Hypertension Has Doubled Globally Over 30 Years

Megan Brooks

August 25, 2021

Over the past 3 decades, the number of adults around the world with hypertension increased from 650 million to 1.28 billion, and nearly half of these people do not know they have hypertension, according to the first comprehensive global analysis of trends in hypertension prevalence, detection, treatment, and control.

There is a "massive gap" in treatment, with a large percentage of people with hypertension who are not treated or even diagnosed, senior author Majid Ezzati, PhD, Imperial College London, told theheart.org | Medscape Cardiology.

"Where progress in treatment has been good, it has been a combination of general improvement in access to healthcare, through universal insurance and also basic availability of health centers and health workers; encouraging physicians/health workers to regularly measure blood pressure through guidelines and training; and availability and affordability of medicines," said Ezzati.

Uncontrolled Hypertension Prevalent

The analysis, led by researchers at Imperial College London and the World Health Organization (WHO), was published online August 24 in the Lancet and will be presented August 30 at the European Society of Cardiology (ESC) Congress 2021.

Ezzati and the noncommunicable disease risk factor collaboration (NCD-RisC) analyzed data from 1201 population-representative studies, involving 104 million people from 184 countries, covering 99% of the world's population.

Hypertension was defined as systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or taking medication for high blood pressure.

Globally, the number of adults 30 to 79 years of age with hypertension jumped from an estimated 331 million women and 317 million men in 1990 to 626 million women and 652 million men in 2019, with most of this increase happening in low- and middle-income countries.

The data show a "shifting of the issue from high-income countries, where rates of hypertension have declined, to low- and middle-income countries and central and eastern Europe, where rates have not changed much or gone up," Ezzati told theheart.org | Medscape Cardiology.

Canada, Peru, and Switzerland had among the lowest prevalence of hypertension in the world in 2019, whereas some of the highest rates were seen in the Dominican Republic, Jamaica, and Paraguay for women and in Hungary, Paraguay, and Poland for men.

Overall, in 2019, 41% of women and 51% of men with hypertension were unaware of their condition, and 53% of women and 62% of men with hypertension were not receiving treatment.

Worldwide, high blood pressure was controlled with medication in fewer than one in four women and one in five men.

Men and women in Canada, Iceland, and South Korea were most likely to receive antihypertensive medication, with more than 70% of those with hypertension receiving treatment in 2019.

By contrast, men and women in sub-Saharan Africa, central, south, and south-east Asia, and Pacific Island nations were the least likely to be on medication. Treatment rates in a number of these regions were below 25% for women and 20% for men.

"Low detection and treatment rates that persist in the world's poorest nations, coupled with the rising number of people who have hypertension, will shift an increasing share of the burden of vascular and kidney diseases to sub-Saharan Africa, Oceania, and south Asia," coauthor Leanne Riley, from WHO, said in a news release.

"Improving the capacity of these countries to detect and treat hypertension as part of primary healthcare and universal health coverage must be accelerated," Riley added.

"Nearly half a century after we started treating hypertension, which is easy to diagnose and treat with low-cost medicines, it is a public-health failure that so many of the people with high blood pressure in the world are still not getting the treatment they need," Ezzati said.

Yet, some middle-income countries have successfully scaled up antihypertensive treatment, and are now achieving better treatment and control rates than most high-income nations. Costa Rica and Kazakhstan are two examples; both countries now have higher treatment rates than most higher-income countries.

New WHO Guidelines

"There is an urgent need for a transformation and innovative approaches to reduce the burden of hypertension globally," write Clara Chow, PhD, and Tu Nguyen, MD, PhD, from the University of Sydney, Australia, in a linked comment.

"We need better strategies to increase diagnosis and management, leveraging primary care or existing systems or identifying new methods to engage consumers in blood pressure management," they say.

Given the "vast" differences in rates of hypertension prevalence, treatment, and control across countries, there is a need to examine local implementation, they add.

"From a medical model point of view, digital transformation such as telemonitoring, home blood pressure monitoring, text message reminders to improve adherence, and other digital health interventions to encourage healthy behaviors, or simpler medical regimens such as initial treatment with a combination therapy — such as a single pill containing ultra-low-dose quadruple combination therapy — should be considered to address barriers to blood pressure control," Chow and Nguyen suggest.

"The standstill in global prevalence and the global control rates of approximately 20% should serve as an important global wakeup call that cardiovascular disease is going to be a main burden of disease for many years to come, especially if we carry on like this," they conclude.

The WHO also released new guidance for pharmacologic treatment of hypertension in adults to help countries improve the management of hypertension.

"The new global guideline on the treatment of hypertension, the first in 20 years, provides the most current and relevant evidence-based guidance on the initiation of with medicines for hypertension in adults," Taskeen Khan, PhD, from the Department of Noncommunicable Diseases at WHO, who led the guideline development, said in a news release.

The recommendations cover the level of blood pressure to start medication, what type of medicine or combination of medicines to use, the target blood pressure level, and how often to do follow-up blood pressure checks.

"The need to better manage hypertension cannot be exaggerated. By following the recommendations in this new guideline, increasing and improving access to blood pressure medication, identifying and treating comorbidities such as diabetes and pre-existing heart disease, promoting healthier diets and regular physical activity, and more strictly controlling tobacco products, countries will be able to save lives and reduce public health expenditures," Bente Mikkelsen, PhD, director of WHO’s Department of Noncommunicable Diseases, said in the release.

The study was funded by the WHO. A complete list of disclosures for authors and comment writers is available with the original article.

Lancet. Published online August 24, 2021. Full text, Comment


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