNetherlands.179

58. TheCharlesBronfmanInstituteforPersonalizedMedicine,IcachnSchoolof180MedicineatMountSinai,NewYork,NY10029.181

59. DepartmentofCardiovascularSciences,UniversityofLeicester,LeicesterLE31829QP,UK.183

60. NIHRLeicesterBiomedicalResearchCentre,GlenfieldHospital,GrobyRoad,184Leicester,LE39QP,UK.185

61. DepartmentofMedical,SurgicalandHealthSciences,UniversityofTrieste,186StradadiFiume447,Trieste,34100,Italy.187

62. MedicalGeneticsSection,CentreforGenomicandExperimentalMedicine,188InstituteofGeneticsandMolecularMedicine,UniversityofEdinburgh,189EdinburghEH42XU,UK.190

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63. GenerationScotland,CentreforGenomicandExperimentalMedicine,University191ofEdinburgh,UK.192

64. CentreforGlobalHealthResearch,UsherInstituteofPopulationHealthSciences193andInformatics,UniversityofEdinburghEH89AG,Scotland,UK194

65. LeeKongChianSchoolofMedicine,NanyangTechnologicalUniversity,195Singapore308232,Singapore.196

66. DepartmentofCardiology,EalingHospital,MiddlesexUB13HW,UK.19767. ImperialCollegeHealthcareNHSTrust,LondonW120HS,UK.19868. CentreforBrainResearch,IndianInstituteofScience,Bangalore,India.19969. InstituteofGeneticsandBiophysics"A.Buzzati-Traverso",CNR,viaP.Castellino200

111,80131Napoli-Italy.20170. IRCCSNeuromed,Pozzilli,Isernia,Italy.20271. MedicalGenomicsandMetabolicGeneticsBranch,NationalHumanGenome203

ResearchInstitute,NIH,Bethesda,MD20892,USA.20472. InstituteofGeneticMedicine,NewcastleUniversity,NewcastleuponTyne,UK.20573. CentreforCognitiveAgeingandCognitiveEpidemiology,Universityof206

Edinburgh,7GeorgeSquare,EdinburghEH89JZ,UK.20774. DepartmentofPsychology,UniversityofEdinburgh,7GeorgeSquare,Edinburgh,208

EH89JZ,UK.20975. DepartmentofInternalMedicine,DivisionofNephrology,Universityof210

Groningen,UniversityMedicalCenterGroningen,POBox30001,9700RB211Groningen,TheNetherlands.212

76. DepartmentofMolecularEpidemiology,LeidenUniversityMedicalCenter,213Leiden,2300RC,theNetherlands.214

77. InstituteforBiomedicine,EuracResearch,Bolzano,Italy-AffiliatedInstituteof215theUniversityofLübeck,Germany.216

78. MathematicalandStatisticalComputingLaboratory,OfficeofIntramural217Research,CenterforInformationTechnology,NationalInstitutesofHealth,218Bethesda,MD20892.219

79. DepartmentofInternalMedicineB,UniversityMedicineGreifswald,Greifswald,22017475,Germany.221

80. DZHK(GermanCentreforCardiovascularResearch),partnersiteGreifswald,222Greifswald,17475,Germany.223

81. Cardiology,DepartmentofMedicine,GenevaUniversityHospital,RueGabrielle-224Perret-Gentil4,1211Geneva14,Switzerland.225

82. CIBERCV&CardiovascularEpidemiologyandGenetics,IMIM.DrAiguader88,226Barcelona,08003Spain.227

83. DepartmentofImmunology,GeneticsandPathology,UppsalaUniversitet,228ScienceforLifeLaboratory,Husargatan3,Uppsala,SE-75108,Sweden.229

84. BigDataInstituteattheLiKaShingCentreforHealthInformationandDiscovery,230UniversityofOxford,Oxford,UK.231

85. CardiovascularMedicineUnit,DepartmentofMedicineSolna,Karolinska232Institutet,Stockholm,17176,Sweden.233

86. CentreforMolecularMedicine,L8:03,KarolinskaUniversitetsjukhuset,Solna,23417176,Sweden.235

87. DepartmentofNumericalAnalysisandComputerScience,StockholmUniversity,236Lindstedtsvägen3,Stockholm,10044,Sweden.237

88. DepartmentofEpidemiology,ErasmusMC,Rotterdam,3000CA,theNetherlands.23889. IRCCS-BurloGarofaloChildrenHospital,Viadell’Istria65,Trieste,Italy.239

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90. DepartmentofPublicHealthandCaringSciences,Geriatrics,Uppsala75237,240Sweden.241

91. ResearchUnitofMolecularEpidemiology,HelmholtzZentrumMünchen,German242ResearchCenterforEnvironmentalHealth,Neuherberg,Germany.243

92. InstituteofEpidemiologyII,HelmholtzZentrumMünchen,GermanResearch244CenterforEnvironmentalHealth,Neuherberg,Germany.245

93. GermanCenterforDiabetesResearch(DZD),Neuherberg,Germany.24694. IRCCS-BurloGarofaloChildrenHospital,Viadell’Istria65,Trieste,Italy.24795. DepartmentofPsychology,SchoolofSocialSciences,Heriot-WattUniversity,248

Edinburgh,EH144AS,UK.24996. FacultyofMedicine,UniversityofIceland,Reykjavik,Iceland.25097. IcelandicHeartAssoication,Kopavogur,Iceland.25198. TheInstituteforTranslationalGenomicsandPopulationSciences,Departmentof252

Pediatrics,LABioMedatHarbor-UCLAMedicalCenter,1124W.CarsonStreet,253Torrance,CA90502,USA.254

99. IntramuralResearchProgram,LaboratoryofEpidemiology,Demography,and255Biometry,NationalInstituteonAging.256

100. DepartmentofPsychiatry,UniversityofGroningen,UniversityMedicalCenter257Groningen,Hanzeplein1,POBox30001,9700RBGroningen,TheNetherlands.258

101. DepartmentofPublicHealthSolutions,NationalInstituteforHealthandWelfare259(THL),Helsinki,Finland.260

102. InstituteforMolecularMedicineFinland(FIMM),UniversityofHelsinki,Helsinki,261Finland.262

103. ClinicalDivisionofNeurogeriatrics,DepartmentofNeurology,Medical263UniversityofGraz,Auenbruggerplatz22,8036Graz,Austria.264

104. InstituteforMedicalInformatics,StatisticsandDocumentation,Medical265UniversityofGraz,Auenbruggerplatz2,8036Graz,Austria.266

105. DepartmentofEpidemiology,HarvardT.H.ChanSchoolofPublicHealth,Boston,267MA02115,USA.268

106. TheFraminghamHeartStudy,FraminghamMA01702.269107. ThePopulationScienceBranch,DivisionofIntramuralResearch,NationalHeart270

LungandBloodInstitutenationalInstituteofHealth,Bethesda,MD20892.271108. DepartmentofMedicalSciences,MolecularEpidemiologyandScienceforLife272

Laboratory,UppsalaUniversity,Uppsala75237,Sweden.273109. DivisionofCardiovascularMedicine,DepartmentofMedicine,Stanford274

UniversitySchoolofMedicine,Stanford,CA94305,USA.275110. DepartmentofPulmonaryPhysiologyandSleep,SirCharlesGairdnerHospital,276

HospitalAvenue,Nedlands6009,H57WesternAustralia.277111. SchoolofMedicineandPharmacology,UniversityofWesternAustralia.278112. DepartmentofPsychiatry,VUUniversityMedicalCenter,NeuroscienceCampus279

Amsterdam,Amsterdam,theNetherlands.280113. BiocenterOulu,P.O.Box5000,Aapistie5A,FI-90014UniversityofOulu,Finland.281114. CenterForLife-courseHealthResearch,P.O.Box5000,FI-90014Universityof282

Oulu,Finland.283115. UnitofPrimaryCare,OuluUniversityHospital,Kajaanintie50,P.O.Box20,FI-284

90220Oulu,90029OYS,Finland.285116. HebrewSeniorLife,HarvardMedicalSchool,1200CentreStreetRoom#609,286

Boston,MA02131.287

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117. NationalHeart,LungandBloodInstitute'sFraminghamHeartStudy,288Framingham,MA01702,USA.289

118. PopulationSciencesBranch,NationalHeart,LungandBloodInstitute,National290InstitutesofHealth,Bethesda,MD20814,USA.291

119. DepartmentofCardiology,LeidenUniversityMedicalCenter,Leiden,2300RCthe292Netherlands.293

120. DepartmentofClinicalPhysiology,TampereUniversityHospital,Tampere29433521,Finland.295

121. DepartmentofClinicalPhysiology,FinnishCardiovascularResearchCenter-296Tampere,FacultyofMedicineandLifeSciences,UniversityofTampere,Tampere29733014,Finland.298

122. BroadInstituteoftheMassachusettsInstituteofTechnologyandHarvard299University,Cambridge,MA02142,USA.300

123. DivisionofCardiovascularSciences,FacultyofMedicine,BiologyandHealth,301UniversityofManchester,Manchester,UK.302

124. DivisionofMedicine,ManchesterUniversityNHSFoundationTrust,Manchester303AcademicHealthScienceCentre,Manchester,UK304

125. DepartmentofPublicHealthandPrimaryCare,InstituteofPublicHealth,305UniversityofCambridge,CambridgeCB22SR,UK.306

126. DataScienceInstituteandLancasterMedicalSchool,LA14YG,Lancaster.307127. DepartmentofPublicHealth,FacultyofMedicine,UniversityofSplit,Croatia.308128. NationalHeartandLungInstitute,ImperialCollegeLondon,London,UK.309129. SwissInstituteofBioinformatics,Lausanne,Switzerland.310130. InstituteofBiomedicineandTranslationalMedicine,UniversityofTartu,Ravila311

Str.19,50412Tartu,Estonia.312131. DepartmentofClinicalChemistry,FimlabLaboratories,Tampere33520,Finland.313132. DepartmentofClinicalChemistry,FinnishCardiovascularResearchCenter-314

Tampere,FacultyofMedicineandLifeSciences,UniversityofTampere,Tampere31533014,Finland316

133. DepartmentofMedicalSciences,CardiovascularEpidemiology,Uppsala317University,Uppsala75185,Sweden.318

134. PrograminMedicalandPopulationGenetics,BroadInstitute,Cambridge,319Massachusetts,USA.320

135. DivisionofPublicHealthSciences,WakeForestSchoolofMedicine,Winston-321Salem,27106,USA.322

136. MindichChildhealthDevelopmentInstitute,TheIcahnSchoolofMedicineat323MountSinai,NewYork,NY10029,USA.324

137. DepartmentofPsychiatry,RoyalCollegeofSurgeonsinIreland,Educationand325ResearchCentre,BeaumontHospital,Dublin,Ireland.326

138. UniversityCollegeDublin,UCDConwayInstitute,CentreforProteomeResearch,327UCD,Belfield,Dublin,Ireland.328

139. InstituteofHealthandSociety,NewcastleUniversity,NewcastleuponTyne,UK.329140. DepartmentofPsychiatry,AmsterdamPublicHealthandAmsterdam330

Neuroscience,VUUniversityMedicalCenter/GGZinGeest,Oldenaller1,1081HJ331AmsterdamAmsterdam,TheNetherlands.332

141. DepartmentofBiostatistics,UniversityofLiverpool,BlockF,Waterhouse333Building,1-5BrownlowStreet,LiverpoolL693GL,UK.334

8

142. DepartmentofEpidemiology,HumanGeneticsandEnvironmentalSciences,335SchoolofPublicHealth,UniversityofTexasHealthScienceCenteratHouston,3361200PresslerSt.,Suite453E,Houston,TX77030,USA.337

143. DataTecnicaInternational,GlenEcho,MD,USA.338144. LaboratoryofNeurogenetics,NationalInstituteonAging,Bethesda,USA.339145. DepartmentofMedicine,TurkuUniversityHospitalandUniversityofTurku,340

Finland.341146. DepartmentofEpidemiology,UniversityofGroningen,UniversityMedicalCenter342

Groningen,Hanzeplein1,POBox30001,9700RBGroningen,TheNetherlands.343147. InterdisciplinaryCenterPsychopathologyandEmotionregulation(ICPE),344

UniversityofGroningen,UniversityMedicalCenterGroningen,POBox30001345(CC72),9700RBGroningen,TheNetherlands.346

148. SGDPCentre,InstituteofPsychiatry,PsychologyandNeuroscience,King's347CollegeLondon,LondonSE58AF,UK.348

149. BritishHeartFoundationGlasgowCardiovascularResearchCentre,Instituteof349CardiovascularandMedicalSciences,CollegeofMedical,VeterinaryandLife350Sciences,UniversityofGlasgow,GlasgowG128TA,UK.351

150. DepartmentofMedicine,ColumbiaUniversityMedicalCenter,622West168th352Street,PH9,East,107,NewYork,NY10032,USA.353

151. AnalyticandTranslationalGeneticsUnit,DepartmentofMedicine,Departmentof354NeurologyandDepartmentofPsychiatryMassachusettsGeneralHospital,355Boston,MA,USA.356

152. TheStanleyCenterforPsychiatricResearchandPrograminMedicaland357PopulationGenetics,TheBroadInstituteofMITandHarvard,Cambridge,MA,358USA.359

153. UniversityofTartu,Tartu,Estonia.360154. Psychiatrichospital“SvetiIvan”,Zagreb,Croatia.361155. DepartmentofNeurology,GeneralCentralHospital,Bolzano,Italy.362156. DepartmentofNeurology,UniversityofLübeck,Lübeck,Germany.363157. DepartmentofClinicalPhysiologyandNuclearMedicine,TurkuUniversity364

Hospital,Turku20521,Finland.365158. ResearchCentreofAppliedandPreventiveCardiovascularMedicine,University366

ofTurku,Turku20520,Finland.367159. DepartmentofGeriatricMedicine,FujianProvincialHospital,FujianKey368

LaboratoryofGeriatrics,FujianMedicalUniversity,Fuzhou,350001,China.369160. WilliamHarveyResearchInstituteBartsandTheLondonSchoolofMedicineand370

Dentistry,QueenMaryUniversityofLondon,JohnVaneScienceCentre,371CharterhouseSquare,LondonEC1M6BQ,UnitedKingdom.372

161. InstituteofPhysiology,UniversityMedicineGreifswald,Karlsburg,17495,373Germany.374

162. DepartmentofBiostatisticsUniversityofWashington,Seattle,WA98101,USA.375163. HarvardMedicalSchool,BostonMA.376164. Publichealth,FacultyofMedicine,UniversityofHelsinki,Finland377165. CentreforGlobalHealthResearch,UsherInstituteofPopulationHealthSciences378

andInformatics,UniversityofEdinburghEH89AG,Scotland,UK.379166. InstituteofMolecularBiologyandBiochemistry,CentreforMolecularMedicine,380

MedicalUniversityofGraz,NeueStiftingtalstraße6,8010Graz,Austria.381167. TheNewYorkAcademyofMedicine.12165thAve,NewYork,NY10029,USA.382

9

168. AlzheimerScotlandDementiaResearchCentre,UniversityofEdinburgh,7383GeorgeSquare,Edinburgh,EH89JZ,UK.384

169. InstituteofCardiovascularandMedicalSciences,FacultyofMedicine,University385ofGlasgow,UnitedKingdom.386

170. PopulationHealthResearchInstitute,StGeorge's,UniversityofLondon,London387SW170RE,UK.388

171. DepartmentofGenetics,UniversityofGroningen,UniversityMedicalCenter389Groningen,POBox30001,9700RBGroningen,TheNetherlands.390

172. InstituteforCommunityMedicine,UniversityMedicineGreifswald,Greifswald,39117475,Germany.392

173. DepartmentofGerontologyandGeriatrics,LeidenUniversityMedicalCenter,393Leiden,2300RC,theNetherlands.394

174. DasmanDiabetesInstitute,Dasman,15462Kuwait.395175. ChronicDiseasePreventionUnit,NationalInstituteforHealthandWelfare,396

00271Helsinki,Finland.397176. DepartmentofPublicHealth,UniversityofHelsinki,00014Helsinki,Finland.398177. SaudiDiabetesResearchGroup,KingAbdulazizUniversity,21589Jeddah,Saudi399

Arabia.400178. DepartmentofInternalMedicine,ErasmusMC,Rotterdam,3000CA,the401

Netherlands.402179. ResearchInstituteforPrimordialPreventionofNon-communicableDisease,403

IsfahanUniversityofMedicalSciences,Isfahan,Iran.404180. InterfacultyInstituteforGeneticsandFunctionalGenomics,UniversityMedicine405

Greifswald,Greifswald,17475,Germany.406181. DepartmentofInternalMedicine,UniversityHospital,CHUV,1011Lausanne,407

Switzerland.408182. ExperimentalGeneticsDivision,SidraMedicalandResearchCenter,POBox409

26999,Doha,Qatar.410183. CentreforPopulationHealthSciences,UsherInstituteofPopulationHealth411

SciencesandInformatics,UniversityofEdinburghEH89AG,Scotland,UK412184. DepartmentofBiology,FacultyofMedicine,UniversityofSplit,Croatia.413185. TheNationalInstituteforHealthResearchBloodandTransplantResearchUnit414

inDonorHealthandGenomics,UniversityofCambridge,UK.415186. DivisionofCardiology,UniversityHospital,Petersgraben4,4031Basel,416

Switzerland.417187. DivisionofCardiology,DepartmentofMedicine,McMasterUniversity,1280Main418

StW,Hamilton,L8S4L8,Canada.419188. InstituteofGeneticandBiomedicalResearch,NationalResearchCouncil(CNR),420

Monserrato,Cagliari,Italy.421189. DepartmentofBiomedicalSciences,UniversityofSassari,Sassari,Italy.422190. InstituteofClinicalMedicine,InternalMedicine,UniversityofEasternFinland423

andKuopioUniversityHospital,Kuopio,Finland.424191. LaboratoryofCardiovascularScience,NIA/NIH,Baltimore,MD21224,USA.425192. DepartmentofPublicHealthandPrimaryCare,LeidenUniversityMedical426

Center,Leiden,theNetherlands.427193. LabormedizinischesZentrumDr.Risch,Landstrasse157,9494Schaan,428

Liechtenstein.429194. PrivateUniversityofthePrincipalityofLiechtenstin,Dorfstrasse24,9495430

Triesen,Liechtenstein.431

10

195. UniversityInsituteofClinicalChemistry,Inselspital,BernUniversityHospital,432UniversityofBern,3010Bern,Switzerland.433

196. DepartmentofCardiology,UniversityofGroningen,UniversityMedicalCenter434Groningen,Hanzeplein1,POBox30001,9700RBGroningen,TheNetherlands.435

197. CenterforGenomicMedicine,MassachusettsGeneralHospital,Boston,MA43602114,USA.437

198. CardiovascularResearchCenter,MassachusettsGeneralHospital,Boston,MA43802114,USA.439

199. NashvilleVA(TVHS)&VanderbiltUniversity.440200. VABostonHealthcare,SectionofCardiologyandDepartmentofMedicine,441

BrighamandWomen’sHospital,HarvardMedicalSchool.442201. CardiovascularHealthResearchUnit,DepartmentsofMedicine,Epidemiology443

andHealthServices,UniversityofWashington,Seattle,WA,USA.444202. KaiserPermanenteWashingtonHealthResearchInstitute,Seattle,WA,USA.445203. NationalInstituteforHealthResearchImperialBiomedicalResearchCentre,446

ImperialCollegeHealthcareNHSTrustandImperialCollegeLondon,London,447UK.448

204. UKDementiaResearchInstitute(UKDRI)atImperialCollegeLondon,London,449UK450

451

Correspondingauthors:MarkCaulfield(m.j.caulfield@qmul.ac.uk)andPauElliott452(p.elliott@imperial.ac.uk)453

454

Abstract455

High blood pressure is a highly heritable and modifiable risk factor for cardiovascular456disease.We report the largest genetic association studyofbloodpressure traits (systolic,457diastolic, pulse pressure) to date in over one million people of European ancestry. We458identify535novelbloodpressurelocithatnotonlyoffernewbiologicalinsightsintoblood459pressureregulationbutalsorevealsharedgeneticarchitecturebetweenbloodpressureand460lifestyle exposures. Our findings identify new biological pathways for blood pressure461regulationwithpotentialforimprovedcardiovasculardiseasepreventioninthefuture.462

463

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High blood pressure (BP) is a leading heritable risk factor for stroke and coronary artery464diseaseandwasresponsible foranestimated7.8milliondeathsand148milliondisability465lifeyearslostworldwidein2015alone1.Studiesindicatethatanindividual’sbloodpressure466(BP) level is determinedby complex interactionsbetween life courseexposuresand their467genetic background2-4. Previous genetic association studies have included genome-wide468meta-analyses,customisedcardiovascularcandidategenecentricanalysesandevaluationof469exome variation. These have identified and validated variants at 274 loci, with modest470effectsonpopulationBPthatinaggregateexplainonly~3%ofthetraitvariance5-12.471

Here,wereportgenome-widediscoveryanalysesofBPtraits(systolic-SBP,diastolic-DBP472andpulsepressure-PP)inpeopleofEuropeanancestrydrawnfromUKBiobank(UKB)13and473the International Consortium of Blood Pressure-Genome Wide Association Studies474(ICBP)11,12.Weadoptedacombinationofaoneandtwo-stagestudydesigntotestcommon475and low-frequency single nucleotide polymorphisms (SNPs) with minor allele frequency476(MAF) ³ 1% in association with BP traits (Fig. 1). We studied over 1 million people of477Europeandescentacrossbothdiscoveryandreplication,includingreplicationdatafromthe478USMillionVeteransProgram(MVP)14andtheEstonianGenomeCentre,UniversityofTartu479(EGCUT)Biobank15.480

Briefly,UKB is aprospective cohort studyof ~500,000 individuals recruitedat ages40-69481years who have been richly phenotyped including BPmeasurements14. Participants were482genotyped using a customized array with imputation from the Haplotype Reference483Consortium(HRC)panel,yielding~7millionSNPs(imputationqualityscore(INFO)³0.1and484MAF ³ 1%)16. After quality control (QC) and exclusions (Online Methods) we performed485genome-wide association studies (GWAS) of BP traits using data from 458,577 UKB486participantsofEuropeandescentunderanadditivegeneticmodel17(SupplementaryTable4871a).FollowingLD-scoreregression18,genomiccontrolwasappliedtotheUKBdatapriorto488meta-analysis(Onlinemethods).489

Inaddition,weperformedGWASanalysesforBPtraits inthenewlyextendedICBPGWAS490datacomprising77 independent studies includingup to299,024participantsofEuropean491ancestry genotyped with various arrays, and imputed to either the 1,000 Genomes492Reference Panel or the HRC platforms (Supplementary Table 1b). After QC we applied493genomic control at the individual study level and obtained summary effect sizes for ~7494millionSNPswithINFO³0.3andCochran’sQstatistic19(testofheterogeneity)filteredatP495≥1×10-4(OnlineMethods).496

WethencombinedtheUKBand ICBPGWASresultsusing inverse-varianceweighted fixed497effects meta-analysis (Online Methods), giving a total discovery sample of 757,601498individuals20.499

In our two-stage design we attempted replication of 1,062 SNPs at P < 1 × 10-6 from500discoverywithconcordanteffectdirectionbetweenUKBand ICBP,using thesentinelSNP501(i.e.SNPwithsmallestP-valueatthelocus)afterexcludingtheHLAregion(chr6:25-34MB)502and all SNPs in Linkage Disequilibrium (LD) (r2 ≥ 0.1) or ±500 Kb from any previously503validatedBP-associatedSNPsatthe274publishedloci.WeusedMVP(upto220,520people504of European descent) and EGCUT (up to 28,742 Europeans) for independent external505

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replication14,15(SupplementaryTable1c).Ourreplicationcriteriaforthetwo-stagedesign506weregenome-widesignificance(P<5×10-8)inthecombinedmeta-analysis,withP<0.01in507thereplicationdataandconcordantdirectionofeffectbetweendiscoveryandreplication.508

Given the larger size of the two discovery datasets (UKB and ICBP) compared with509replication resources, we additionally undertook a one-stage design with internal510replication, tominimize the risk ofmissing true positive associations from our two-stage511analysis.Toensuretherobustnessofthisapproach,andtoavoidfalsepositivefindings,we512usedP<5×10-9astheP-valuethresholdfromthediscoverymeta-analysis,i.e.anorderof513magnitudemore stringent than genome-wide significance21.Wealso required an internal514replication P-value of < 0.01 in each of the UKB and ICBP GWAS analyses and with515concordantdirectionofeffect,toensuresupportfrombothdatasources.516

WethenexploredtheputativefunctionoftheBPassociatedsignalsusingarangeofinsilico517resources, including expression quantitative trait loci (eQTLs), tissue and DNase I site518enrichment, long range chromatin interactions (Hi-C), pathwayanalysis and ‘druggability’.519WeinvestigatedmetabolomicsignaturesassociatedwithournovelsentinelSNPs,evaluated520theoverlapwith lifestyleexposuresthat influenceBP,andexaminedtheco-occurrenceof521BP-associated lociwithothercomplex traitsanddiseases.Wealsocarriedoutconditional522analyses using genome-wide complex trait analysis (GCTA)22. Finally, we developed a523genetic risk score and performed analysis to model the impact that all BP-associated524variantshaveonBPlevel,riskofhypertension(HTN),othercardiovasculardiseasesandon525BPinnon-Europeanancestries.526

RESULTS527

Wepresentatotalof535novelloci(Fig.2,SupplementaryFig.1):325lociclaimedfromthe528two-stagedesign(SupplementaryTables2a-c)andanadditional210claimedfromourone-529stagedesignwith internal replication (Supplementary Tables 3a-c).Of the325 two-stage530variants,204wouldalsohavemettheone-stagecriteria,while121wereuniquelyidentified531fromourtwo-stagedesign(Fig.3a).Thususingthisdualapproach,wewereabletoidentify532largenumbersofadditional loci thatwouldnothavebeendetectedbyeither theone-or533two-stage designs alone, as well as finding considerable overlap (Fig. 3a). For SBP, the534distributionsofeffect sizesof theone-stage loci (median=0.219mmHgperallele; Inter-535QuartileRange(IQR)=0.202-0.278)andtwo-stageloci(median=0.224;IQR=0.195-0.267)536are similarwithin the discovery data (P= 0.447) (Supplementary Fig. 2). Of the 210 loci537foundonlyintheone-stageanalysisofUKBandICBP,186arealsogenome-widesignificant538(P<5×10-8)inthecombinedmeta-analysisofallfourdiscoveryandreplicationresources,539withallvariants,exceptone,havingconcordantdirectionofeffectbetweendiscoveryand540replication(SupplementaryTables3a-c).Oftheremaining24SNPswhicharenotgenome-541widesignificantoverallinthecombinedmeta-analysis,10stillhaveconcordantdirectionof542effect.543

We confirm previous findings with support in our data for all 274 published BP loci544(Supplementary Fig. 1 & 2 and Supplementary Table 4) and >95% of the previously545reportedSNPscoveredwithinourdataaregenome-widesignificant.Only6availableSNPs546

13

did not reach Bonferroni-significance, likely because they were originally identified from547non-European ancestries (e.g. rs6749447, rs10474346, rs11564022), or from a gene-age548interaction analysis (rs16833934). In addition, we confirmed a further 92 loci that had549previously been reported but not replicated (Supplementary Table 5)9. Overall,with 274550previouslyreported lociconfirmed,92 locireplicatedforthefirst time,and535novel loci551identifiedhere,thereare901BP-associatedlociintotal.552

Discoveryofnovelgeneticlociforbloodpressure553

Ofthe535independentnovelloci,363SNPswereassociatedwithonlyonetrait;160with554twotraitsand12withallthreeBPtraits(Fig.3b),reflectingtheinter-correlationsbetween555BPtraitsdespitetheirdifferentphysiology.556

FromtheconditionalanalysesusingGCTAweadditionallyidentified163independent557secondarysignalswithMAF≥1%,whichareassociatedwithBPatgenome-widesignificance558level(SupplementaryTable6).Ofthese163secondarysignals,19SNPsareinLD(r2≥0.1)559withpreviouslyreportedsecondarysignals,resultinginatotalof144newsecondarysignals560identifiedhere.Henceintotaltherearenowover1,000independentBPsignalsreported.561

TheestimatedSNP-wideheritability(h2)ofBPtraitsinourdatawas0.213,0.212and0.194562forSBP,DBPandPPrespectively,andthereisagaininthepercentageofBPvariance563explained.Forexample,forSBP,thepercentagevarianceexplainedincreasedfrom2.8%for564the274previouslypublishedlocito5.7%forallsentinelandsecondarySNPsidentifiedatall565901loci(SupplementaryTable7).566

Functionalanalyses567

OurfunctionalanalysesapproachissummarisedinSupplementaryFigure3.First,foreach568ofthe901lociweannotatedallSNPs(basedonLDr2≥0.8)tothenearestgenewithin5kb569ofaSNP.Therewere1644genesinthenovellociand962genesintheknownloci.Thenwe570investigated these loci for tissue enrichment, DNase hypersensitivity site enrichment and571pathway analyses. At 66 of the 535 novel loci we identified 97 non-synonymous SNPs,572including8predictedtobedamaging(SupplementaryTable8).573

We used chromatin interaction Hi-C data from endothelial cells (HUVEC)23, neural574progenitorcells(NPC),mesenchymalstemcells(HVMSC)andtissuefromtheaorta(HAEC)575and adrenal gland24 to identify distal associated genes. There were 498 novel loci that576contained a potential regulatory SNP and in 484 of these we identified long-range577interactions in at least one of the tissues or cell types.We found several potential long-578rangetargetgenesthatdonotoverlapwiththesentinelSNPsintheLDblock.Forexample,579theTGFB2geneformsa1.2Mblongregulatory loopwiththeSNPs intheSLC30A10 locus,580and the TGFBR1 promoter forms a 100kb loop with the COL15A1 locus (Supplementary581Table8).582

Our eQTL analysis identified 60 novel lociwith eQTLs in arterial tissue and 20 in adrenal583tissue (Supplementary Table 9); this is a substantial increaseover those identified inour584previously published GWAS on ~140K UKB individuals10. An example is SNP rs31120122585which defines an aortic eQTL that affects expression of theMED8 gene within the SZT2586

14

locus. In combination with Hi-C interaction data in MSC this finding supports a role for587MED8 in BP regulation, possibly mediated through repression of smooth muscle cell588differentiation.Hi-C interactionsprovidesupportiveevidence for involvementofa further58936 arterial eGenes (geneswhose expression is affectedby the eQTLs) thatweredistal to590theireQTLs(e.gPPHLN1,ERAP2,FLRT2,ACVR2A,POU4F1).591

Weinvestigatedwhichtranscriptionfactorsandchromatinmarksareinvolvedinregulatory592interactions using the functional predictions from DeepSEA. We found 198 SNPs in 121593novel lociwithpredictedeffectson transcription factorbindingoronchromatinmarks in594tissues relevant for BP biology, such as vascular tissue, smooth muscle and the kidney595(SupplementaryTable8).596

Weusedourgenome-widedataatafalsediscoveryrate(FDR)<1%torobustlyassessthe597tissueenrichmentofBP lociusingDEPICTand identifiedenrichmentacross50tissuesand598cells (Supplementary Fig 4; Supplementary Table 10a). Enrichment was greatest for the599cardiovascularsystemespeciallybloodvessels(P=1.5×10-11)andtheheart(P=2.7×10-5).600Enrichmentwashigh inadrenaltissue(P=3.7×10-4)and,forthefirsttime,weobserved601high enrichment in adipose tissues (P = 9.8 × 10-9) corroborated by eQTL enrichment602analysis(P<0.05)(SupplementaryFig.4;SupplementaryTable10a).Evaluationofenriched603mouseknockoutphenotypetermsalsopointstotheimportanceofvascularmorphology(P604=6×10-15)anddevelopment(P=2.1×10-18)inBP.DuetotheadditionofournovelBPloci,605we identified new findings from both the gene ontology and protein-protein interaction606subnetwork enrichments, which highlight the TGFb (P = 2.3 × 10-13) and related SMAD607pathways(P=7×10-15)(SupplementaryTable10b,SupplementaryFig.5b-d).608

WeusedFORGE25toinvestigatetheregulatoryregionsforcelltypespecificityfromDNaseI609hypersensitivity sites, which showed strongest enrichment (P < 0.001) in the vasculature610andhighlyvascularisedtissues,asreportedinpreviousBPgeneticstudies10(Supplementary611Fig.6).612

Potentialtherapeutictargets613

Ingenuity pathway analysis and upstream regulator assessment showed enrichment of614canonical pathways implicated in cardiovascular disease including pathways targeted by615antihypertensivedrugs(e.g.nitricoxidesignalling)andalsosuggestedsomepotentialnew616targets, such as relaxin signalling. Notably, upstream regulator analysis identified several617known mediators of BP including therapeutic targets such as angiotensinogen, calcium618channels, progesterone, natriuretic peptide receptor, angiotensin converting enzyme,619angiotensinreceptorsandendothelinreceptors(SupplementaryFig.7).620

We developed a cumulative tally of functional evidence at each variant to assist in621variant/geneprioritisationateachlocus.622

Wepresentasummaryofthevascularexpressedgenescontainedwithinthe535novelloci,623including a review of their potential druggability (Supplementary Fig. 8). The overlap624betweengenesassociatedwithBPandthoseassociatedwithantihypertensivedrugtargets,625furtherdemonstratesnewgenetic support for knowndrugmechanisms. Forexample,we626

15

report five novel BP associations with the targets of five antihypertensive drug classes627(SupplementaryTable11).TheseincludethePKD2L1,SLC12A2,CACNA1C,CACNB4andCA7628loci, which are targeted by potassium-sparing diuretics (amiloride), loop diuretics629(bumetanide and furosemide), dihydropyridine, calcium channel blockers, non-630dihydropyridines and thiazide-like diuretics (chlortalidone) respectively. Notably in all but631thelastcase,functionalvariantsinthesegenesarethebestcandidatesineachlocus.632

ConcordanceofBPvariantsandlifestyleexposures633

UKBiobankhascollectedextensivelifestylerelateddata,someofwhichareassociatedwith634BP epidemiologically and in trials. These includemacronutrients,water, tea, caffeine and635alcoholintake,anthropomorphictraits,physicalactivityandinactivity,smokingandurinary636sodium,potassiumandcreatinineexcretion14.WeinvestigatedwhethersentinelSNPsatthe637901BPlociwereassociatedwithlifestyletraitsinUKBineithertheStanfordGlobalBiobank638Engine(N=327,302)orGeneATLAS(N=408,455),withcorrectedP<1×10-6.Forexample,639wefoundthataBPSNPrs34783010inGIPRisassociatedwithdailyfruitintake(P=1.03×64010-7), urinary sodium and creatinine concentration (P = 1.5 × 10-13 and 1.2 × 10-9641respectively), body mass index (BMI, P = 3.3 × 10-41), weight (P = 7.3 × 10-35) andwaist642circumference(P=7.7×10-30);rs6495122,nearCPLX3andULK3,andrs1378942inCSKare643associatedwithwater(P=1.3×10-22and2.6x10-20respectively),caffeine(P=1.3×10-46644and2.2×10-43)andteaintake(P=7.6×10-38and8.1×10-33),aswellasurinarycreatinine645concentrations (P= 5.6 × 10-8 and P= 3.2 x 10-8 respectively). In addition, the BP SNP646rs13107325 inSLC39A8, isanovel locus for frequencyofdrinkingalcohol (P=3.5×10-15)647andtimespentwatchingTV(P=2.3×10-11)aswellasbeingassociatedwithBMI(P=1.6×64810-33), weight (P = 8.8 × 10-16)and waist circumference (P = 4.7 × 10-11) (Supplementary649Table12).Weusedunsupervisedhierarchicalclusteringforthe36BP loci thatshowedat650least one association with the lifestyle related traits in UKB at P < 1 × 10-6 (Fig. 4). The651heatmapsummarisesthelocusspecificassociationsacrosstherangeoftraitsandhighlights652heterogeneous effects with anthropometric traits across the range of loci examined. For653example, it showsaclusterofassociationsbetweenBP raisingallelesand increasedadult654heightandweightandanotherclusterofgenesthatshowassociationsbetweenBPraising655alleles and decreased adult height and weight. We note that some observed cross-trait656associationsareincounter-directionstowhatmaybeexpectedepidemiologically.657

Associationlookupswithothertraitsanddiseases658

We further evaluated cross-trait and disease associations using GWAS catalog26,659PhenoScanner27 and DIsGeNET, which integrates data from expert curated repositories,660GWAS catalogues, animal models and the literature28,29. The GWAS catalog and661PhenoScanner search of published GWAS showed that 77 of our 535 novel loci (using662sentinel SNPs or proxies; r2≥ 0.8) are also significantly associated with other traits and663diseases(Fig.5,SupplementaryTable13).WeidentifiedAPOEasahighlycross-relatedBP664locus showing associations with lipid levels, cardiovascular related outcomes and665Alzheimer’sdisease,afindingthathighlightsacommonlinkbetweencardiovascularriskand666

16

cognitive decline (Fig. 5). Several other loci overlapwith anthropometric traits, including667BMI, birth weight and height (Fig 5). DisGeNET terms related to lipid measurements,668cardiovascularoutcomesandobesityoverlapwithBPloci(Fig.6).669

We used 1H NMR lipidomics data on plasma (N=2,022) and data from the Metabolon670platform(N=1,941)forsubsetsofparticipantsoftheAirwaveHealthMonitoringStudy30for671lookups of our sentinel SNPs. We also used PhenoScanner to test each SNP against672publishedsignificant(P<5×10-8)genomevsmetabolome-wideassociationsinplasmaand673urine(OnlineMethods).TenBPSNPsshowassociationwithlipidparticlemetabolitesanda674further 31 SNPs (8 also on PhenoScanner) show association with metabolites on the675Metabolon platform, highlighting lipid pathways, amino acids (glycine, serine, glutamine),676tri-carboxylic acid cycle intermediates (succinylcarnitine) and drug metabolites677(SupplementaryTables14and15).ThesefindingssuggestaclosemetaboliccouplingofBP678regulationwithlipid,andforthefirsttime,withenergymetabolism.679

Geneticriskofincreasedbloodpressure,hypertensionandcardiovasculardisease680

We created a genetic risk score (GRS) for BP levels weighted according to the effect681estimatesfromICBP(forknownloci)andtheMVP+EGCUTreplication(fornovelloci)across682all901loci(OnlineMethods).ThecombinationoftheseBPvariantswasassociatedwitha68310.39mmHghigher,sex-adjustedmeanSBPinUKBiobankforthecomparisonbetweenthe684upperandlowerquintilesoftheGRSdistribution(95%CI:10.19to10.58mmHg,P<1×10-685300) and with 12.85 mmHg difference in SBP (95% CI: 12.57 to 13.13, P < 1 × 10-300)686comparingtheupperandlowerdeciles(Fig.7a,SupplementaryTable16). Inaddition,we687observedovertwo-foldsex-adjustedhigherriskofhypertension(OR2.66;95%CI:2.60to6882.72;P<1×10-300)betweentheupperandlowerquintilesoftheGRSinUKBiobank(Fig.7).689SensitivityanalysesintheindependentAirwavecohortgavesimilarresults(Supplementary690Table17).691

FromrecordlinkagetoHospitalEpisodeStatisticsandmortalityfollow-upinUKBweshow692that theGRS isassociatedwith increased, sex-adjusted riskof incident stroke,myocardial693infarctionandallincidentcardiovascularoutcomes,comparingtheupperandlowerdeciles694oftheGRSdistribution,withoddsratiosof1.47(95%CI:1.35to1.59,P=1.12×10-20),1.50695(95% CI: 1.28 to 1.76, P = 7.99 × 10-7) and 1.52 (95% CI: 1.26 to 1.82, P = 7.4 × 10-6)696respectively(Fig.7b,SupplementaryTable16).697

Extendinganalysestootherancestries698

WeexaminedassociationswithBPofboth individual SNPsand theGRSamongunrelated699individualsofAfricanandof SouthAsianancestries inUKB, for the901knownandnovel700loci. IncomparisonwiththeresultsforEuropeanancestry,62.4%,62.5%and64.8%ofthe701variants among people of African (N=7,782), and 74.2%, 72.3% and 75% of South Asian702(N=10,323)ancestryhaveconcordantdirectionofeffect forSBP,DBPandPP respectively703(Supplementary Table 18; Supplementary Fig. 9). Pearson correlation coefficients with704effectestimatesinEuropeanswerer2=0.37and0.78forAfricanandSouthAsianancestries705respectively (Supplementary Fig. 10).We then applied the GRS derived from European706ancestry findings tounrelated individuals ofAfrican (N=6,970) and SouthAsian (N=8,827)707

17

ancestries. BP variants in combination were associated with 6.1 mmHg (95% CI: 4.50 to7087.65; P = 4.9 × 10-14) and 7.4mmHg (95% CI: 6.00 to 8.69; P = 1.7 × 10-26) higher, sex-709adjustedmean systolic pressure among individuals ofAfrican and SouthAsian ancestries,710respectively, for the comparison between the upper and lower quintiles of the GRS711distribution(SupplementaryTables19aand19b).712

DISCUSSION713

Ourstudyofover1millionpeopleoffersan importantstep forward inunderstandingthe714geneticarchitectureofBP.Wehaveidentifiedover1,000independentsignalsat901locifor715BP traits, andwith 535 novel lociwe havemore than tripled the number of BP loci and716doubledthepercentagevarianceexplainedforBP.Bynowexplaining27%oftheestimated717heritabilityforBP,wemakemajorinroadsintothemissingheritabilityinfluencingBPlevel718in the population31. These findings illustrate the power of a large-scale standardised719approachtodatacollection,biobanking,genotyping,qualitycontrolandimputation,suchas720was achieved inUKB. The novel loci open the vista of entirely newbiology and highlight721generegionsinsystemsnotpreviouslyimplicatedinBPregulation.Thisisparticularlytimely722as the global prevalence of people with SBP over 110-115 mm Hg, above which723cardiovascular risk increases ina continuousgradedmanner,nowexceeds3.5billionand724thosewithinthetreatmentrangeexceed1billion32,33.725

Ourfunctionalanalysishighlightstheroleofthevasculatureandassociatedpathwaysinthe726geneticsunderpinningBPtraits.Weshowaroleforseverallociinthetransforminggrowth727factor beta (TGFβ) pathway including SMAD family genes and theTGFβ gene locus itself.728This pathway affects sodiumhandling in the kidney, ventricular remodelling and recently729plasma levels of TGFβ have been correlatedwith hypertension (Fig. 8)34,35. The activin A730receptor type 1C (ACVR1C) gene mediates the effects of the TGFβ family of signalling731molecules. AnotherBP locuscontains theBoneMorphogeneticProtein2 (BMP2)gene in732the TGFβ pathway, which prevents growth suppression in pulmonary arterial smooth733muscle cells and is associated with pulmonary hypertension36.We identified another BP734locus including the Kruppel-like family 14 (KLF14) gene of transcription factorswhich are735induced by low levels of TGFβ receptor II gene expression. This gene has also been736associatedwithtype2diabetes,hypercholesterolaemiaandatherosclerosis37.737

OuranalysisshowsenrichmentofBPgenes intheadrenaltissue.Theadrenalglandhasa738keyrole inBPregulation,withautonomousaldosteroneproductionby theadrenalglands739thoughttoberesponsiblefor5-10%ofallhypertension,risingto~20%amongstpeoplewith740resistant hypertension38. Some of our novel loci are linked functionally to aldosterone741secretion39,40. For example, theCTNNB1 locus encodes β-catenin, the centralmolecule in742thecanonicalWnt signalling system, required fornormaladrenocorticaldevelopment41,42.743Somaticadrenalmutationsofthisgenethatpreventserine/threoninephosphorylationlead744tohypertensionthroughthegenerationofaldosterone-producingadenomas43,44.745

Our novel loci also include genes involved in vascular remodelling, such as vascular746endothelial growth factor A (VEGFA), the gene product of which induces proliferation,747migrationofvascularendothelialcellsandstimulatesangiogenesis.Disruptionofthisgene748inmiceresultedinabnormalembryonicbloodvesselformation,whileallelicvariantsofthis749

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gene have been associated withmicrovascular complications of diabetes, atherosclerosis750and the antihypertensive response to enalapril45. We previously reported a fibroblast751growthfactor(FGF5)genelocusinassociationwithBP.Here,weadditionallyidentifyanew752BP locus encoding FGF9, which has been linked to enhanced angiogenesis and vascular753smoothmusclecelldifferentiationbyregulatingVEGFAexpression.754

Several of our novel loci contain lipid related geneswhich supports the observed strong755associationsacrossmultiplecardio-metabolictraits.Forexample,theapolipoproteinEgene756(APOE)encodesthemajorapoproteinofthechylomicron.Recently,APOEserumlevelshave757been correlated with systolic BP in population-based studies and in murine knockout758models;disruptionofthisgeneledtoatherosclerosisandhypertension46,47.Asecondnovel759BPlocuscontainsthelow-densitylipoproteinreceptor-relatedprotein4(LRP4)genewhich760maybe a target forAPOE and is strongly expressed in the heart inmice andhumans. In761addition, we identified a novel locus including the apolipoprotein L domain containing 1762gene (APOLD1) that is highly expressed in the endothelium of developing tissues763(particularlyheart)duringangiogenesis.764

ManyofournovelBPlociencodeproteinswhichmaymodulatevasculartoneorsignalling.765For example, the locus containing urotensin-2 receptor (UTS2R) gene encodes a class A766rhodopsin family G-protein coupled-receptor that upon activation by the neuropeptide767urotensinII,producesprofoundvasoconstriction.OneofthenovellociforSBPcontainsthe768relaxingenewhichencodesaG-proteincoupledreceptorwithroles invasorelaxationand769cardiac function,andwhich signalsbyphosphatidylinositol3-kinase (PI3K)48,49, anenzyme770which inhibits vascular smoothmuscle cell proliferation and neo-intimal formation50.We771identify thePI3K genehere as a novel BP locus.Wealso identify thenovelRAMP2 locus772whichencodesanadrenomedullinreceptor51;wepreviouslyidentifiedtheadrenomedullin773(ADM)geneasaBPlocus12.AdrenomedullinisknowntoexertdifferentialeffectsonBPin774thebrain(vasopressor)andthevasculature(vasodilator).Inaddition,alocuscontainingRho775guaninenucleotideexchangefactor25(ARHGEF25)genegeneratesafactorwhichinteracts776with Rho GTPases involved in contraction of vascular smooth muscle and regulation of777responsestoangiotensinII52.778

Weevaluatedthe901BPlociforextantorpotentiallydruggabletargets.Wenotethatloci779encodingMARK3,PDGFC,TRHR,ADORA1,GABRA2,VEGFA andPDE3A arewithin systems780thathaveexistingdrugsnotcurrently linkedtoaknownantihypertensivemechanismand781mayofferrepurposingopportunitiese.g.detectionofSLC5A1asthestrongestrepurposing782candidateinanewBPlocuswhichistargetedbythetype2diabetesdrugcanagliflozin.This783is important as between 8-12% of patients with hypertension exhibit resistance or784intolerancetocurrenttherapiesandrepositioningofatherapywithaknownsafetyprofile785mayreducedevelopmentcosts.786

Ourfindingswith largersamplesize,strengthenourpreviouslyreportedgeneticriskscore787analysis indicating that all BP elevating alleles combined could increase systolic BP by 10788mmHgormoreacrossquintilesordecilesofthepopulationdistribution,givingsubstantially789increased risk of cardiovascular events (stroke and coronary disease)10. We previously790

19

suggestedthatgenotypingBPelevatingvariantsintheyoungmayleadtotargetedlifestyle791interventioninearlylifethatmightattenuatetheBPriseatolderages10.792

We identified several BP-associated loci which are also associated with lifestyle traits,793suggestingapossiblesharedgeneticarchitecturebetweenBPandlifestyleexposuresknown794from randomised clinical trials and observational data to be associated with BP53. We795adjustedourBPGWASanalysesforBMI,whichshouldhavereducedpossibleconfounding796effects,thoughweacknowledgethepotentialforcolliderbiasbetweenalifestylefactorand797BP54.Nonetheless,ourfindingsofpossiblegeneticoverlapbetweenlociassociatedwithBP798andlifestyleexposurescouldsupportrenewedfocusonalteringspecificlifestylemeasures799knowntoaffectBP55.800

Despite smaller sample sizes in the single-variant analyses of non-European ancestry801samples,weobservedhighconcordanceoftheeffectsofBPvariantsinpeopleofAfrican(>80262%)andSouthAsian(>72%)ancestryforallBPtraits.Furthermore,theGRSanalysesshow803that,incombination,BPvariantsidentifiedinEuropeananalysesarealsoassociatedwithBP804innon-Europeanancestries,thoughsizeoftheeffectwas30-40%smaller.Nonetheless,new805knowledgeonthegeneticarchitectureofBPinEuropeansalsoextends,atleastinpart,to806populationsofotherancestries.807

Ourdiscoveryof535novellocifromacombinationofatwo-stageGWASwithindependent808replicationandone-stageGWASdesignwithinternalreplicationillustratesthevalueofthis809approachtominimizetheeffectsofstochasticvariationandheterogeneity.Theone-stage810approach was included in order to report signals that had independent and concordant811support(P<0.01)frombothUKBandICBP(thusminimizingtheimpactofwinners’curseon812our reported findings). Indeed, all but two of the 210 SNPs discovered in the one-stage813analysisreachP<5×10-6 ineitherUKBor ICBP(thetwoexceptionshaveP=7.8×10-6 in814UKB, P =1.4 × 10-5 in ICBP; and P =1.2 × 10-5 in UKB, P = 5.3 × 10-6 in ICBP). To further815minimize the risk of reporting false positive loci within our one-stage design, we set a816stringent overall discovery meta-analysis P-value threshold of P < 5 × 10-9, an order of817magnitude smaller than a genome-wide significance P-value, in line with thresholds818recommended for whole genome sequencing22. We also found high concordance in the819directionofeffectsbetweendiscoverydata intheone-stageapproachandthereplication820resources,withsimilardistributionsofeffectsizesfortheone-stagevstwo-stagediscovery821data.Wenotethat24oftheone-stageSNPswhichreachedP<5×10-9indiscoveryfailed822toreachgenome-widesignificance(P<5×10-8)inthecombinedmeta-analysisofdiscovery823andreplicationresourcesandhencemaystillrequirefurthervalidationinfuturestudiesif824largerreplicationresourcesbecameavailable.825

ThenewdiscoveriesreportedheremorethantriplethenumberoflociforBPtoatotalof826901andrepresentasubstantialadvanceinunderstandingthegeneticarchitectureofBP.By827identifyingsomanynovelgenesacrossthegenome,thesefindingscouldpartlysupportan828omnigenic model for complex traits where genome-wide association of multiple829interconnected pathways is observed. However, as our strong tissue enrichment shows830particular relevance to the biology of BP and cardiovascular disease56, the genetic831architecture of BP still shows trait-specificity, which could argue against an omnigenic832

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model. Our confirmation of the impact of these variants on BP level and cardiovascular833events,coupledwithidentificationofsharedriskvariantsforBPandadverselifestylecould834contributetoanearlylifeprecisionmedicinestrategyforcardiovasculardiseaseprevention.835

URLs836

FORGE:http://browser.1000genomes.org/Homo_sapiens/UserData/Forge?db=core837Fantom5data:http://fantom.gsc.riken.jp/5/838ENCODEDNaseIdata:(wgEncodeAwgDnaseMasterSites;accessedusingTablebrowser)839ENCODEcelltypedata:http://genome.ucsc.edu/ENCODE/cellTypes.html.840GTEx:www.gtexportal.org841DeepSEA:http://deepsea.princeton.edu/842WebGetstalt:http://www.webgestalt.org843IPA:www.qiagen.com/ingenuity844MouseGenomeInformatics(MGI):http://www.informatics.jax.org/batch845DrugGeneInteractiondatabase:www.dgidb.org846PhenoScanner:http://www.phenoscanner.medschl.cam.ac.uk(Phenoscannerintegrates847resultsfromtheGWAScatalogue:https://www.ebi.ac.uk/gwas/andGRASP:848https://grasp.nhlbi.nih.gov/)849DisGeNEt:http://www.disgenet.org850GeneATLAS:http//geneatlas.roslin.ed.ac.uk851GlobalBiobankEngine:https://biobankengine.stanford.edu852853

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992Acknowledgements993

H.R.W.wasfundedbytheNationalInstituteforHealthResearch(NIHR)aspartofthe994portfoliooftranslationalresearchoftheNIHRBiomedicalResearchCentreatBartsandThe995LondonSchoolofMedicineandDentistry.D.M-AissupportedbytheMedicalResearch996Council[grantnumberMR/L01632X.1].B.M.holdsanMRCeMedLabMedicalBioinformatics997CareerDevelopmentFellowship,fundedfromawardMR/L016311/1.H.G.wasfundedby998theNIHRImperialCollegeHealthCareNHSTrustandImperialCollegeLondonBiomedical999ResearchCentre.C.P.C.wasfundedbytheNationalInstituteforHealthResearch(NIHR)as1000partoftheportfoliooftranslationalresearchoftheNIHRBiomedicalResearchCenterat1001BartsandTheLondonSchoolofMedicineandDentistry.S.T.wassupportedbyCanadian1002InstitutesofHealthResearch;UniversitéLaval(QuebecCity,Canada).G.P.wassupportedby1003CanadaResearchChairinGeneticandMolecularEpidemiologyandCISCOProfessorshipin1004IntegratedHealthBiosystems.I.K.wassupportedbytheEUPhenoMeNalproject(Horizon10052020,654241).C.P.K.issupportedbygrantsR01DK096920andU01DK102163fromtheNIH-1006NIDDK,andbyresourcesfromtheMemphisVAMedicalCenter.P.S.T.wassupportedbyVA1007Award#I0BX003362.C.P.K.isanemployeeoftheUSDepartmentofVeteransaffairs.1008Opinionsexpressedinthispaperarethoseoftheauthors’anddonotnecessarilyrepresent1009theopinionoftheDepartmentofVeteransAffairs.S.D.wassupportedforthisworkby1010grantsfromtheEuropeanResearchCouncil(ERC),theEUJointProgramme-1011NeurodegenerativeDiseaseResearch(JPND),theAgenceNationaledelaRecherche(ANR).1012M.BOEissupportedbyNIHgrantR01-DK062370.H.W.andA.G.acknowledgesupportofthe1013TripartiteImmunometabolismConsortium[TrIC],NovoNordiskFoundation(grant1014

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NNF15CC0018486).N.V.wassupportedbyMarieSklodowska-CurieGFgrant(661395)and1015ICIN-NHI.C.M.isfundedbytheMRCAimHy(MR/M016560/1)projectgrant.M.A.N1016participationissupportedbyaconsultingcontractbetweenDataTecnicaInternationaland1017theNationalInstituteonAging,NIH,Bethesda,MD,USA.M.BR.,M.CO.,I.G.,P.G.,G.G,1018A.MO.,A.R.,D.V.weresupportedbytheItalianMinistryofHealthRF2010toPaolo1019Gasparini,RC2008toPaoloGasparini.D.I.B.issupportedbytheRoyalNetherlands1020AcademyofScienceProfessorAward(PAH/6635).J.C.C.issupportedbytheSingapore1021MinistryofHealth’sNationalMedicalResearchCouncilunderitsSingaporeTranslational1022ResearchInvestigator(STaR)Award(NMRC/STaR/0028/2017).C.C.,P.B.MandM.R.Bwere1023fundedbytheNationalInstitutesforHealthResearch(NIHR)aspartoftheportfolioof1024translationalresearchoftheNIHRBiomedicalResearchCentreatBarts.M.R.isrecipient1025fromChinaScholarshipCouncil(No.2011632047).C.L.wassupportedbytheMedical1026ResearchCouncilUK(G1000143;MC_UU_12015/1;MC_PC_13048;MC_U106179471),1027CancerResearchUK(C864/A14136),EUFP6programme(LSHM_CT_2006_037197).G.B.Eis1028supportedbytheSwissNationalFoundationSPUMprojectFN33CM30-124087,Geneva1029University,andtheFondationpourRecherchesMédicales,Genève.C.M.Lissupportedby1030theLiKaShingFoundation,WT-SSI/JohnFellfundsandbytheNIHRBiomedicalResearch1031Centre,Oxford,byWidenlifeandNIH(CRR00070CR00.01).R.J.F.L.issupportedbytheNIH1032(R01DK110113,U01HG007417,R01DK101855,R01DK107786).D.O.M-K.issupportedby1033DutchScienceOrganization(ZonMW-VENIGrant916.14.023).M.Mwassupportedbythe1034NationalInstituteforHealthResearch(NIHR)BioResourceClinicalResearchFacilityand1035BiomedicalResearchCentrebasedatGuy'sandStThomas'NHSFoundationTrustandKing's1036CollegeLondon.H.W.andM.F.acknowledgethesupportoftheWellcomeTrustcoreaward1037(090532/Z/09/Z)andtheBHFCentreofResearchExcellence(RE/13/1/30181).A.G,H.W.1038acknowledgeEuropeanUnionSeventhFrameworkProgrammeFP7/2007-2013undergrant1039agreementno.HEALTH-F2-2013-601456(CVGenes@Target)&andA.G,theWellcomeTrust1040Institutionalstrategicsupportfund.A.P.M.wasaWellcomeTrustSeniorResearchFellowin1041BasicBiomedicalScience(WT098017).L.R.wassupportedbyForschungs-undFörder-1042StiftungINOVA,Vaduz,Liechtenstein.M.TO.issupportedbyBritishHeartFoundation1043(PG/17/35/33001).P.v.d.H.wassupportedbyICIN-NHIandMarieSklodowska-CurieGF(call:1044H2020-MSCA-IF-2014,ProjectID:661395).N.J.W.wassupportedbytheMedicalResearch1045CouncilUK(G1000143;MC_UU_12015/1;MC_PC_13048;MC_U106179471),Cancer1046ResearchUK(C864/A14136),EUFP6programme(LSHM_CT_2006_037197).E.Z.was1047supportedbytheWellcomeTrust(WT098051).J.N.H.andA.G.weresupportedbyVAgrant10481I01CX000982.T.L.E.andD.R.V.E.weresupportedbygrantR21HL121429fromNIH/NHLBI.1049A.M.H.wassupportedbyVAAward#I01BX003360.C.J.O.wassupportedbytheVABoston1050Healthcare,SectionofCardiologyandDepartmentofMedicine,BrighamandWomen’s1051Hospital,HarvardMedicalSchool.TheMRC/BHFCardiovascularEpidemiologyUnitis1052supportedbytheUKMedicalResearchCouncil[MR/L003120/1];BritishHeartFoundation1053[RG/13/13/30194];andUKNationalInstituteforHealthResearchCambridgeBiomedical1054ResearchCentre.J.DAisaBritishHeartFoundationProfessorandNIHRSeniorInvestigator.1055L.V.W.holdsaGlaxoSmithKline/BritishLungFoundationChairinRespiratoryResearch.P.E.1056acknowledgessupportfromtheNationalInstituteforHealthResearch(NIHR)Imperial1057BiomedicalResearchCentre,theNIHRHealthProtectionResearchUnitinHealthImpactof1058

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EnvironmentalHazards(HPRU-2012-10141),andtheMedicalResearchCouncil(MRC)and1059PublicHealthEngland(PHE)CentreforEnvironmentandHealth(MR/L01341X/1).P.E.isa1060UKDementiaResearchInstitute(DRI)professor,UKDRIatImperialCollegeLondon,funded1061bytheMRC,Alzheimer’sSocietyandAlzheimer’sResearchUK.M.J.C.wasfundedbythe1062NationalInstituteforHealthResearch(NIHR)aspartoftheportfoliooftranslational1063researchoftheNIHRBiomedicalResearchCenteratBartsandTheLondonSchoolof1064MedicineandDentistry.M.J.C.isaNationalInstituteforHealthResearch(NIHR)senior1065investigatorandthisworkisfundedbytheMRCeMedLabawardtoM.J.C.andM.R.B.and1066theNIHRBiomedicalResearchCentreatBarts.1067

ThisresearchwassupportedbytheBritishHeartFoundation(grantSP/13/2/30111).Project1068title:Large-ScaleComprehensiveGenotypingofUKBiobankforCardiometabolicTraitsand1069Diseases:UKCardioMetabolicConsortium(UKCMC).Thisresearchhasbeenconducted1070usingtheUKBiobankResourceunderapplicationnumber236.1071

Computing:Thisworkwasenabledusingthecomputingresourcesofthei)UKMEDical1072BIOinformaticspartnership-aggregation,integration,visualisationandanalysisoflarge,1073complexdata(UKMED-BIO)whichissupportedbytheMedicalResearchCouncil[grant1074numberMR/L01632X/1]andii)theMRCeMedLabMedicalBioinformaticsInfrastructure,1075supportedbytheMedicalResearchCouncil[grantnumberMR/L016311/1].1076

Conflicts/Disclosures1077M.A.N.consultsforIlluminaInc,theMichaelJ.FoxFoundationandUniversityofCalifornia1078Healthcareamongothers.M.J.C.isChiefScientistforGenomicsEngland,aUKGovernment1079company.1080

Theviewsexpressedinthismanuscriptarethoseoftheauthorsanddonotnecessarily1081representtheviewsoftheNationalHeart,Lung,andBloodInstitute;theNationalInstitutes1082ofHealth;ortheU.S.DepartmentofHealthandHumanServices.Thispublicationdoesnot1083representtheviewsoftheDepartmentofVeteransAffairsortheUnitedStatesGovernment.10841085Authorcontributions10861087Centralanalysis:E.E.,H.R.W.,D.M-A.,B.M.,R.P.,H.G.,G.N.,N.D.,C.P.C.,I.K.,F.N.,M.E.,1088K.W.,E.T.L.V.W.1089

Writingofthemanuscript:E.E.,H.R.W.,D.M-A.,B.M.,R.P.,H.G.,I.T.,M.R.B.,L.V.W.,P.E.,1090M.J.C.(withgroupleadsEE,H.R.W,L.V.W.,P.E.,M.J.C.)1091

ICBP-Discoverycontributor:(3C-Dijon)S.D.,M.S.,P.AM.,G.C.,C.T.;(AGES-Reykjavik)V.GU.,1092L.J.L.,A.V.S.,T.B.H.;(ARIC)D.E.A.,E.B.,A.CH.A.C.M.,P.N.;(ASCOT)N.R.P.,D.C.S.,A.S.,1093S.THO.,P.B.M.,P.S.,M.J.C.,H.R.W.;(ASPS)E.H.,Y.S.,R.S.,H.S.;(B58C)D.P.S.,BHSA.J.,1094N.SHR.;(BioMe(formerlyIPM))E.P.B.,Y.LU.,R.J.F.L.;(BRIGHT)J.C.,M.F.,M.J.B.,P.B.M.,1095M.J.C.,H.R.W.;(CHS)J.C.B.,K.R.,K.D.T.,B.M.P.;(Cilentostudy)M.C.,T.NU.,D.R.,R.SO.;1096(COLAUS)M.B.,Z.K.,P.V.;(CROATIA_Korcula)J.MART.,A.F.W.;(CROATIA_SPLIT)I.KO.,O.P.,1097T.Z.;(CROATIA_Vis)J.E.H.,I.R.,V.V.;(EPIC)K-T.K.,R.J.F.L.,N.J.W.;(EPIC-CVD)W-Y.L.,P.SU.,1098A.S.B.,J.DA.,J.M.M.H.;(EPIC-Norfolk,Fenland-OMICS,Fenland-GWAS)J-H.Z.;(EPIC-Norfolk,1099

26

Fenland-OMICS,Fenland-GWAS,InterAct-GWAS)J.L.,C.L.,R.A.S.,N.J.W.;(ERF)N.A.,B.A.O.,1100C.M.v.D.;(Fenland-Exome,EPIC-Norfolk-Exome)S.M.W.,FHSS-J.H.,D.L.;(FINRISK1101(COROGENE_CTRL))P.J.,K.K.,M.P.,A-P.S.;(FINRISK_PREDICT_CVD)A.S.H.,A.P.,S.R.,V.S.;1102(FUSION)A.U.J,M.BOE.,F.C.,J.T.,(GAPP)S.T.,G.P.,D.CO.,L.R.;(GenerationScotland1103(GS:SFHS))T.B.,C.H.,A.C.,S.P.;(GoDARTs)N.S.,A.S.F.D.,A.D.M.,C.N.A.P.;(GRAPHIC)P.S.B.,1104C.P.N.,N.J.SA.,M.D.T.;(H2000_CTRL)A.JU.,P.K.,S.KO.,T.N.;(HABC)Y.L.,M.A.N.,T.B.H.;1105(HCS)E.G.H.,C.O.,R.J.SC.;(HTO)K.L.A.,H.J.C.,B.D.K.,M.TO,C.MA.;(ICBP-SC)G.A.,T.F.,M-1106R.J.,A.D.J.,M.LA.,C.N.;(INGI-CARL)I.G.,G.G.,A.MO.,A.R.;(INGI-FVG)M.BR.,M.CO.,P.G.,1107D.V.;(INGI-VB)C.M.B.,N.J.S.,D.T.,M.T.;(JUPITER)F.G.,L.M.R.,P.M.R.,D.I.C.;(KORAS3)1108C.G.,M.L.,E.O.,S.S.;(KORAS4)A.PE.,J.S.R.;(LBC1921)S.E.H.,D.C.M.L.,A.PA.,J.M.S.;1109(LBC1936)G.D.,I.J.D.,A.J.G.,L.M.L.;(Lifelines)N.V.,M.H.d.B.,M.A.S.,P.v.d.H.;(LOLIPOP)1110J.C.C.,J.S.K.,B.L.,W.Z.;(MDC)P.A.,O.M.;(MESA)X.G.,W.P.,J.I.R.,J.Y.;(METSIM)A.U.J.,1111M.LAA.;(MICROS)F.D.G.M.,A.A.H.,P.P.P.;(MIGEN)R.E.,S.K.,J.M.,D.SI.;(ΝΕΟ)R.L.,R.d.M.,1112R.N.,D.O.M-K.;(NESDA)Y.M.,I.M.N.,B.W.J.H.P.,H.SN.;(NSPHS)S.E.,U.G.,Å.JO.;(NTR)1113D.I.B.,E.J.d.G.,J-J.H.,G.W.;(ORCADES)H.C.,P.K.J.,S.H.W.,J.F.W.;(PIVUS)L.LI.,C.M.L.,J.S.,1114A.M.;(Prevend)N.V.,P.v.d.H.;(PROCARDIS)M.F.,A.G.,H.W.;(PROSPER)J.DE.,J.W.J.,D.J.S.,1115S.TR.;(RS)O.H.F.,A.HO.,A.U.,G.C.V.;(SardiNIA)J.D.,Y.Q.,F.CU.,E.G.L.;(SHIP)M.D.,R.R.,1116A.T.,U.V.;(STR)M.FR.,A.H.,R.J.S.,E.I.;(TRAILS)C.A.H.,A.J.O.,H.R.,P.J.v.d.M.;(TwinsUK)1117M.M.,C.M.,T.D.S.;(UKHLS)B.P.,E.Z.;(ULSAM)V.G.,A.P.M.,A.M.,E.I.;(WGHS)F.G.,L.M.R.,1118P.M.R.,D.I.C.;(YFS)M.K.,T.L.,L-P.L.,O.T.R.1119

Replicationstudycontributor:(MVP)J.N.H.,A.G.,D.R.V.E.,Y.V.S.,K.C.,J.M.G.,P.W.F.W.,1120P.S.T.,C.P.K.,A.M.H.,C.J.O.,T.L.E.;(EGCUT)T.E.,R.M.,L.M.A.ME.1121

AirwaveHealthMonitoringStudy:E.E,H.G,A-C.V.,R.P.,I.K.,I.T.,P.E.1122

Allauthorscriticallyreviewedandapprovedthefinalversionofthemanuscript1123

1124

27

Figure1.Studydesignschematicfordiscoveryandvalidationofloci.ICBP;International1125ConsortiumforBloodPressure;N,samplesize;QC,qualitycontrol;PCA,principal-component1126analysis;GWAS,Genome-wideAssociationStudy;1000G1000Genomes;HRC,HaplotypeReference1127Panel;BP:bloodpressure;SNPs,singlenucleotidepolymorphisms;BMI,bodymassindex;LMM;1128linearmixedmodel;UKB,UKBiobank,MAF,minorallelefrequency;HLA,HumanLeukocyteAntigen;1129MVP,MillionVeteransProgram;EGCUT;EstonianGenomeCenter,UniversityofTartu;SBP,systolic1130bloodpressure;DBP,diastolicbloodpressure;PP,pulsepressure.1131

1132

Genetic/phenotypic data QC → N=458,577Exclude samples with high missingness/heterozygosity,

sex discordance, QC failures, missing covariates, pregnant, retracted informed consent

restrict to Europeans using PCA

Two-stage analysisFollow-up SNPs with P < 1 × 10-6 for any BP trait

(with concordant direction of effect for UKB vs ICBP)

Independent Replication meta-analysis→ Lookups of sentinel SNPs

in MVP (N=220,520) and EGCUT (N=28,742)→ combined meta-analysis (N=1,006,863)

(i) genome-wide significant (P < 5 × 10-8) in combined meta(ii) P < 0.01 in replication meta-analysis

(iii) concordant direction of effect

325 novel replicated locifrom two-stage analysis

SBP (130), DBP (91), PP (104)

92 newly replicated loci (previously published without

independent replication)

535 novel loci

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Genetic/phenotypic data QC → N=299,024150,134 previously published (54 cohorts), centrally QC-ed

Plus 148,890 samples from 23 newly QC-ed cohorts. Including study-level GC-adjustment

European samples only

ICBP dataN=299,024 from 77 different cohorts

UK Biobank dataN=502,620 with genetic & phenotypic data

One-stage analysisConsider any novel sentinel lookup SNPs which do

not replicate from 2-stage analysis

→ UKB-ICBP Internal Replication

(i) P < 5 × 10-9 from UKB+ICBP discovery meta(ii) P < 0.01 in UKB GWAS

(iii) P < 0.01 in ICBP GWAS meta-analysis(iv) concordant direction of effect UKB vs ICBP

210 novel loci from one-stage analysis(internally replicated)

SBP (60), DBP (103), PP (47)

Exclude all SNPs in 274 known BP loci, using SNPs previously reported at time of analysisLocus Definition: (r2 ≥ 0.1; 1Mb region ±500kb from sentinel SNP)

(also fully exclude HLA region: chr6:25-34 Mb)

ICBP-Plus meta-analysis ICBP-GWAS of imputed SNPs (1000G or HRC panels)Fixed effects inverse variance weighted meta-analysis;

stringent meta-level QC-filtering

UK Biobank GWAS analysis UKB GWAS of HRC imputed SNPs

BP ~ SNP + sex + age + age2 + BMI + arrayusing BOLT-LMM

→ LD Score Regression → GC-adjustment

UKB+ICBP- GWAS Discovery meta-analysis (N=757,601)

28

Figure2.ManhattanplotshowingtheminimumP-valuefortheassociationacrossallblood1133pressuretraitsinthediscoverystageexcludingknownandpreviouslyreportedvariants.1134Manhattanplotofthediscoverygenome-wideassociationmeta-analysisin757,601individuals1135excludingvariantsin274knownloci.TheminimumP-valueacrossSBP,DBPandPPispresented.The1136yaxisshowsthe–log10Pvaluesandthexaxisshowstheirchromosomalpositions.Horizontalred1137andbluelinerepresentsthethresholdsofP=5x10-8forgenome-widesignificanceandP=1x10-61138forselectingSNPsforreplication,respectively.SNPsinblueareinLD(r2>0.8)withthe325novel1139variantsindependentlyreplicatedfromthe2-stagedesignwhereasSNPsinredareinLD(r2>0.8)1140with210SNPsidentifiedthroughthe1-stagedesignwithinternalreplication.Anylociinblackor1141greythatexceedthesignificancethresholdsweresignificantinthediscoverymeta-analysis,butdid1142notmeetthecriteriaofreplicationintheone-ortwo-stagedesigns.1143

1144

1145

29

Figure3:VennDiagramsofNovelLociResults(a)“Comparisonof1-stageand2-stagedesign1146analysiscriteria”:Forall535novelloci,wecomparetheresultsaccordingtotheassociationcriteria1147usedfortheone-stageandthetwo-stagedesign.Two-hundredandtenlociexclusivelymettheone-1148stageanalysiscriteria(P<5x10-9inthediscoverymeta-analysis,P<0.01inUKB,P<0.01inICBPand1149concordantdirectionofeffectbetweenUKBandICBP).Ofthe325novelreplicatedlocifromthe2-1150stageanalysis(genome-widesignificanceinthecombinedmeta-analysis,P<0.01inthereplication1151meta-analysisandconcordantdirectionofeffect),204lociwouldalsohavemettheone-stage1152criteria,whereas121wereonlyidentifiedbythetwo-stageanalysis.(b)“OverlapofAssociations1153acrossBloodPressureTraits”.Forall535novelloci,weshowthebloodpressuretraitsassociated1154witheachlocus.Wepresentthetwo-stagelocifirst,followedbytheone-stageloci.Thelocusnames1155providedinalphabeticalordercorrespondtothenearestannotatedgene.SNPs:Singlenucleotide1156polymorphisms;SBP:systolicbloodpressure;DBP:diastolicbloodpressure;PP:pulsepressure;UKB:1157UKBiobank;ICBP:InternationalConsortiumofBloodPressure1158

1159

1160

210 204 121

(A) (B)

30

Figure4.Associationofbloodpressurelociwithlifestyletraits.Plotshowshierarchicalclusteringof1161BPlocibasedonassociationswithlifestyle-relatedfactors.ForthesentinelSNPateachBPlocus(x1162axis),wecalculatedthe-log10(P)*sign(β)(alignedtoBP-raisingallele)asretrievedfromtheGene1163Atlascatalogue(http://geneatlas.roslin.ed.ac.uk).BPlociandtraitswereclusteredaccordingtothe1164Euclideandistanceamongst-log10(P)*sign(β).Redsquaresindicatedirectassociationswiththetrait1165ofinterestandbluesquaresinverseassociations.OnlySNPswithatleastoneassociationatP<10-61166withatleastoneofthetraitsexaminedareannotatedintheheat-map.All901lociareconsidered,1167bothknownandnovel:novellociareprintedinboldfont.SNPs:SingleNucleotidePolymorphisms;1168BP:BloodPressure.1169

1170

1171

31

Figure5.Associationofbloodpressurelociwithothertraits.Plotshowsresultsfromassociations1172withothertraitswhichwereextractedfromtheGWAScatalogandPhenoScannerdatabasesforthe1173535novelsentinelSNPsincludingproxiesinLinkageDisequilibrium(r2≥0.8)withgenome-wide1174significantassociations.SBP:SystolicBloodPressure;DBP:DiastolicBloodPressure;PP:Pulse1175Pressure;HR:HeartRate;ECG:Electrocardiographictraits;CAD:CoronaryArteryDiseaseCHD;1176CoronaryHeartDiseaseMI;MyocardialInfraction;T2D:TypeIIDiabetes.1177

1178

1179

AnthropometricAutoimmune Cancer Eye

HR/ECG/CAD/CHD/MI

Kidney&Thyroid

LifestyleLipids

Neuro

T2D/Metabolic

Other

Haematological

Thrombosis&Coagulation

32

Figure6.Associationofbloodpressurelociwithothertraits.Plots(a)and(b)showoverlap1180betweenvariantsassociatedto(a)traitsand(b)diseasesinthemanually-curatedversionofthe1181DisGeNETdatabase,andallvariantsinLDr2>0.8withtheknown(redbars)SNPsfromthe2741182publishedloci,andall(greenbars)BPvariantsfromall901loci.Numbersontopofthebarsdenote1183thenumberofSNPsincludedinDisGeNETforthespecifictraitordisease.Traits/diseaseswithan1184overlapofatleast5variantsinLDwithallmarkersareshown.TheYaxisshowsthepercentageof1185variantsassociatedwiththediseasesthatiscoveredbytheoverlap.Forthesakeofclarity,the1186DisGeNETtermsforbloodpressureandhypertensionarenotdisplayed,whereasthefollowing1187diseaseshavebeencombined:coronaryarterydisease(CAD),coronaryheartdisease(CHD)and1188myocardialinfarction(MI);prostateandbreastcarcinoma;Crohn'sandinflammatorybowel1189diseases.1190

1191

1192

1193

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Known lociAll loci

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N=168

N=226N=190

N=221

N=50

N=249N=86

N=91

N=101

N=114

N=189N=146

N=65

N=30

N=705N=553 N=274

N=948

N=336

N=274

N=111

N=181

N=342

33

Figure7.Relationshipofdecilesofthegeneticriskscore(GRS)basedonall901lociwithblood1194pressure,riskofhypertensionandcardiovasculardiseaseinUKBiobank.Theplotsshowsex-1195adjusted(a)meansystolicbloodpressure(SBP)andoddsratiosofhypertension(HTN)and(b)odds1196ratiosofincidentcardiovasculardisease(CVD),myocardialinfarction(MI)andstroke,comparing1197eachoftheuppernineGRSdecileswiththelowestdecile;dottedlinesrepresenttheupper95%1198confidenceintervals.1199

1200

a b

34

Figure8:KnownandnovelBPassociationsintheTGFβsignallingpathway.Geneswithknown1201associationswithBPareindicatedincyan.GeneswithnovelassociationswithBPreportedinthis1202studyareindicatedinred.TGFβpathwaywasderivedfromaningenuitycanonicalpathway.BP:1203BloodPressure.1204

1205

1206

1207

ONLINEMETHODS1208

UKBiobank(UKB)data1209

We performed a Genome Wide Association Study (GWAS) analysis in 458,577 UKB1210participants13 (Supplementary Methods). These consist of 408,951 individuals from UKB1211genotypedat825,927variantswithacustomAffymetrixUKBiobankAxiomArraychipand121249,626 individuals genotyped at 807,411 variants with a custom Affymetrix UK BiLEVE1213AxiomArraychipfromtheUKBiLEVEstudy57,whichisasubsetofUKB.SNPswereimputed1214centrallybyUKBusingareferencepanelthatmergedtheUK10Kand1000GenomesPhase12153panelaswellastheHaplotypeReferenceConsortium(HRC)panel58.Forcurrentanalysis1216onlySNPsimputedfromtheHRCpanelwereconsidered.1217

UKBphenotypicdata1218

Following Quality Control (QC) (Supplementary Methods), we restricted our data to a1219subset of post-QC individuals of European ancestry combining information from self-1220reportedandgeneticdata(SupplementaryMethods)resultinginamaximumofN=458,5771221individuals(Fig.1,SupplementaryFig.11).1222

Three BP traits were analysed: systolic (SBP), diastolic (DBP) and pulse pressure (PP)1223(differencebetweenSBPandDBP).WecalculatedthemeanSBPandDBPvaluesfromtwo1224automated(N=418,755)ortwomanual(N=25,888)BPmeasurements.Forindividualswith1225

35

onemanualandoneautomatedBPmeasurement(N=13,521),weusedthemeanofthese1226twovalues.ForindividualswithonlyoneavailableBPmeasurement(N=413),weusedthis1227singlevalue.AftercalculatingBPvalues,weadjustedformedicationusebyadding15and122810mmHg toSBPandDBP, respectively, for individuals reported tobe takingBP-lowering1229medication (94,289 individuals)59. Descriptive summary statistics are shown in1230SupplementaryTable1a.1231

UKBanalysismodels1232

FortheUKBGWASweperformed linearmixedmodel (LMM)associationtestingunderan1233additive geneticmodel of the three (untransformed) continuous,medication-adjusted BP1234traits(SBP,DBP,PP)forallmeasuredandimputedgeneticvariantsindosageformatusing1235the BOLT-LMM (v2.3) software17.We also calculated the estimated SNP-wide heritability1236(h2) in our data. We used genotyped SNPs filtered for MAF > 5%; HWEP > 1 x 10-6;1237missingness<0.015, toestimate theparametersof the linearmixedmodel, for the initial1238modellingsteponly.Withintheassociationanalysis,weadjustforthefollowingcovariates:1239sex,age,age2,BMIandabinaryindicatorvariableforUKBvsUKBiLEVEtoaccountforthe1240differentgenotypingchips.TheassociationanalysisperformedbyBOLT-LMM(v2.3)corrects1241forpopulationstructureandcrypticrelatednessinverylargedatasets17.Thegenome-wide1242associationanalysisofallHRC-imputedSNPswasrestrictedtovariantswithMAF≥1%and1243INFO>0.1.1244

Genomicinflationandconfounding1245

WeappliedtheunivariateLDscoreregressionmethod(LDSR)18totestforgenomicinflation1246(expected for polygenic traits like BP, with large sample sizes, and especially also from1247analyses of such dense genetic datawithmany SNPs in high LD)60. LDSR intercepts (and1248standarderrors)were1.217 (0.018),1.219 (0.020)and1.185 (0.017) forSBP,DBPandPP1249respectively,andwereusedtoadjusttheUKBGWASresultsforgenomicinflation,priorto1250themeta-analysis.1251

InternationalConsortiumforBloodPressure(ICBP)GWAS1252

ICBP GWAS is an international consortium to investigate BP genetics6. We combined1253previously reported post-QC GWAS data from 54 studies (N=150,134)11,12,61, with newly1254available GWAS data from a further 23 independent studies (N=148,890) using a fixed1255effectsinversevarianceweightedmeta-analysis. The23studiesprovidingnewdatawere:1256ASCOT-SC,ASCOT-UK,BRIGHT,Dijon3C,EPIC-CVD,GAPP,HCS,GS:SFHS,Lifelines,JUPITER,1257PREVEND,TWINSUK,GWAS-Fenland, InterAct-GWAS,OMICS-EPIC,OMICS-Fenland,UKHLS,1258GoDARTS-IlluminaandGoDarts-Affymetrix,NEO,MDC,SardiNIA,METSIM.1259

All study participants were of European ancestry and were imputed to either the 10001260GenomesProjectPhase1integratedreleasev.3[March2012]allancestryreferencepanel621261or the Haplotype Reference Consortium (HRC) panel16. The final enlarged ICBP GWAS1262datasetincluded77cohorts(N=299,024individuals).1263

36

DefinitionofphenotypedataandGWASanalysesofSBP,DBPandPPwereasperprevious1264ICBP protocol for 54 studies11, extended to the additional 23 studies forwhich newdata1265were available. Full study names, cohort information and general study methods are1266includedinSupplementaryTable1bandinSupplementaryTables20a-c.Genomiccontrol1267wasappliedatstudy-level.TheLDSR intercepts (standarderror) forthe ICBPGWASmeta-1268analysis were 1.089 (0.012), 1.086 (0.012) and 1.066 (0.011) for SBP, DBP and PP,1269respectively.1270

Meta-analysesofdiscoverydatasets1271

Weperformedafixed-effects inversevarianceweightedmeta-analysisusingMETAL20,63to1272obtain summary results from the combined UKB and ICBP GWAS, for up to N=757,6011273participantsand~7.1MSNPswithMAF≥1%forvariantspresentinboththeHRC-imputed1274UKBdataandICBPmeta-analysisforallthreetraits.TheLDSRintercepts(standarderror),in1275thediscoverymeta-analysisofUKBand ICBPwere1.156 (0.020),1.160 (0.021)and1.1131276(0.018) for SBP, DBP and PP respectively. The LDSR intercept (standard error), after the1277exclusionofallpublishedBPvariants(seebelow)inthediscoverymeta-analysisofUKBand1278ICBPwas1.090(0.018),1.097(0.017)and1.064(0.015) forSBP,DBPandPPrespectively,1279hence showing little inflation in thediscoveryGWASafter the exclusionof published loci1280(SupplementaryFig.12).Nofurthercorrectionwasappliedtothediscoverymeta-analysis1281ofUKBandICBPGWAS.1282

Previouslyreportedvariants1283

We compiled from the peer-reviewed literature all 357 SNPs previously reported to be1284associatedwithBPatthetimethatouranalysiswascompleted,thathavebeenidentified1285andvalidatedasthesentinelSNPinprimaryanalysesfrompreviousBPgeneticassociation1286studies. These 357 published SNPs correspond to 274 distinct loci, according to locus1287definition of: (i) SNPs within ±500kb distance of each other; (ii) SNPs in Linkage1288Disequilibrium (LD), using a threshold of r2 ≥ 0.1, calculated with PLINK (v2.0).We then1289augmentthislisttoallSNPspresentwithinourdata,whicharecontainedwithinthese2741290publishedBP loci, i.e. all SNPswhich are located±500kb fromeachof the357published1291SNPsand/orinLDwithanyofthe357previouslyvalidatedSNPs(r2≥0.1).1292

Identificationofnovelsignals:Two-stageandone-stagestudydesigns1293

To identifynovel signalsofassociationwithBP, twocomplementary studydesigns (which1294we termhere “two-stagedesign” and “one-stagedesign”)were implemented in order to1295maximizetheavailabledataandminimizereportingoffalsepositiveassociations.1296

Two-stagedesign:Overview:1297

Allofthefollowingcriteriahadtobesatisfiedforasignaltobereportedasanovelsignalof1298associationwithBPusingourtwo-stagedesign:1299

37

(i) thesentinelSNPshowssignificance(P<1×10-6)inthediscoverymeta-analysis1300ofUKBandICBP,withconcordantdirectionofeffectbetweenUKBandICBP;1301

(ii) thesentinelSNPisgenome-widesignificant(P<5×10-8)inthecombinedmeta-1302analysis of discovery and replication (MVP and EGCUT) (replication, described1303below);1304

(iii) the sentinel SNP shows support (P < 0.01) in the replication meta-analysis of1305MVPandEGCUTalone(SupplementaryMethods);1306

(iv) thesentinelSNPhasconcordantdirectionofeffectbetweenthediscoveryand1307thereplicationmeta-analyses;1308

(v) thesentinelSNPmustnotbelocatedwithinanyofthe274previouslyreported1309locidescribedabove.1310

The primary replicated trait was then defined as the BP trait with the most significant1311association from the combined meta-analysis of discovery and replication (in the case1312whereaSNPwasreplicatedformorethanoneBPtrait.)1313

Two-stagedesign:Selectionofvariantsfromthediscoverymeta-analysis1314

We considered for follow-up SNPs in loci non-overlapping with previously reported loci1315accordingtobothanLDthresholdatr2of0.1anda1Mbintervalregion,ascalculatedby1316PLINK64.Weobtaineda list of such SNPswithP < 1 × 10-6 for anyof the threeBP traits,1317whichalsohadconcordantdirectionofeffectbetweenUKBvsICBP.ByrankingtheSNPsby1318significance in order of minimum P-value across all BP traits, we performed an iterative1319algorithmtodeterminethenumberofnovelsignals(SupplementaryMethods),andidentify1320thesentinelSNP(mostsignificant)perlocus.1321

Two-stagedesign:Replicationanalysis1322

Weusedtwoindependentexternaldatasetsforreplication(SupplementaryMethods).We1323consideredSNPswithMAF≥1%foranindependentreplicationinMVP(maxN=220,520)141324and in EGCUT Biobank (N=28,742)15. This provides a total of N = 249,262 independent1325samples of European descent available for replication. Additional information on the1326analyses of the two replication datasets is provided in Supplementary Methods and in1327SupplementaryTable1c.1328

Thetwodatasetswerethencombinedusingfixedeffectsinversevarianceweightedmeta-1329analysisandsummaryresults forall traitswereobtained for thereplicationmeta-analysis1330dataset.1331

Two-stagedesign:Combinedmeta-analysisofdiscoveryandreplicationmeta-analyses1332

The meta-analyses were performed within METAL software63 using fixed effects inverse1333varianceweightedmeta-analysis (SupplementaryMethods). The combinedmeta-analysis1334ofboththediscoverydata (N=757,601)andreplicationmeta-analysis (maxN=249,262)1335providedamaximumsamplesizeofN=1,006,863.1336

One-stagedesign:Overview1337

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Variantsthatwerelooked-upbutdidnotreplicateaccordingtothetwo-stagecriteriawere1338consideredinaone-stagedesign.Allofthefollowingcriteriahadtobesatisfiedforasignal1339tobereportedasanovelsignalofassociationwithBPusingourone-stagecriteria:1340

i) thesentinelSNPhasP<5×10-9inthediscovery(UKB+ICBP)meta-analysis;1341ii) thesentinelSNPshowssupport(P<0.01)intheUKBGWASalone;1342iii) thesentinelSNPshowssupport(P<0.01)intheICBPGWASalone;1343iv) the sentinel SNP has concordant direction of effect between UKB and ICBP1344

datasets;1345v) ThesentinelSNPmustnotbelocatedwithinanyofthe274previouslyreported1346

locidescribedaboveortherecentlyreportednon-replicatedloci fromHoffman1347etal.9(SupplementaryTable21).1348

Weselected theone-stageP-value threshold tobeanorderofmagnitudemorestringent1349than a genome-wide significanceP-value, so as to ensure robust results and tominimize1350false positive findings. The threshold of P < 5 × 10-9 has been proposed as a more1351conservative statistical significance threshold, e.g. for whole-genome sequencing-based1352studies21anditwasmorestringentthanthesuggestedp-value(1×10-8)weobtainedfrom1353ourowncalculationsforthenumberofindependentSNPstestedinthedata.1354

Selectionofvariantsfromthemeta-analysisofUKBandICBPwasperformedasdescribed1355aboveforthetwo-stagedesign.1356

ConditionalAnalysis1357

Wealsoperformed conditional analysesusing theGWASdiscoverymeta-analysis data, in1358ordertoidentifyanyindependentsecondarysignalsinadditiontothesentinelSNPsatthe1359901loci.Weusedtwodifferentmethodologicalapproaches,eachusingtheGenome-wide1360ComplexTraitsAnalysis(GCTA)software22:(i)full“genome-wideconditionalanalysis”with1361jointmultivariateanalysis and stepwisemodel selectionacross all threeBP traits; and (ii)1362“locus-specific conditional analysis” for the primary BP trait conditioning on the sentinel1363SNPswithin each locus (SupplementaryMethods). For robustness, secondary signals are1364only reported if obtained from both approaches. All secondary signals were selected at1365genome-wide significance level, with MAF ≥ 1% and confirmed to be pairwise-LD-1366independent(r2<0.1),aswellasnotbeinginLDwithanyofthepublishedorsentinelSNPs1367at anyof the901BP-associated loci (r2 < 0.1). In all cases theUKBdatawasused as the1368reference genetic data for LD calculation, restricted to individuals of European ancestry1369only.1370

Functionalanalyses:Variants1371

Weusedanintegrativebioinformaticsapproachtocollatefunctionalannotationatboththe1372variantlevel(foreachsentinelSNPwithinallBPloci)andthegenelevel(usingSNPsinLDr21373≥0.8withthesentinelSNPs).Atthevariantlevel,weuseVariantEffectPredictor(VEP)to1374obtaincomprehensivecharacterizationofvariants,includingconsequence(e.g.downstream1375

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or non-coding transcript exon), information on nearest genomic features and, where1376applicable, amino acid substitution functional impact, based on SIFT and PolyPhen. The1377biomaRtRpackageisusedtofurtherannotatethenearestgenes.1378

WeevaluateallSNPsinLD(r2≥0.8)withournovelsentinelSNPsforevidenceofmediation1379of expression quantitative trait loci (eQTL) in all 44 tissues using the Genotype-Tissue1380Expression(GTEx)database,tohighlightspecifictissuetypeswhichshoweQTLsforalarger1381than expected proportion of novel loci. We further seek to identify novel loci with the1382strongestevidenceofeQTLassociationsinarterialtissue,inparticular.Alocusisannotated1383withagiveneGeneonlyifthemostsignificanteQTLSNPforthegiveneGeneisinhighLD(r21384≥0.8)withthesentinelSNP,suggestingthattheeQTLsignalco-localiseswiththesentinel1385SNP.1386

Weannotatednearestgenes,eGenes(geneswhoseexpressionisaffectedbyeQTLs)andHi-1387C interactorswithHUVEC,HVMSCandHAECexpressionfromtheFantom5project.Genes1388that had higher thenmedian expression levels in the given cell types were indicated as1389expressed.1390

ToidentifySNPsinthenovellocithathaveanon-codingfunctionaleffect(influencebinding1391of transcription factors or RNA polymerase, or influence DNase hypersensitivity sites or1392histonemodifications),weusedDeepSEA,adeeplearningalgorithm,thatlearntthebinding1393and modification patterns of ~900 cell/factor combinations65. A change of >0.1 in the1394binding score predicted byDeepSEA for the reference and alternative alleles respectively1395hasbeenshowntohavehightruepositiverate~80-95%andlowfalsepositiverate~5-10%,1396thereforeweusedthiscut-offtofindalleleswithnon-codingfunctionaleffect.1397

We identify potential target genes of regulatory SNPs using long-range chromatin1398interaction (Hi-C) data from HUVECs23, aorta, adrenal glands, neural progenitor and1399mesenchymal stem cell,which are tissues and cell types that are considered relevant for1400regulatingBP24.Hi-CdataarecorrectedforgenomicbiasesanddistanceusingtheHi-CPro1401and Fit-Hi-C pipelines according to Schmitt et al. (40kb resolution – correction applied to1402interactionswith50kb-5Mbspan)24.Wefindthemostsignificantpromoterinteractionsfor1403allpotentialregulatorySNPs(RegulomeDBscore£5)inLD(r2≥0.8)withournovelsentinel1404SNPsandpublishedSNPs,andchoose the interactorswith theSNPsofhighest regulatory1405potentialtoannotatetheloci.1406

Wethenperformoverallenrichmenttestingacrossall loci.Firstly,weuseDEPICT66 (Data-1407driven Expression Prioritized Integration for Complex Traits) to identify tissues and cells1408which are highly expressed at genes within the BP loci. DEPICT uses a large number of1409microarrays (~78K) to identifycellsand tissueswhere thegenesarehighlyexpressedand1410usespre-computedGWASphenotypestoadjust forcofoundingsources.Secondly,weuse1411DEPICTtotestforenrichmentingenesetsassociatedwithbiologicalannotations(manually1412curated andmolecular pathways, phenotypedata frommouseKO studies).Using the co-1413expressiondataDEPICTcalculatesaprobabilityforeachgenetobelongtoagivengeneset1414

40

and uses this to weight the enrichment of the genes present in the tested loci. DEPICT1415provides a P-value of enrichment and false discovery rates adjusted P-values for each1416tissue/cellsorgenesettested.Wereportsignificantenrichmentswithafalsediscoveryrate1417<0.01. The variants tested were i) the 357 published BP associated SNPs at the time of1418analysisandii)asetincludingall(publishedandnovel)variants(withnovelSNPsfilteredby1419highestsignificance,P<1×10-12).1420

Furthermore, to investigate cell type specific enrichment within DNase I sites, we used1421FORGE,whichtestsforenrichmentofSNPswithinDNaseIsites in123celltypesfromthe1422Epigenomics Roadmap Project and ENCODE25 (Supplementary Methods). Two analyses1423werecompared(i)usingpublishedSNPsonly;(ii)usingsentinelSNPsatall901loci,inorder1424toevaluatetheoveralltissuespecificenrichmentofBPassociatedvariants.1425

Functionalanalyses:Genes1426

At the gene level, we use Ingenuity Pathway Analysis (IPA) software (IPA®, QIAGEN1427Redwood City) to review genes with prior links to BP, based on annotation with the1428“DisorderofBloodPressure”, “EndothelialDevelopment”and “VascularDisease”Medline1429Subject Heading (MESH) terms. We used the Mouse Genome Informatics (MGI) tool to1430identifyBPandcardiovascularrelevantmouseknockoutphenotypesforallgeneslinkedto1431BPinourstudy.WealsousedIPAtoidentifygenesthatinteractwithknowntargetsofanti-1432hypertensivedrugs.Geneswerealsoevaluatedforevidenceofsmallmoleculedruggability1433orknowndrugsbasedonqueriesoftheDrugGeneInteractiondatabase.1434

Lookupsinnon-Europeanancestries1435

As a secondary analysis, we look up all known and novel BP-associated SNPs in African1436(7,782) and South Asian (10,322) ancestry samples of UKB. An equivalent GWAS-LMM1437analysis was performed using BOLT-LMM for each BP trait within each ancestry1438(SupplementaryMethods).1439

Effectsonothertraitsanddiseases1440

We query SNPs against GWAS catalog26 and PhenoScanner27, including genetics and1441metabolomicsdatabases,toinvestigatecross-traiteffects,extractingallassociationresults1442withgenome-widesignificanceatP<5×10-8forallSNPsinhighLD(r2≥0.8)withthe5351443sentinelnovelSNPs,tohighlightthelociwithstrongestevidenceofassociationwithother1444traits.WefurtherevaluatedtheseeffectsusingDisGeNET,aresourcethat integratesdata1445fromexpert curated repositories,GWAScatalogues,animalmodelsand the literature28,29.1446Specifically,at theSNP level,overlapswithDisGeNETtermswerecomputed,withroughly1447thesamenumberofmarkers inthepublishedandnovelBPloci.Thus,giventheexpected1448saturationof theoverlaps,amorethandouble increase indicates thatstrongassociations1449aremorefrequentforthenovelBPloci.Atthegenelevel,overrepresentationenrichment1450analysis (ORA) with WebGestalt67 on the nearest genes to all BP loci was carried out.1451Moreover,we testedsentinelSNPsatallpublishedandnovel (N=901) loci forassociation1452

41

withlifestylerelateddataincludingfood,waterandalcoholintake,anthropomorphictraits1453and urinary sodium, potassium and creatinine excretion using the recently developed1454StanfordGlobalBiobankEngineandtheGeneATLAS68.BotharesearchenginesforGWAS1455findings for multiple phenotypes in UK Biobank. We used a Bonferroni corrected1456significancethresholdofP<1×10-6todeemsignificance.1457

Geneticriskscoresandpercentageofvarianceexplained1458

Wecalculatedageneticriskscore(GRS)toprovideanestimateofthecombinedeffectof1459theBPraisingvariantsonBPandriskofhypertension,andappliedthistotheUKBdata.We1460firstcreatetwotrait-specificweightedGRSs(i.e.SBP,DBP),forallpairwise-independent,LD-1461filtered(r2<0.1)previouslyreportedvariantsand535novelsentinelvariantscombined.For1462thepreviously reportedvariants,weweightBP increasingallelesby the trait-specificbeta1463coefficientsfromthenewICBPmeta-analysisGWASthat ispartofthediscoverystage(to1464minimizewinner’s curse bias compared to using UKBwhere themajority of discovery of1465publishedSNPshasbeenderived).Forthenovelvariants,betacoefficientsofthereplication1466meta-analysisforeachBPtraitareusedasindependent,unbiasedweights.Wethenderive1467asingleBPGRSastheaverageoftheGRSforSBPandDBP,andstandardizeittohavemean1468zero and standard deviation of one. GRS were calculated for 487,409 individuals. For1469statistical analysis of GRS, we focused on unrelated individuals only. The UKB database1470included 502,638 individuals. We removed pregnant women (n=372) and withdrawn1471individuals (n=19).Wemerged GRS and phenotype data (n merged=487,048) and excluded1472individualswith first or second degree related individuals. The final database for analysis1473included423,713unrelated individualsofEuropeanancestryofwhom392,092 individuals1474werefreeofcardiovasculareventsatbaseline.1475

WeassesstheassociationofthecontinuousGRSvariableonBPbysimplelinearregression,1476anduselogisticregressiontoexaminetheassociationoftheGRSwithriskofhypertension,1477withandwithoutadjustmentforsex.Wethenuselinearandlogisticregressiontocompare1478BPlevelsandriskofhypertension,respectively,forindividualsinthetopvsbottomquintiles1479of theGRSdistribution.Similaranalyseswereperformed for the topvsbottomdecilesof1480theGRS distribution. All analyseswere restricted to the 392,092 unrelated individuals of1481EuropeanancestryfromUKB.Asasensitivityanalysistoassessforevidenceofbiasinthe1482UKB results, we also carried out similar analyses in Airwave, an independent cohort of1483N=14,004unrelatedparticipantsofEuropeandescent30(SupplementaryMethods).1484

We also assessed the association of the GRS with cardiovascular disease in unrelated1485participants in UKB data, based on self-reported medical history, and linkage to1486hospitalizationandmortalitydata.Weuselogisticregressionwithbinaryoutcomevariables1487for composite incident cardiovascular disease (Supplementary Methods), incident1488myocardialinfarctionandincidentstroke(usingthealgorithmicUKBdefinitions)andGRSas1489explanatoryvariable(withandwithoutsexadjustment).1490

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Wealso calculated the associationof thisGRSwithBP inunrelated individuals ofAfrican1491(N=6,970)andSouthAsian(N=8,827)ancestryfromtheUKBusingtheapproachdescribed1492above, to see whether BP-associated SNPs identified from GWAS predominantly in1493EuropeansarealsoassociatedwithBPinpopulationsofnon-Europeanancestry.1494

We calculated the percentage of variance in BP explained by genetic variants using the1495independentAirwavecohort (N=14,004).Wegeneratedtheresiduals fromaregressionof1496each trait against age, age2, sexandBMI.We then fit a second linearmodel for the trait1497residualswiththeGRSplusthetop10principalcomponents,andestimatedthepercentage1498variance of the dependent (BP) variable explained by the GRS. We considered three1499differentlevelsoftheGRS:(i)allpairwise-independent,LD-filtered(r2<0.1)publishedSNPs1500within the known loci; (ii) all known SNPs and sentinel SNPs at novel loci; (iii) all1501independentsignalsatall901knownandnovellociincludingthe163secondarySNPs.1502

Dataavailabilitystatement1503

The genetic and phenotypic UKB data are available upon application to the UK Biobank1504(https://www.ukbiobank.ac.uk). All replication data generated during this study are1505includedinthepublishedarticle.Forexample,associationresultsof look-upvariantsfrom1506ourreplicationanalysesandthesubsequentcombinedmeta-analysesarecontainedwithin1507theSupplementaryTablesprovided.1508

EthicsStatement1509

TheUKBstudyhasapprovalfromtheNorthWestMulti-CentreResearchEthicsCommittee.1510Anyparticipants fromUKBwhowithdrewconsenthavebeen removed fromouranalysis.1511EachcohortwithintheICBPmeta-analysisaswellasourindependentreplicationcohortsof1512MVPandEGCUThadethicalapprovallocally.Moreinformationontheparticipatingcohorts1513isavailableinSupplementaryMethods.1514

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