Résumé

Objectif

Examiner la gestion de l'hypertension dans différents pays et au fil du temps en utilisant des méthodes cohérentes et comparables.

Méthodes

Une recherche systématique a identifié des enquêtes sur les examens de santé représentatifs à l'échelle nationale dans 20 pays, contenant des données de 1980 à 2011 sur les mesures de la tension, le diagnostic et le traitement de l'hypertension et son contrôle avec des médicaments antihypertenseurs. Pour chaque pays, on a esimé la prévalence de l'hypertension (tension artérielle systolique ≥ 140 mmHg ou utilisation d'antihypertenseurs) et la proportion de patients souffrant d'hypertension, dont la maladie a été diagnostiquée, traitée ou contrôlée par des médicaments (tension systolique < 140 mmHg).

Résultats

La prévalence de l'hypertension normalisée selon l'âge variait entre les pays: pour les individus âgés de 35 à 49 ans, elle variait de 12% au Bangladesh, en Égypte et en Thaïlande à environ 30% en Arménie, au Lesotho et en Ukraine; pour les individus âgés de 35 à 84 ans, elle variait de 20% au Bangladesh à plus de 40% en Allemagne, en Turquie et dans la Fédération de Russie. C'est aux États-Unis d'Amérique que le pourcentage normalisé selon l'âge des individus souffrant d'hypertension dont la maladie a été diagnostiquée, traitée ou contrôlée était le plus élevé: pour les individus âgés de 35 à 49 ans, il atteignait 84%, 77% et 56%, respectivement. Ces pourcentages ont été particulièrement faibles en Albanie, en Arménie, en Turquie et pour la République islamique d'Iran. Bien que les tendances récentes de la prévalence diffèrent en Angleterre, au Japon et aux États-Unis, la couverture du traitement et le contrôle de l'hypertension artérielle se sont améliorés au fil du temps, notamment en Angleterre.

Conclusion

Globalement, la proportion de patients souffrant d'hypertension dont la maladie a été diagnostiquée, traitée ou contrôlée par des médicaments reste faible. Des efforts supplémentaires sont nécessaires pour améliorer le contrôle de l'hypertension, ce qui réduirait la charge que représentent les maladies non transmissibles.

Resumen

Objetivo

Examinar la gestión de la hipertensión entre países y a lo largo del tiempo con métodos consistentes y comparables.

Métodos

Se realizó una búsqueda sistemática a fin de identificar encuestas de salud por examen representativas a nivel nacional de 20 países con datos recogidos de 1980 a 2011 sobre las mediciones de la presión arterial, el diagnóstico y el tratamiento de la hipertensión, así como su control con fármacos antihipertensivos. Se estimó la prevalencia de la hipertensión arterial en cada país (es decir, la presión arterial sistólica ≥ 140 mmHg o el uso de antihipertensivos) y la proporción de hipertensos que fueron diagnosticados, tratados o controlados con medicamentos para su condición (es decir, presión sistólica < 140 mmHg).

Resultados

La prevalencia estandarizada por edad de la hipertensión varió entre países: en las personas de entre 35 y 49 años osciló entre el 12 % en Bangladesh, Egipto y Tailandia, y cerca del 30 % en Armenia, Lesotho y Ucrania. En las personas entre 35 y 84 años varió entre el 20 % en Bangladesh, y más del 40 % en Alemania, la Federación Rusa y Turquía. El porcentaje estandarizado por edad de las personas hipertensas que recibieron un diagnóstico, tratamiento o control con medicamentos para su condición fue mayor en los Estados Unidos de América. En concreto, fue del 84 %, 77 % y 56 %, respectivamente, en las personas entre 35 y 49 años. Los porcentajes fueron particularmente bajos en Albania, Armenia, la República Islámica del Irán y Turquía. Aunque las tendencias recientes en la prevalencia difirieron en Inglaterra, Japón y Estados Unidos, la cobertura del tratamiento y el control de la hipertensión han mejorado con el tiempo, sobre todo en Inglaterra.

Conclusión

A nivel mundial, la proporción de hipertensos que recibe tratamiento y control con medicamentos sigue siendo baja. Deben realizarse mayores esfuerzos para mejorar el control de la hipertensión, lo que reduciría la carga de enfermedades no transmisibles.

ملخص

الغرض

دراسة تدبير فرط ضغط الدم عبر البلدان وبمرور الوقت باستخدام طرق متسقة وقابلة للمقارنة.

الطريقة

حدد بحث منهجي مسوح الفحص الصحي الممثلة على الصعيد الوطني من 20 بلداً تحتوي على بيانات من عام 1980 إلى 2011 حول قياسات ضغط الدم وتشخيص فرط ضغط الدم وعلاجه ومكافحته بالأدوية الخافضة لضغط الدم. وبالنسبة لكل بلد، تم تقدير انتشار فرط ضغط الدم (ضغط الدم الانقباضي أكبر من أو يساوي 140 ملليمتر زئبق أو استخدام الأدوية الخافضة لضغط الدم) ونسبة الأفراد المصابين بفرط ضغط الدم الذين تم تشخيص حالتهم أو علاجها أو مكافحتها بالأدوية (ضغط الدم الانقباضي أقل من 140 ملليمتر زئبق).

النتائج

اختلف الانتشار الموحد حسب الأعمار لفرط ضغط الدم بين البلدان: بالنسبة للأشخاص الذين تراوحت أعمارهم من 35 إلى 49 عاماً، تراوح من 12 % تقريباً في بنغلاديش ومصر وتايلند إلى حوالي 30 % في أرمينيا وليسوتو وأوكرانيا؛ وبالنسبة للأشخاص الذين تراوحت أعمارهم من 35 إلى 84 عاماً، تراوح من 20 % في بنغلاديش إلى أكثر من 40 % في ألمانيا والاتحاد الروسي وتركيا. وكانت أعلى النسب المئوية الموحدة حسب الأعمار للأشخاص المصابين بفرط ضغط الدم الذين تم تشخيص حالتهم أو علاجها أو مكافحتها في الولايات المتحدة الأمريكية: وبالنسبة للأشخاص الذين تراوحت أعمارهم من 35 إلى 49 عاماً، كانت النسبة المئوية 84 %، و77 %، و56 % على التوالي. وكانت النسب المئوية منخفضة ولاسيما في ألبانيا وأرمينيا وجمهورية إيران الإسلامية وتركيا. وعلى الرغم من اختلاف الاتجاهات الحديثة في الانتشار في إنجلترا واليابان والولايات المتحدة، تحسنت تغطية العلاج ومكافحة فرط ضغط الدم بمرور الوقت، ولاسيما في إنجلترا.

الاستنتاج

على الصعيد العالمي، تظل نسبة الأشخاص المصابين بفرط ضغط الدم الذين يتم علاج حالتهم أو مكافحتها بالأدوية منخفضة. ويتعين بذل جهود أكبر لتحسين مكافحة فرط ضغط الدم، الأمر الذي سيقلل عبء الأمراض غير السارية.

摘要

目的

使用一致和可比的方法调查各国长期以来的高血压管理。

方法

系统搜索确定了来自20 个国家全国代表性健康调查,其中包含从1980 年到2011 年血压测量、高血压诊断和治疗及其使用抗高血压药物对其控制方面的相关数据。对每个国家,估计高血压的患病率(即收缩压≥ 140 mmHg或降压药使用)和已经对病情进行诊断、治疗或使用药物控制(即收缩压< 140 mmHg)的高血压患者的比例。

结果

不同国家之间年龄标化高血压患病率各异:对于35 岁到49 岁人群,在孟加拉国、埃及和泰国的12%左右到亚美尼亚、莱索托和乌克兰的30%左右的范围;在35 到84 岁人群中,其范围是从孟加拉国的20%到德国、俄罗斯联邦、土耳其的40%以上。病情经过诊断、治疗或控制的年龄标准化高血压患者百分比在美国最高:对于35 至49 岁的人群分别为84%、77%和56%。百分比特别低的是阿尔巴尼亚、亚美尼亚、伊朗伊斯兰共和国和土耳其。尽管在英国、日本和美国最近的患病率趋势不同,但随着时间的推移,治疗覆盖率和高血压控制有所改善,英国尤其如此。

结论

病情经过治疗或使用药物控制的高血压患者从全球来看比例仍然很低。需要更大的努力来改善高血压控制,这将会减少非传染性疾病的负担。

Резюме

Цель

Исследовать методы терапии гипертензии в разных странах в разные периоды времени с использованием устойчивых и подающихся сравнению методов.

Методы

Проведение систематического поиска репрезентативных национальных медицинских осмотров из 20 стран, содержащих данные с 1980 по 2011 г. по измерениям артериального давления, диагностике и лечении гипертензии и ее контроль антигипертензиивными препаратами. Для каждой страны оценивалась распространенность гипертензии (т.е. систолическое артериальное давление ≥ 140 мм.рт.ст. или применение антигипертензивных препаратов) и доля страдающих гипертензией лиц, чье заболевание диагностировалось, подвергалось лечению или контролю медицинскими препаратами (т.е. систолическое давление доводилось до уровня < 140 мм.рт.ст.).

Результаты

Стандартизированная по возрасту распространенность гипертензии варьировалась между странами: для лиц в возрасте от 35 до 49 лет она составляла от приблизительно 12% в Бангладеш, Египте и Таиланде до приблизительно 30% в Армении, Лесото и Украине; для возрастной группы от 35 до 84 лет она варьировалась от 20% в Бангладеш до более 40% в Германии, Российской Федерации и Турции. Приведенные к возрасту процентные доли лиц с гипертензиией, чье состояние было диагностировано, подвергнуто лечению или контролю, были наивысшими в Соединенных Штатах Америки: для группы от 35 до 49 лет они составляли 84%, 77% и 56%, соответственно. Особенно низкий процент был зафиксирован в Албании, Армении, Исламской республике Иран и Турции. Хотя последние тенденции по распространенности в Англии, Японии и США различаются, охват лечением и контроль гипертензии с течением времени улучшился, особенно в Англии.

Вывод

Во всемирном масштабе доля лиц с гипертензией, чье состояние контролируется медицинскими препаратами, остается низкой. Необходимы дальнейше усилия для улучшения контроля гипертензии, что потенциально снизит бремя болезни и развитие осложнений в виде неинфекционных заболеваний.

Introduction

High blood pressure, also known as hypertension, is a major contributor to the global disease burden and was responsible for 7% of all disability-adjusted life years in 2010.¹1 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224–60. doi: http://dx.doi.org/10.1016/S0140-6736(12)61766-8 PMID:23245609
https://doi.org/10.1016/S0140-6736(12)61... Moreover, the number of people with uncontrolled hypertension has increased to around 1 billion worldwide in the past three decades.²2 Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ et al.; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure). National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants. Lancet 2011;377:568–77. doi: http://dx.doi.org/10.1016/S0140-6736(10)62036-3 PMID:21295844
https://doi.org/10.1016/S0140-6736(10)62... As a result, the effective control of hypertension has become a priority for global health policy and, with growing interest in the prevention and control of noncommunicable diseases (NCDs),³3 The NCD Alliance [Internet]. Global NCD framework campaign. Geneva: NCD Alliance; 2012. Available from: http://www.ncdalliance.org/global-ncd-framework-campaign[accessed 19 September 2013].
http://www.ncdalliance.org/global-ncd-fr... it is vital that health-care systems deliver appropriate interventions for tackling high blood pressure.

The formulation of effective policies for decreasing the burden of uncontrolled hypertension depends on knowledge of the current rate of hypertension control at the population level. Several countries have carried out health examination surveys of nationally representative samples to measure blood pressure and to assess awareness, treatment and control of hypertension in the general population.⁴4 Banegas JR, Rodríguez-Artalejo F, de la Cruz Troca JJ, Guallar-Castillón P, del Rey Calero J. Blood pressure in Spain: distribution, awareness, control, and benefits of a reduction in average pressure. Hypertension 1998;32:998–1002. doi: http://dx.doi.org/10.1161/01.HYP.32.6.998 PMID:9856963
https://doi.org/10.1161/01.HYP.32.6.998... ^–1111 Farzadfar F, Murray CJL, Gakidou E, Bossert T, Namdaritabar H, Alikhani S et al. Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study. Lancet 2012;379:47–54. doi: http://dx.doi.org/10.1016/S0140-6736(11)61349-4 PMID:22169105
https://doi.org/10.1016/S0140-6736(11)61... In addition, trends in indicators of hypertension management have been reported in Canada,¹²12 McAlister FA, Wilkins K, Joffres M, Leenen FHH, Fodor G, Gee M et al. Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades. CMAJ 2011;183:1007–13. doi: http://dx.doi.org/10.1503/cmaj.101767 PMID:21576297
https://doi.org/10.1503/cmaj.101767... England¹³13 Falaschetti E, Chaudhury M, Mindell J, Poulter N. Continued improvement in hypertension management in England: results from the Health Survey for England 2006. Hypertension 2009;53:480–6. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.108.125617 PMID:19204180
https://doi.org/10.1161/HYPERTENSIONAHA.... and the United States of America¹⁴14 Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension 2008;52:818–27. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.108.113357 PMID:18852389
https://doi.org/10.1161/HYPERTENSIONAHA.... ^,1515 Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA 2010;303:2043–50. doi: http://dx.doi.org/10.1001/jama.2010.650 PMID:20501926
https://doi.org/10.1001/jama.2010.650... and coverage of effective treatment for hypertension has been studied in the Islamic Republic of Iran¹¹11 Farzadfar F, Murray CJL, Gakidou E, Bossert T, Namdaritabar H, Alikhani S et al. Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study. Lancet 2012;379:47–54. doi: http://dx.doi.org/10.1016/S0140-6736(11)61349-4 PMID:22169105
https://doi.org/10.1016/S0140-6736(11)61... and Mexico.¹⁶16 Gakidou E, Lozano R, González-Pier E, Abbott-Klafter J, Barofsky JT, Bryson-Cahn C et al. Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 2006;368:1920–35. doi: http://dx.doi.org/10.1016/S0140-6736(06)69568-8 PMID:17126725
https://doi.org/10.1016/S0140-6736(06)69... ^,1717 Lozano R, Soliz P, Gakidou E, Abbott-Klafter J, Feehan DM, Vidal C et al. Benchmarking of performance of Mexican states with effective coverage. Lancet 2006;368:1729–41. doi: http://dx.doi.org/10.1016/S0140-6736(06)69566-4 PMID:17098091
https://doi.org/10.1016/S0140-6736(06)69...

Despite the wealth of data available from national health surveys on the management of hypertension in the general population, it is not always possible to compare published results directly because of differences in survey methods and analytical strategies.¹⁸18 Hajjar I, Kotchen JM, Kotchen TA. Hypertension: trends in prevalence, incidence, and control. Annu Rev Public Health 2006;27:465–90. doi: http://dx.doi.org/10.1146/annurev.publhealth.27.021405.102132 PMID:16533126
https://doi.org/10.1146/annurev.publheal... ^,1919 Wolf-Maier K, Cooper RS, Banegas JR, Giampaoli S, Hense HW, Joffres M et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 2003;289:2363–9. doi: http://dx.doi.org/10.1001/jama.289.18.2363 PMID:12746359
https://doi.org/10.1001/jama.289.18.2363... Previous studies have reviewed findings from several national surveys on the crude prevalence of hypertension and on awareness, treatment and control of the condition²⁰20 Fuentes R, Ilmaniemi N, Laurikainen E, Tuomilehto J, Nissinen A. Hypertension in developing economies: a review of population-based studies carried out from 1980 to 1998. J Hypertens 2000;18:521–9. doi: http://dx.doi.org/10.1097/00004872-200018050-00003 PMID:10826553
https://doi.org/10.1097/00004872-2000180... ^,2121 Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens 2004;22:11–9. doi: http://dx.doi.org/10.1097/00004872-200401000-00003 PMID:15106785
https://doi.org/10.1097/00004872-2004010... but the issue of comparability was left unresolved. Although one study analysed microdata from national examination surveys, it covered only countries in Europe and North America.¹⁹19 Wolf-Maier K, Cooper RS, Banegas JR, Giampaoli S, Hense HW, Joffres M et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 2003;289:2363–9. doi: http://dx.doi.org/10.1001/jama.289.18.2363 PMID:12746359
https://doi.org/10.1001/jama.289.18.2363... ^,2222 Wolf-Maier K, Cooper RS, Kramer H, Banegas JR, Giampaoli S, Joffres MR et al. Hypertension treatment and control in five European countries, Canada, and the United States. Hypertension 2004;43:10–7. doi: http://dx.doi.org/10.1161/01.HYP.0000103630.72812.10 PMID:14638619
https://doi.org/10.1161/01.HYP.000010363... Another recent study used regression modelling techniques to aggregate data and improve comparability.²2 Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ et al.; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure). National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants. Lancet 2011;377:568–77. doi: http://dx.doi.org/10.1016/S0140-6736(10)62036-3 PMID:21295844
https://doi.org/10.1016/S0140-6736(10)62... However, awareness, treatment and control of hypertension were not analysed. Thus, comparative information – as is already available for diabetes and hypercholesterolaemia – is needed to benchmark and compare how health systems perform in controlling hypertension.²³23 Gakidou E, Mallinger L, Abbott-Klafter J, Guerrero R, Villalpando S, Ridaura RL et al. Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys. Bull World Health Organ 2011;89:172–83. doi: http://dx.doi.org/10.2471/BLT.10.080820 PMID:21379413
https://doi.org/10.2471/BLT.10.080820... ^,2424 Roth GA, Fihn SD, Mokdad AH, Aekplakorn W, Hasegawa T, Lim SS. High total serum cholesterol, medication coverage and therapeutic control: an analysis of national health examination survey data from eight countries. Bull World Health Organ 2011;89:92–101. doi: http://dx.doi.org/10.2471/BLT.10.079947 PMID:21346920
https://doi.org/10.2471/BLT.10.079947...

Our aim was to provide comparable, comprehensive and consistent evidence on the management of hypertension internationally by analysing data from health surveys in 20 countries that included blood pressure measurement.

Methods

Two investigators obtained information on national health examination surveys by systematically searching: (i) published research papers using Medline and Google Scholar; and (ii) health survey databases, such as the Global InfoBase of the World Health Organization (WHO)²⁵25 The WHO Global InfoBase [Internet]. Geneva: World Health Organization; 2008. Available from: http://www.who.int/infobase/report.aspx [accessed 19 September 2013].
http://www.who.int/infobase/report.aspx... and the STEPwise approach to Surveillance (STEPS) database,²⁶26 World Health Organization [Internet]. STEPwise approach to surveillance (STEPS). Geneva: WHO; 2009. Available from: http://www.who.int/chp/steps/en/ [accessed 19 September 2013].
http://www.who.int/chp/steps/en/... the European Health Interview and Health Examination Surveys database,²⁷27 Scientific Institute of Public Health in Belgium; National Institute for Health and Welfare in Finland. [Internet]. European Health Interview & Health Examination Surveys Database; 2009. Available from: https://hishes.wiv-isp.be/index.php?hishes=home[accessed 21 April 2009]
https://hishes.wiv-isp.be/index.php?hish... the Demographic and Health Survey database²⁸28 Measure DHS Demographic and Health Surveys [Internet]. Calverton: Measure DHS; 2009. Available from: http://www.measuredhs.com/start.cfm [accessed 19 September 2013].
http://www.measuredhs.com/start.cfm... and databases on other web sites identified during the search process. The keywords used were blood pressure, high blood pressure, hypertension, prevalence, treatment, control and national health survey as well as country names. Articles and survey reports were reviewed to determine whether they: (i) involved a random sample of adults in a whole country; (ii) included both sexes; (iii) contained data on blood pressure measurements; and (iv) contained data on the diagnosis of hypertension and on the use of antihypertensive medications.

We identified nationally representative household surveys that met our four criteria for 73 of the 193 WHO Member States: 12 were low-income countries, 38 were middle-income countries and 20 were high-income countries; income was not classified for 3 countries. For these 73 countries, we tried to obtain anonymized individual-level data. We downloaded publicly available data sets for England, the Russian Federation, the United States and 9 countries for which Demographic and Health Survey data were available. For the other 61 countries, we requested data from the institutions that conducted the surveys and we obtained permission to use data from 8 countries. Overall, we obtained individual-level data for 20 countries in which the latest available surveys had been conducted between 1992 and 2011 (Table 1, available at: http://www.who.int/bulletin/volumes/92/1/13-121954). All Demographic and Health Surveys, except those for Bangladesh and South Africa, included only women of reproductive age and their husbands. Data from several different years were available for England, Japan and the United States.

Table 1 summarizes the procedures used to measure blood pressure in the surveys included in this study. In most surveys, blood pressure was measured more than twice but only single measurements were recorded in the surveys carried out in Colombia and in Japan in 1980 and between 1986 and 1999. Digital blood pressure metres were used in England and all countries participating in Demographic and Health Surveys except Uzbekistan. All surveys recorded blood pressure in the right arm of seated participants, except those in South Africa and Turkey.

Individuals were regarded as having hypertension if their systolic blood pressure was equal to or greater than 140 mmHg or they reported current use of blood-pressure-lowering medications. We did not include diastolic blood pressure in our definition of hypertension because prospective studies suggest that systolic pressure is a better predictor of cardiovascular disease risk, particularly in older individuals.⁴⁶46 Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13. doi: http://dx.doi.org/10.1016/S0140-6736(02)11911-8 PMID:12493255
https://doi.org/10.1016/S0140-6736(02)11... ^,4747 Neaton JD, Wentworth D; Multiple Risk Factor Intervention Trial Research Group. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med 1992;152:56–64. doi: http://dx.doi.org/10.1001/archinte.1992.00400130082009 PMID:1728930
https://doi.org/10.1001/archinte.1992.00... Moreover, systolic pressure rises consistently with age, whereas diastolic pressure increases until the age of 50 to 60 years and starts decreasing thereafter.⁴⁸48 Franklin SS, Gustin W 4th, Wong ND, Larson MG, Weber MA, Kannel WB et al. Hemodynamic patterns of age-related changes in blood pressure: the Framingham Heart Study. Circulation 1997;96:308–15. doi: http://dx.doi.org/10.1161/01.CIR.96.1.308 PMID:9236450
https://doi.org/10.1161/01.CIR.96.1.308... For each individual, we calculated systolic blood pressure as the average of all measurements taken, excluding the first measurement, when three or more measurements were available; when only one or two measurements were available, we used the single or second measurement, respectively.

Among people with hypertension, we estimated the fraction that had been diagnosed with the condition, the fraction treated and the fraction whose condition was controlled using antihypertensive medications. We regarded participants as having been diagnosed with hypertension if they answered “yes” when asked whether a doctor or any other health professional had told them they had high blood pressure. The questions used to determine whether a participant had been diagnosed with hypertension were slightly different in some countries: in all surveys in England, except those performed in 2007 and 2008, two questions were asked to determine whether a diagnosis had been made in a clinical setting; in the German survey, “health professionals” were not specifically mentioned; and, in surveys in the Islamic Republic of Iran, Jordan and Thailand, the recall period was limited to the previous 12 months (Table 2, available at: http://www.who.int/bulletin/volumes/92/1/13-121954). In addition, the 2007 and 2008 surveys in England and the surveys in Japan in all years except 1980, 1990 and 2000 did not ask about a history of hypertension.

We considered hypertensive patients to be receiving treatment if they reported currently using an antihypertensive medication and we regarded a systolic blood pressure less than 140 mmHg as indicating that the hypertension was controlled. Most surveys employed a single yes–no question to ask respondents about their current use of antihypertensive drugs (Table 2). The German survey and Japanese surveys in 1980 and 1990 to 2002 asked about the frequency of medication use and we considered only those who answered “daily” to be receiving treatment. Most surveys did not ask about treatment if the respondent answered “no” to a question about being diagnosed with hypertension. In Colombia, only individuals who had been diagnosed with hypertension two or more times were asked about the use of antihypertensive medications. The South African survey asked for the names of the medications to verify that they really were for lowering blood pressure.

We included all individuals aged 35 to 84 years in the analysis to maximize the overlap of age ranges across surveys. We excluded women who were pregnant or breastfeeding and individuals for whom data on any of the following were missing: systolic blood pressure; a history of hypertension (except for some of the English and Japanese surveys, which did not ask about this item); and the use of antihypertensive medications. We could not identify pregnant women in the Jordanian survey because of a lack of data.

Overall, we compiled a data set covering 173 920 individuals from 20 countries for the cross-sectional analysis and, for the trend analysis, we had data on 63 903 individuals from England, 155 212 from Japan and 30 410 from the United States.

We estimated the age-standardized prevalence of hypertension in individuals aged 35 to 49 years in the latest surveys from 20 countries and, in individuals aged 35 to 84 years, in surveys from 11 countries. In these groups, we also estimated the age-standardized proportion of individuals with hypertension whose condition was diagnosed, treated or controlled by means of antihypertensive drugs. In addition, we examined secular trends in these indicators in the population aged 35 to 84 years in England, Japan and the United States. We derived a reference population for the age standardization of prevalence data by calculating an average for the proportion in each 5-year age group in all countries included in the analysis using population estimates for the year 2000.⁴⁹49 World population prospects: the 2010 revision [Internet]. New York: United Nations, Department of Economic and Social Affairs; 2011. Available from: http://www.alapop.org/2009/Docs/ProjectionsSeminar/FinalPresentations/Presentation_RioNov2011_Heilig.pdf [accessed 19 September 2013].
http://www.alapop.org/2009/Docs/Projecti... For the age standardization of the proportion of individuals whose hypertension was diagnosed, treated or controlled, we derived a standard hypertensive population from the reference population by using an average estimate of the prevalence of hypertension in each 5-year age group across all countries. We used Stata version 12 (StataCorp. LP, College Station, USA) for the analysis and to adjust for complex survey designs that included stratification, clustering and sample weights.

Results

The age-standardized prevalence of hypertension in individuals aged 35 to 49 years ranged from around 12% in Bangladesh, Egypt and Thailand to around 30% in Armenia, Lesotho and Ukraine (Table 3). In those aged 35 to 84 years, it varied from nearly 20% in Bangladesh to more than 40% in Germany, the Russian Federation and Turkey (Table 3).

In individuals with hypertension aged 35 to 49 years, the age-standardized percentage diagnosed with the condition was highest in the United States, at 83.9%, followed by Uzbekistan and Lesotho. It was under 34% in Albania, Armenia, Colombia, the Islamic Republic of Iran and Turkey (Table 4). The age-standardized percentage whose blood pressure was controlled with medications was 55.7% in the United States, whereas it was less than 10% in Albania, Armenia, Germany, the Islamic Republic of Iran and Turkey (Table 4).

In individuals with hypertension aged 35 to 84 years, the age-standardized percentage whose high blood pressure was diagnosed, treated or controlled was highest in the United States and lowest in Germany, Thailand and Turkey (Table 4). The percentage diagnosed ranged from less than 50% in Thailand and Turkey to 85.3% in the United States (Table 4). The percentage of hypertensive individuals who were diagnosed but not on medication was highest in Turkey, at 20.7%. The percentage whose hypertension was controlled with medications varied from less than 8% in Germany and Turkey to 59.1% in the United States (Table 4).

Our analysis of the secular trend in the age-standardized prevalence of hypertension in individuals aged 35 to 84 years showed that the prevalence was substantially lower in the United States in the early 1990s than it was in England or Japan, the other two countries in which the trend was analysed (Table 5). However, the prevalence increased in the United States during the 1990s, whereas it decreased in England and Japan. Subsequently, the prevalence became comparable across the three countries in the 2000s. The age-standardized percentage of hypertensive individuals whose hypertension was diagnosed, treated or controlled increased over time in all three countries (Table 6, available at: http://www.who.int/bulletin/volumes/92/1/13-121954). The increase was particularly remarkable in England: although the percentage whose hypertension was treated or controlled in England was lower than in Japan in the early 1990s, by the late 2000s, the percentage in England exceeded that in Japan.

Discussion

To the best of our knowledge, this is the first study to compare the management of high blood pressure in countries from different regions of the world by using individual-level data from nationally representative health examination surveys. Our results suggest that hypertension is not adequately controlled with medication in many parts of the world. This finding has important implications for medical and public health authorities worldwide and should be considered when formulating and implementing programmes for controlling hypertension.

We found that the prevalence of hypertension was substantial in some low- and middle-income countries, which indicates that the condition is an important contributor to the growing burden of NCDs in developing countries. Moreover, blood pressure control in hypertensive individuals was particularly poor in Albania, Armenia, the Islamic Republic of Iran and Turkey, as well as in Germany in the late 1990s. Among former socialist states in Europe and central Asia, the proportion of adults aged 35 to 49 years with hypertension whose condition was controlled was much greater in Azerbaijan, Ukraine and Uzbekistan than in Albania and Armenia. Although few studies of changes in the management of hypertension have been carried out in transitional economies, one investigation showed that, in Armenia, inadequate health care utilization was partly due to the high cost for users.⁵⁰50 Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilization in the former Soviet Union: evidence from eight countries. Health Serv Res 2004;39(6p2):1927–50. doi: http://dx.doi.org/10.1111/j.1475-6773.2004.00326.x PMID:15544638
https://doi.org/10.1111/j.1475-6773.2004... A study in Mexico revealed that health system reform during the early 2000s reduced blood pressure in the population by only around one fifth of the maximum potential decrease that could have been achieved with antihypertensive drugs.¹⁶16 Gakidou E, Lozano R, González-Pier E, Abbott-Klafter J, Barofsky JT, Bryson-Cahn C et al. Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 2006;368:1920–35. doi: http://dx.doi.org/10.1016/S0140-6736(06)69568-8 PMID:17126725
https://doi.org/10.1016/S0140-6736(06)69... ^,1717 Lozano R, Soliz P, Gakidou E, Abbott-Klafter J, Feehan DM, Vidal C et al. Benchmarking of performance of Mexican states with effective coverage. Lancet 2006;368:1729–41. doi: http://dx.doi.org/10.1016/S0140-6736(06)69566-4 PMID:17098091
https://doi.org/10.1016/S0140-6736(06)69... Our results confirmed that there is still considerable room for improvement in Mexico. In Thailand, the prevalence of hypertension was lower than in other countries in our study but hypertension control was relatively poor. This finding supports a previous study's proposal that the screening, treatment and control of hypertension in Thailand should be strengthened.⁸8 Aekplakorn W, Abbott-Klafter J, Khonputsa P, Tatsanavivat P, Chongsuvivatwong V, Chariyalertsak S et al. Prevalence and management of prehypertension and hypertension by geographic regions of Thailand: the Third National Health Examination Survey, 2004. J Hypertens 2008;26:191–8. doi: http://dx.doi.org/10.1097/HJH.0b013e3282f09f57 PMID:18192831
https://doi.org/10.1097/HJH.0b013e3282f0...

The fact that the age-adjusted prevalence of hypertension remained between 35 and 40% throughout the 2000s in England, Japan and the United States suggests that there has been little progress in the primary prevention of the condition in these countries. Moreover, previous studies showed that the prevalence of hypertension increased in the United States in the 1990s,¹⁴14 Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension 2008;52:818–27. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.108.113357 PMID:18852389
https://doi.org/10.1161/HYPERTENSIONAHA.... ^,1515 Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA 2010;303:2043–50. doi: http://dx.doi.org/10.1001/jama.2010.650 PMID:20501926
https://doi.org/10.1001/jama.2010.650... perhaps partly on account of the increasing number of overweight and obese individuals.¹⁴14 Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension 2008;52:818–27. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.108.113357 PMID:18852389
https://doi.org/10.1161/HYPERTENSIONAHA.... In England, the substantial decrease in the prevalence of hypertension observed in the 1990s and early 2000s¹³13 Falaschetti E, Chaudhury M, Mindell J, Poulter N. Continued improvement in hypertension management in England: results from the Health Survey for England 2006. Hypertension 2009;53:480–6. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.108.125617 PMID:19204180
https://doi.org/10.1161/HYPERTENSIONAHA.... seemed to have ceased by the late 2000s. It is a challenge for these highly industrialized countries to resume progress in reducing the prevalence of hypertension, particularly in older individuals.

Of all the countries included in our analysis, the United States showed the highest rates of diagnosis, treatment and control of hypertension. Since the late 1990s, England has been rapidly catching up with the United States. The improvement may partly be explained by the influence of a series of guidelines on the management of hypertension disseminated by the British Hypertension Society and by a pay-for-performance system introduced in the new General Medical Services contract that gives general practitioners an incentive to lower patients' blood pressure.¹³13 Falaschetti E, Chaudhury M, Mindell J, Poulter N. Continued improvement in hypertension management in England: results from the Health Survey for England 2006. Hypertension 2009;53:480–6. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.108.125617 PMID:19204180
https://doi.org/10.1161/HYPERTENSIONAHA.... In contrast, progress in controlling hypertension with medications has been relatively slow in Japan. Although substantial efforts have been made in the country to improve the management of hypertension, many physicians may be cautious about aggressively treating the condition, particularly in elderly patients. A fundamental change in physicians' attitudes may be needed to achieve the same level of hypertension control as has been achieved in England and the United States.

Our study had several limitations. First, although we used the latest available surveys, those of Germany, the Russian Federation and South Africa all dated from the 1990s and were too old for us to draw conclusions about the current state of hypertension management in those countries. Second, although systolic blood pressure is a better predictor of cardiovascular risk, the exclusion of diastolic blood pressure from our definition of hypertension may have led us to underestimate the prevalence of the condition in individuals younger than 50 years. Third, information about diagnosis and treatment was obtained from survey respondents' answers to questions and may have been affected by recall bias and variations in the wording of questions. Fourth, most surveys employed a question with a yes–no answer to record the use of antihypertensive medications and did not ask about frequency of use. Consequently, our estimates of the proportion of hypertensive individuals being treated may have included those taking medications less than daily and this may have resulted in underestimates of the proportion whose hypertension was under control. Fifth, in this study, we focused on treatment with antihypertensive medications. The prevalence of hypertension and the proportions of hypertensive individuals whose high blood pressure is treated or controlled would be different in countries in which nonpharmacological interventions, such as dietary modification and physical activity, are common. Sixth, although it was a nationally representative sample, the survey sample in Jordan was small. Consequently, the figures for the percentage of hypertensive individuals, particularly older individuals, whose condition was diagnosed, treated or controlled by medication should be interpreted with caution.

The strength of our study is that the use of individual-level data enabled us to apply consistent definitions and analytical methods when comparing estimates of the prevalence, awareness, treatment and control of hypertension across countries and over time. The use of consistent analytical methods is crucial for assessing how well individual health systems are responding to the health needs of the population. Therefore, we believe our study is important as a first attempt at providing consistent and comparable information on the management of hypertension globally.

Considerably more national health examination surveys on high blood pressure have been conducted around the world than on high blood glucose or cholesterol concentrations.²³23 Gakidou E, Mallinger L, Abbott-Klafter J, Guerrero R, Villalpando S, Ridaura RL et al. Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys. Bull World Health Organ 2011;89:172–83. doi: http://dx.doi.org/10.2471/BLT.10.080820 PMID:21379413
https://doi.org/10.2471/BLT.10.080820... ^,2424 Roth GA, Fihn SD, Mokdad AH, Aekplakorn W, Hasegawa T, Lim SS. High total serum cholesterol, medication coverage and therapeutic control: an analysis of national health examination survey data from eight countries. Bull World Health Organ 2011;89:92–101. doi: http://dx.doi.org/10.2471/BLT.10.079947 PMID:21346920
https://doi.org/10.2471/BLT.10.079947... Nevertheless, largely owing to financial constraints, most countries have not carried out surveys that involve blood pressure measurement and very few have established continuous surveys. In our study, we were able to obtain access to individual-level data for only 20 of 73 countries identified. Consequently, our final survey selection was somewhat opportunistic, which may have limited the representativeness of our data and its generalizability to other countries. In addition, opportunities to assess, benchmark and compare the performance of health policies and programmes internationally may have been missed. As has been proposed for the assessment of hypercholesterolaemia,²⁴24 Roth GA, Fihn SD, Mokdad AH, Aekplakorn W, Hasegawa T, Lim SS. High total serum cholesterol, medication coverage and therapeutic control: an analysis of national health examination survey data from eight countries. Bull World Health Organ 2011;89:92–101. doi: http://dx.doi.org/10.2471/BLT.10.079947 PMID:21346920
https://doi.org/10.2471/BLT.10.079947... there is a clear need for a standardized protocol for implementing blood pressure surveys. Those we identified adopted different ways of measuring blood pressure and many asked respondents themselves to report their history of hypertension and current treatment status. Errors that result from the heterogeneity in survey methods are difficult to correct. In resource-poor settings, the user-friendly techniques employed by Demographic and Health Surveys would be helpful for gathering biomarker data. Use of these techniques should be promoted by the global campaigns on the prevention and control of NCDs planned for coming years.

In conclusion, globally the proportion of hypertensive patients whose disease is treated effectively with medications remains low, especially in some low- and middle-income countries. Since hypertension is the leading risk factor associated with morbidity and mortality from NCDs worldwide, greater efforts should be devoted to improving hypertension control. Countries and different clinical disciplines should work together to adopt a comprehensive approach to the prevention and control of high blood pressure. Effective and affordable drugs are available. It is time to act, since the alternative is expensive and a large portion of the population is affected.

Acknowledgements

We thank Catherine Claiborne, Majid Ezzati and Emmanuela Gakidou. Rafael Lozano is also affiliated with the Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA.

Funding:

Competing interests:

Reference

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