Number of People With Hypertension Doubles Since 1990

Over the past three decades, the growth and aging of the population has pushed the number of people with hypertension to about 1.28 billion, twice as high as what it was in 1990, according to the first analysis covering every country in the world.

Hypertension’s prevalence has remained stable—at about one-third—over that span, but that reflects a decline in high-income countries being offset by increases in low- and middle-income countries, the NCD Risk Factor Collaboration reports in a study published online August 24, 2021, ahead of print in the Lancet.

Overall gains were observed in detection, treatment, and control of high blood pressure, but there, too, success has varied widely across countries.

“Sub-Saharan Africa, Oceania, and South Asia have the lowest rates of detection, treatment, and control and many countries in these regions have seen little improvement in these outcomes over the past 30 years,” the authors write.

On the flip side, they continue, “the large improvements observed in some upper-middle-income and recently high-income countries show that the expansion of universal health coverage and primary care can be leveraged to enhance hypertension care and reduce the health burden of this condition.”

Two main messages can be taken away from these findings, senior author Majid Ezzati, PhD (Imperial College London, England), told TCTMD. First, “hypertension is not a condition of affluence,” he said, highlighting the burden borne by lower-income and marginalized communities in the United States.

And second, “it’s completely addressable by using low-cost drugs, and it should really be a matter of [employing] appropriate and equitable financing and guidelines and programs that encourage health systems and workers, physicians, to actually address it.”

To that end, the World Health Organization (WHO), which funded the study, released a guideline on the pharmacological treatment of hypertension in adults on the same day the findings were published.

In a press release, Bente Mikkelsen, MD, director of the WHO’s department of noncommunicable diseases, said, “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 preexisting 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.”

A Global Look

Although much is known about hypertension, there has not been a truly global study of the condition. In this new analysis, “what we wanted to do was in a really consistent way tell the story of what’s happening with hypertension and with treatment of hypertension for every country in the world,” Ezzati said.

To do that, investigators from NCD Risk Factor Collaboration gathered data from 1,201 population-representative studies that included 104 million participants ages 30 to 79 from 200 countries and territories. The data spanned 1990 to 2019.

Using a Bayesian hierarchical model, the researchers estimated that the number of people with hypertension increased from 331 million women and 317 men in 1990 to 626 million women and 652 million men in 2019.

By the end of the study period, overall prevalence was lowest for women in Switzerland, Peru, Canada, Taiwan, Spain, and South Korea (all 21% or lower) and for men in Eritrea, Peru, Bangladesh, Canada, Ethiopia, Solomon Islands, and Papua New Guinea (all 25% or lower). At the other end of the spectrum were Paraguay, Tuvalu, and Dominica for women (50% to 51%) and Paraguay, Hungary, and Poland for men (55% to 62%).

Globally, in 2019, women were more likely than men to have a diagnosis for their high blood pressure (59% vs 49%), and—among those with a diagnosis—to be treated (47% vs 38%) and to have their hypertension under control (23% vs 18%).

South Korea, Canada, and Iceland performed best, with treatment rates over 70% and control rates over 50%. The US, Costa Rica, Germany, Portugal, and Taiwan also had high rates of treatment and control.

Treatment rates were below 25% for women and 20% for men in Nepal, Indonesia, and certain countries in sub-Saharan Africa and Oceania, while control rates remained lower than 10% for people living in certain parts of the Middle East, North Africa, Central and South Asia, and Eastern Europe.

On a positive note, most regions of the world experienced improvements in treatment and control rates over the study period, although there wasn’t much change in sub-Saharan Africa and Oceania. The biggest gains were achieved by high-income countries, central European nations, and countries that were either upper middle income or recently high income, including Brazil, Chile, Costa Rica, Iran, Kazakhstan, South Africa, Taiwan, and Turkey.

What Does It Take?

As for lessons regarding the successful management of hypertension, the researchers note that “some countries, such as Canada, Costa Rica, South Korea, and Taiwan, have achieved low hypertension prevalence or high control through both improved prevention and improving every stage of the treatment cascade.”

Ezzati highlighted the importance of universal health coverage, which tends to be the norm in places where hypertension is treated widely and effectively. “There is a broader story here, which is the story of people having access to healthcare,” he said.

Still, he and his colleagues point out, that “should be complemented with primary care strengthening, evidence-based hypertension guidelines that are up to date and are adapted to the country contexts, health workforce training, and a robust system of drug procurement and distribution.” And any hypertension programs, they stress, “should also be regularly assessed, both at the population level, as our work has done, and in health facilities to ensure accountability and stimulate improvement.”

The fact that certain middle-income countries, like Costa Rica, are outperforming their high-income counterparts indicates “that it’s not just a matter of the wealth of your country, it’s a matter of having a systematic program,” Ezzati said. Where gains have been made, “it really has taken a push,” he added. “The disappointment is that that push has not happened more systematically.”

Tu Nguyen, MD, PhD, and Clara Chow, MBBS, PhD (both University of Sydney, Australia), echo that sentiment in an accompanying comment. “The disappointing message of this study . . . is that despite much research, health systems, and global policy efforts, progress has been slow in the global control of hypertension. There is an urgent need for a transformation and innovative approaches to reduce the burden of hypertension globally.”

Nguyen and Chow call for “better strategies to increase diagnosis and management, leveraging primary care or existing systems or identifying new methods to engage consumers in blood pressure management,” and they suggest taking a look at local implementation.

They also say digital tools to encourage healthy behaviors and simpler medical regimens—single-pill combinations, for example—should be considered to improve blood pressure control.

“Finally,” Nguyen and Chow write, “the standstill in global prevalence and the global control rates of approximately 20% should serve as an important global wake-up 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.”