This systematic review evaluates the evidence linking lead exposure to cardiovascular endpoints in humans. It finds a consistent positive association between lead exposure and blood pressure across multiple studies, including prospective and homogeneous socioeconomic groups. A dose-response relationship is observed, though the magnitude of the association may be underestimated due to measurement error. Experimental models confirm the hypertensive effects of lead. Beyond hypertension, studies in general populations show a positive association between lead exposure and clinical cardiovascular outcomes, such as cardiovascular disease, coronary heart disease, stroke, and peripheral arterial disease, though the number of studies is small. Associations were observed at blood lead levels below 5 μg/dL. The review concludes that there is sufficient evidence to infer a causal relationship between lead exposure and hypertension. However, the evidence is suggestive but not sufficient to infer a causal relationship between lead exposure and clinical cardiovascular outcomes or heart rate variability. Public health implications include lowering current occupational safety standards for blood lead and establishing screening criteria for elevated lead exposure in adults. Risk assessment and economic analyses of lead exposure should include cardiovascular effects. Regulatory and public health interventions are needed to further prevent and reduce lead exposure. Lead exposure is linked to increased blood pressure and hypertension, as well as cardiovascular mortality in occupational populations. Studies show varying associations, with some indicating higher mortality risks among workers with prolonged exposure. Lead exposure is also associated with intermediate cardiovascular outcomes, such as left ventricular hypertrophy and impaired diastolic function. However, the evidence for these associations is limited, and studies often have methodological limitations. Lead exposure is associated with reduced heart rate variability, though the evidence is suggestive but not sufficient to infer a causal relationship. The review highlights the need for further research to better understand the mechanisms and extent of lead's cardiovascular effects. Public health actions are necessary to address the impact of lead exposure on cardiovascular health, including lowering safety standards and implementing interventions to reduce exposure.This systematic review evaluates the evidence linking lead exposure to cardiovascular endpoints in humans. It finds a consistent positive association between lead exposure and blood pressure across multiple studies, including prospective and homogeneous socioeconomic groups. A dose-response relationship is observed, though the magnitude of the association may be underestimated due to measurement error. Experimental models confirm the hypertensive effects of lead. Beyond hypertension, studies in general populations show a positive association between lead exposure and clinical cardiovascular outcomes, such as cardiovascular disease, coronary heart disease, stroke, and peripheral arterial disease, though the number of studies is small. Associations were observed at blood lead levels below 5 μg/dL. The review concludes that there is sufficient evidence to infer a causal relationship between lead exposure and hypertension. However, the evidence is suggestive but not sufficient to infer a causal relationship between lead exposure and clinical cardiovascular outcomes or heart rate variability. Public health implications include lowering current occupational safety standards for blood lead and establishing screening criteria for elevated lead exposure in adults. Risk assessment and economic analyses of lead exposure should include cardiovascular effects. Regulatory and public health interventions are needed to further prevent and reduce lead exposure. Lead exposure is linked to increased blood pressure and hypertension, as well as cardiovascular mortality in occupational populations. Studies show varying associations, with some indicating higher mortality risks among workers with prolonged exposure. Lead exposure is also associated with intermediate cardiovascular outcomes, such as left ventricular hypertrophy and impaired diastolic function. However, the evidence for these associations is limited, and studies often have methodological limitations. Lead exposure is associated with reduced heart rate variability, though the evidence is suggestive but not sufficient to infer a causal relationship. The review highlights the need for further research to better understand the mechanisms and extent of lead's cardiovascular effects. Public health actions are necessary to address the impact of lead exposure on cardiovascular health, including lowering safety standards and implementing interventions to reduce exposure.