Although further intervention efforts, as outlined earlier, need to be pursued within individual health systems, the implications of broader versus more restrictive guidelines also need to be examined. The American Heart Association is qualified 501(c)(3) tax-exempt Some of the studies were based on a random probability sample of the entire nation, whereas others were a series of regional samples; none were restricted mainly to a single province or subregion within the country (Table 1). It is mandatory to procure user consent prior to running these cookies on your website. Central and eastern Europe have the highest rates for men, while the highest rates for women are in sub-Saharan Africa. The aim of this study was to use original data from surveys to compare levels of hypertension treatment and control in the United States, Canada, England, Germany, Sweden, Italy, and Spain. WHO Excludes Cause of Death Data For the following countries: Andorra, Cook Islands, Dominica, Marshall Islands, Monaco, Nauru, Niue, Palau, Saint Kitts, San Marino, Tuvalu. Researchers reviewed 844 studies from 154 countries. The findings Customer Service The potential impact of excluding low-risk patients was examined in Spain, England, and Canada as illustrative examples by using the definitions in force in each of the specific countries.14,16,17 In Spain and England, control in low-risk hypertensives was 8% and 10% at the 140/90 mm Hg threshold, whereas these values were 1% and 4%, respectively, in those classified as high risk. 7272 Greenville Ave. Hypertension was defined as a blood pressure of 160/95 mm Hg or 140/90 mm Hg, plus persons taking antihypertensive medication. According to WHO estimates (Figure 5), high blood pressure affects 20% of the population in Israel rising up to 39% in Estonia. organization. The primary obstacle to an unbiased comparison across countries is the large number of persons with a pretreatment BP between 140/90 mm Hg and 160/95 mm Hg. This website uses cookies to improve your experience. Two large international studies using primary care data, the EUROASPIRE primary care surveys[107] and the EURIKA study[108] consistently showed low control rates in hypertensive patients between 48% in Greece and 28% in Romania (Figure 7). is highest in low-income and middle-income countries.38 Table 3 shows the rates of hypertension awareness, treatment, and control in several developing coun-tries.5,20–25,32 Women generally have higher rates of hyper-tension awareness, treatment, and control than do men. The percentage of hypertensives reported to be on treatment and having a BP <140/90 mm Hg was much lower in all European countries, ie, ≤10%. As noted here, the United States has a much lower proportion of uncontrolled hypertensives and stroke rates that are about half of those in Europe,29 which might in part be a result of a broader treatment strategy. 5 Despite availability of antihypertensive therapy, control rates remain low, largely due to lack of awareness. Find facts, statistics, maps, and other data related to hypertension. A review of current trends shows that the number of adults with hypertension increased from 594 million in 1975 to 1.13 billion in 2015, with the increase seen largely in low- and middle-income countries. We thank Diego Vanuzzo, who carried out the original survey, and Maria Fenicia Vescio for analysis. Hypertension control for women, by age group and country: 140/90 mm Hg. Of course, restricting treatment to only high-risk individuals is more cost-effective when measured at the level of the individual patient encounter. Although these aspects limit the accuracy of our results, the overall differences between the United States, Canada, and Europe are large and unlikely to change over relatively short periods of time. Although differences in criteria for diagnosis and thresholds for treatment alter case definitions, less variation would be anticipated in the level of control among treated cases. Hypertension has the unusual attribute of being sufficiently common to represent a public health concern, yet its control depends primarily on the successful treatment of individual patients by physicians. The structure of financial incentives within these systems could additionally play an important role in this health care outcome. During the last 30 years, hypertension treatment has improved dramatically, contributing to a decrease in the incidence of mortality due to stroke and coronary heart disease (CHD).2 The majority of patients’ BPs remain uncontrolled in all societies, and the decline in CVD, particularly stroke, has slowed in some countries.3–5. 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 the United States, irrespective of risk status, persons with an SBP or DBP of 140 or 90 mm Hg or greater are presently candidates for treatment, and among patients with CVD, renal disease, or diabetes, treatment is recommended for a BP ≥130/85 mm Hg (Joint National Committee IV). Prevalence ranged from 15% in West Africa to 25% in East Africa, and between 42% and 54% in South Africa. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. The European countries were Germany, Women in all countries were more likely to be treated than men; gender differences were especially strong in the United States and Canada (44% in men vs 63% in women in the United States and 28% in men vs 45% in women in Canada, based on 140/90 mm Hg; Table 4). Among women, the proportion of hypertensives receiving treatment was reasonably constant across the age range in the United States, whereas it rose rapidly in other countries, reaching 50% in the elderly. However, using the BP ≥140/90 mm Hg cutpoint, the net effect of misclassification is small; in NHANES III, for example, the prevalence of hypertension declined only 2% from the first to the second visit. Community surveys do not determine hypertension status on the same basis as clinical guidelines. Based on the current standard of 140/90 mm Hg, England had the lowest level of treatment (25%), followed by Sweden and Germany (both 26%), Spain (27%), and Italy (32%). Older hypertensive patients have lower rates of hypertension control despite comparable rates of awareness and treatment compared with middle-aged hypertensives (23, 64). [146] use prohibited. Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB), Journal of the American Heart Association (JAHA), Customer Service and Ordering Information, Basic, Translational, and Clinical Research, Journal of the American Heart Association, Circulation: Cardiovascular Quality and Outcomes, Hypertension Treatment and Control in Five European Countries, Canada, and the United States, Clinical and Demographic Characteristics Associated With Suboptimal Primary Stroke and Transient Ischemic Attack Prevention, Improving Blood Pressure Control Through Pharmacist Interventions: A Meta‐Analysis of Randomized Controlled Trials, Direct Angiotensin II Type 2 Receptor Stimulation in Nω-Nitro-l-Arginine-Methyl Ester–Induced Hypertension, Central Antihypertensive Effects of Orally Active Aminopeptidase A Inhibitors in Spontaneously Hypertensive Rats, Catheter-Based Renal Sympathetic Denervation for Resistant Hypertension, Multicenter Cluster-Randomized Trial of a Multifactorial Intervention to Improve Antihypertensive Medication Adherence and Blood Pressure Control Among Patients at High Cardiovascular Risk (The COM99 Study), Compliance, Safety, and Effectiveness of Fixed-Dose Combinations of Antihypertensive Agents, Treating Arteries Instead of Risk Factors, The Impact of a Multidisciplinary Information Technology–Supported Program on Blood Pressure Control in Primary Care, Continued Improvement in Hypertension Management in England, Response to Gender and Blood Pressure Control, Screening, Treatment, and Control of Hypertension in US Private Physician Offices, 2003–2004, Vascular Remodeling and Duration of Hypertension Predict Outcome of Adrenalectomy in Primary Aldosteronism Patients, Effect of Board Certification on Antihypertensive Treatment Intensification in Patients With Diabetes Mellitus, Using Public Health Indicators to Measure the Success of Hypertension Control, Differences in Blood Pressure Control and Stroke Mortality Across Spain, Effectiveness of Blood Pressure Control Outside the Medical Setting, Effects of Aging and Hypertension on the Microcirculation, Blood Pressure Lowering for Primary and Secondary Prevention of Stroke, Epidemiology of Uncontrolled Hypertension in the United States, Novel Approach to Examining First Cardiovascular Events After Hypertension Onset, Blood Pressure Control and Risk of Stroke, Mean SBP/DBP in mm Hg (35–64 years; men and women combined). Control was 2-fold higher in women compared with men in Spain, Italy, Canada, and the United States. Age- and gender-adjusted hypertension control by country: 140/90 mm Hg.Download figureDownload PowerPointFigure 3. The authors are grateful for the use of data from the Osservatorio Epidemiologico Cardiovascolare, Italy. In the United States, two thirds of the hypertensive population had their BP controlled at the 160/95 mm Hg threshold, and the corresponding figure was 49% in Canada (Table 3 and Figure 1). Across Europe primary and secondary prevention strategies There are again significant variations between countries and studies. Even more important than treatment rates are control rates. Data Accuracy Not Guaranteed. Rate. TABLE 1. European developed countries. All studies had at least 2 measurements, and the second BP was used to create the mean for the age-gender groups. The degree of intensity of screening for target-organ damage in persons at low to medium risk will also lead to variable case definition.12,13 The public health impact of these various standards for evaluation and treatment urgently needs to be evaluated. https://doi.org/10.1161/01.HYP.0000103630.72812.10, National Center Hypertension control at the 140/90 mm Hg threshold among women in the youngest age group ranged from 5% to 13% in the European countries, 21% in Canada, and 36% in the United States . To eliminate this source of bias, a complementary analysis was undertaken to determine the proportion of study participants whose BP was uncontrolled at the 160/95 mm Hg threshold (ie, had BP higher than this value, whether treated or not). In 1980, the country’s obesity rate was only 10.4%, but increased to 16.3% within a period of 10 years, and then reached 28.2% in 2010. Figure 4. Possible ways to increase adherence to guidelines include education by respected personnel, implementation of reminder systems, outlining of vital recommendations from the public health perspective, and improved presentation by user-friendly format and annual updates.36. Hypertension rates are highest in those European countries where people report the lowest A ) blood cholesterol levels B ) relative deprivation We reviewed surveys on hypertension treatment and control in Europe and North America since 1990 and identified those that were either national in scope or that comprised a series of regional samples, as previously described.19 Two North American and 5 European surveys were included: England,14 Germany,15 Spain,16 (7) In addition, it directly causes approximately 25% of heart attacks in Europe. TABLE 2. Levels of control among older women (65 to 74 years) were highest in the United States (37%), whereas levels of control in Canada were similar to those in Europe (5% to 17%). Rates also vary markedly within regions with rates as low as 3.4% (men) and 6.8% (women) in rural India and as high as 68.9% (men) and 72.5% (women) in Poland. Greece and Malta: no national hypertension guideline[9]). © Copyright Stroke Alliance for Europe, 2020. These persons will be designated as “controlled” if the threshold of 160/95 mm Hg is applied, when they did not meet the case criteria, thus falsely elevating the rate. Second, among the high-risk are the elderly and those with higher pretreatment BPs, which are inherently more difficult to control. Facts About Hypertension. Blood pressure control is a relevant measure that needs to be encouraged in future studies. These data dramatically reinforce the impression of previous individual reports that substantial heterogeneity exists in the approach to the control of CVD through pharmacologic treatment of elevated BP between Europe and North America.14–17,23,26. It is unlikely that any of the countries studied have reached the maximum level of treatment and control that can be attained. In several other European studies, low treatment rates of hypertension have been observed, but with some improvements since 2000 (Table 6), Figure 6: Population affected by hypertension (WHO data) and self-reported use of antihypertensives (Eurostat 2008 data, ranked by the relative gap between hypertension and the use of antihypertensives, Table6: Percentage of hypertensive patients taking antihypertensives (primary prevention), Significant increase in patients prior to and in the year after stroke (UK primary care database 1999-2008)[106]. Although that approach would yield historically accurate information within a given country, it would defeat the purpose of a comparison that requires a common standard across countries. Hypertension control for men, by age group and country: 140/90 mm Hg. This site uses cookies. The validity of these comparisons between countries therefore depends critically on the comparability of the survey methods. Figure 7: Proportion of hypertensive patients with controlled blood pressure (<140/90mmHg, EURIKA: proportion of all hypertensive patients (treatment rates >90%), EURASPIRE: proportion of treated patients), Table 7: Proportion of hypertensive patients with controlled blood pressure (Control rate). Ireland. Countries in East Central Europe, particularly Bulgaria, Romania, and Slovakia, and the Mediterranean area (particularly Greece) reported the highest proportion (≥ 50%… Awareness was defined as answering “yes” to the question: “Have you ever been told that you had high blood pressure?” Treatment was defined as current use of antihypertensive medications. A significant age-gradient was observed for hypertension with 52% of those aged over 75 years being affected, ranging from 36% in Belgium to 73% in Bulgaria. Figure 6 shows the percentage of the population reporting the use of antihypertensives in 15 European countries in 2008 according to Eurostat data together with the estimated percentage of the population affected by high blood pressure[86]. All rights reserved. Hypertension is the leading cause of global mortality accounting for 10.5 million deaths annually. Based on most non-US guidelines, low-risk patients—generally defined as those with a BP <150/95 mm Hg without CVD risk factors—would not be candidates for treatment. These cookies do not store any personal information. Over those years, the annual mortality rate rose from 135.6 to 145.2 per 100,000 among those with a systolic pressure of at least 110 to 115 mm Hg. Previous studies have documented lower levels of control in older hypertensive men at high risk compared with those at low risk27 and similarly low levels of hypertension treatment and control among high-risk patients with CHD in several European countries.28 After risk stratification, patients at high risk would need to be treated at a BP threshold lower than the threshold for those at low risk and consequently, should be better controlled. As a sensitivity analysis of the impact of risk stratification on treatment thresholds, we applied the national guidelines in force in Canada and the risk stratification in England and Spain to the data from those countries. JNC indicates Joint National Committee; WHO, World Health Organization; ISH, International Society for Hypertension; and DM, diabetes mellitus. Stroke guidelines issued by the European Stroke Organisation in 2008 include primary prevention measures, such as regular checks of blood pressure, blood glucose, and cholesterol, as well as advocating a healthy lifestyle with regards to smoking, alcohol, physical activity, and diet. the biggest risk factor for stroke. Guidelines in the respective countries and the published opinions of experts reflect divergent views regarding the relative value of which BP levels require treatment and how high risk is defined.4,7–10 In this study, we attempted to compare the overall effectiveness of various approaches through a standardized analysis of large, representative surveys. The findings for men and women by region were similar. Given the timing of the surveys and the varied introduction of guidelines, however, it would not have been possible to conduct a comparative analysis without using a single standard. Secondly, high hypertension prevalence rates but high hypertension awareness and treatment rates: Shanghai and Beijing. Levels of hypertension treatment and control have been noted to vary between Europe and North America, although direct comparisons with similar methods have not been undertaken. Figure 8 presents data from the stroke-specific module of the EUROASPIRE study (2006-8 data[115]), showing control rates of 32% or less in those with known hypertension in four European countries. Age-standardized prevalence of hypertension, by age group, 20 countries, 1992–2011 html, 10kb Hypertension control for women, by age group and country: 140/90 mm Hg. Age- and gender-adjusted hypertension control by country: 140/90 mm Hg. The researchers also found a strong correlation with death rates from strokethe average mortality rate from stroke in the European countries was 41.2 per 100000 population vs … Further details are presented in the earlier report of the prevalence findings.19. Unauthorized In Canada, on the other hand, the comparable control rate was 15% for persons at low risk and 12% among those at high risk. 2–4 The prevalence of hypertension in Kenya is 24.5%. For example, BP control at <140/90 mm Hg was achieved in routine practice settings among two thirds of 33 000 participants in a recent clinical trial.35 Hypertensives who are at high risk of CVD but who have not yet suffered an event represent a crucial opportunity for clinical prevention.5 To further reduce CVD secondary to hypertension, more efforts are needed in the public at large and among health care providers to increase the awareness of the associated risk and benefits of treatment. © American Heart Association, Inc. All rights reserved. HTN prevalence was 44.0%, with the lowest rates in Peru (17.7%) and the highest rates in Brazil (52.5%). As of April 4, 2021, Czechia had the highest rate of coronavirus deaths among its population in the European Economic Area at 254.06 deaths per 100,000 population. Summary of Key Aspects of Recent Hypertension Treatment Guidelines, Hypertension prevalence and treatment and control rates were age-adjusted by averaging the 10-year age-gender groups. Hypertension was defined by 2 standard criteria, namely, systolic BP (SBP) ≥160 or diastolic BP (DBP) ≥95 mm Hg; SBP ≥140 or DBP ≥90 mm Hg; or current use of antihypertensive medication. Figure 3. Treatment of hypertension was highest in the United States (53%), followed by Canada (36%). 1 Africa has the highest age-adjusted prevalence which is increasing. The accuracy of existing figures is dependent on access to diagnostic testing and monitoring which varies from country to country. A New York City Health and Nutrition Examination Survey study found substantially higher hypertension rates for Asians (38.0%) and Hispanics (33.0%) compared to NHWs (27.5%). Modest heterogeneity was observed in age- and gender-adjusted treatment rates at both the 160/95 and 140/90 mm Hg cutpoints among the studied European countries (Tables 3 and 4). Clearly, there is a considerable issue of under-treatment. Some countries have developed secondary prevention, but no primary prevention guidelines (e.g. A higher proportion of women than men reported that they had hypertensive diseases The highest shares of self-reported hypertensive diseases among the population aged 15 years and over were recorded in Hungary (31.9 %), Bulgaria (29.6 %), Latvia (29.4 %), Germany (28.5 %) and Lithuania (28.1 %). Turkey. 1-800-242-8721 BP ≥160/100 mm Hg (or ≥160/105 mm Hg if ≥60 years). Although guidelines vary among countries, resulting in different case definitions, this does not account entirely for the varying success of different national control efforts. By continuing to browse this site you are agreeing to our use of cookies. Despite universal recognition of its importance in the control of CVD, this comparative analysis demonstrates that hypertension treatment has been pursued more aggressively in North America than in Europe. Age-Adjusted Hypertension Awareness, Treatment, and Control in the Population and Control in Treated Hypertensive Patients Aged 35–64 Years at the 140/90 mm Hg Threshold. Levels of control among older women (65 to 74 years) were highest in the United States (37%), whereas levels of control in Canada were similar to those in Europe (5% to 17%). Contrariwise, many persons with BPs <160/95 mm Hg will have been started on treatment by physicians, thus falsely elevating the apparent control rate when 160/95 mm Hg is used as the threshold. (8) Figure 1. At least 2 explanations can be offered. Hypertension is significantly more common in stroke patients than in the general population (Appendix 1, Table 1). Moreover, the data are consistent with other published epidemiologic literature and CVD mortality rates in the sampled countries.28,29. Table 3. The control rate (or, more precisely, the proportion) was the number of treated hypertensives with a BP <160/90 or <140/90 mm Hg divided by the total number of hypertensives. Similar discrepancies were apparent at the 140/90 mm Hg threshold, at which 29% of hypertensives in the United States, 17% in Canada, and ≤10% in European countries had their blood pressure controlled. The Canadian guidelines in force in the 1990s recommended treatment at 160/100 mm Hg in “low-risk” individuals, decreasing to 140/90 mm Hg in patients with diabetes or renal disease.9 A variety of European guidelines have been promulgated, although most are broadly consistent with the World Health Organization/International Society for Hypertension approach that sets 150/95 mm Hg as the threshold in low-risk individuals, decreasing to 130/85 mm Hg in those with diabetes or renal disease.7,8,10 Revisions of these guidelines were adopted at various points in time relative to the surveys as well. Based on a threshold of 160/95 mm Hg, apparent control rates were 23% to 38% in Europe, compared with 49% to 66% in the Canada and United States, respectively. Treatment guidelines vary among the studied countries and over time (Table 2). Despite this, national data of blood pressure levels or blood pressure control is not systematically collected in most European countries. 2.1 Campaigns to encourage healthy lifestyles and risk factor awareness, Creative Commons Attribution-NonCommercial 3.0 Unported License, multi-centre[102]; significant regional differences[103], 43% of treated patients, 25% of hypertensive patients 2008/10 (16% in 2000/1), 58% of treated patients in 2013/14, 33% in 2000 to 2011, 33% of treated patients (51% of hypertensive patients were treated), 72% of treated patients in 2008/11, 42% in 1998, 27% of hypertensive patients in Icelandic GP database. In the NHANES 1999–2002 data, the control rates were 31.4% in those 60 or older and 40.5% in those between 40 and 59 years . Although low levels of treatment were noted in Europe in the younger age groups of men, they approximated those in the United States by age 65. E-mail. Unlike most medical conditions, community surveillance has been the most common approach to evaluating the success of efforts to treat and control high BP. The highest reported rates of awareness and treatment Although surveys are not a perfect evaluation tool, they are necessary to obtain information about persons who are unaware that they have hypertension or are not compliant with medical advice. Low control rates have been reported from many European countries. Stroke Association House Much of the variation in the success rate in hypertension control reported here appears to be attributable to the treatment strategy adopted by individual countries. The English sample was risk-stratified to apply the local treatment algorithm that defines subgroups of hypertensives by using a model derived from the Framingham Heart Study, and the participants were divided at a 10-year CHD risk threshold of 15%.24,25 The Canadian and Spanish samples were also risk-stratified by using a global risk algorithm.9, The prevalence of age-adjusted hypertension (140/90 mm Hg or treatment) for persons 35 to 64 years was substantially lower in the United States (28%) and Canada (27%) compared with the European countries (Sweden [38%], Italy [38%], England [42%], Spain [47%], and Germany [55%]). It might well be, however, that from the perspective of a health system that is already seeing patients for other reasons, adding treatment to those at lower risk adds little marginal cost. Control was defined as a BP <160/90 or <140/90 mm Hg among medicated hypertensives. Download figureDownload PowerPointFigure 1. The highest reported rates of awareness and treatment are from Cuba and the lowest rates are in Mozambique. Age-Adjusted Hypertension Awareness, Treatment, and Control in the Population and Control in Treated Hypertensive Patients Aged 35–64 Years at the 160/95 mm Hg Threshold, TABLE 4. The highest percentage of self-reported hypertension (adults aged ≥15 years) was recorded in Hungary (32%), Bulgaria (30%), Latvia (29%), Germany (29%), and Lithuania (28%), whereas the lowest shares were recorded in Norway (13%), France (14%), Sweden (16%), the United Kingdom (16%), and the Benelux countries (all below 17%). Of course, net reduction in the number of hypertensive cases will translate into a correspondingly higher control rate. In this study, we sought to estimate the relative impact of hypertension treatment strategies in Germany, Sweden, England, Spain, Italy, Canada, and the United States by using sample surveys conducted in the 1990s. These prevalence findings have been presented in detail in a previous report.19. We reviewed surveys on hypertension treatment and control in Europe and North America since 1990 and identified those that were either national in scope or that comprised a series of regional samples, as previously described.19 Two North American and 5 European surveys were included: England,14 Germany,15 Spain,16 Italy,20 Sweden,21,22 United States,23 and Canada.17 Persons 35 to 74 years were available in all surveys except Spain, for which only persons up to age 65 were enrolled. During the past decade, many countries have conducted large-scale, national health surveys to determine the prevalence and treatment of hypertension in addition to other CVD risk factors.14–17 When measurements are comparable, these national surveys can also be used to make international comparisons.18 This information might provide insights into ways to improve public health strategies to prevent target-organ damage. Age- and gender-adjusted hypertension control by country: 160/95 mm Hg.Download figureDownload PowerPointFigure 2. We were not able to determine whether treatment and control levels differed by presence of specific CVD risk factors or diabetes/kidney disease. To make the analysis relevant to current practice, we have therefore chosen to use the 2 most widely applied threshold values in discussions of treatment and control. In its progressed form of cardiovascular disease, it cause 42% of all is estimated to deaths across the European Region annually. Germany had the highest hypertension rates, with 55% of those surveyed having high blood pressure, followed by Finland (49%) and Spain (47%). 1-800-AHA-USA-1 *After trial of lifestyle modifications (specific length varies in guidelines according to severity of BP and risk factors). In contrast, 17% and 29% of hypertensives in Canada and the United States, respectively, were at the treatment goal (Table 4 and Figure 2). Hypertension is still one of the most prevalent non-communicable pathological states anywhere on earth. Introduction. Characteristics of Selected National Surveys in Europe and North America, The mercury sphygmomanometer was used for BP measurements in every country except for England, where the Dinamap 8100 was used. Of those identified as hypertensive, 73% in Austria, 45% in Hungary and 67% in Slovakia were newly diagnosed as a result of this screening. Multivariate analyses controlling for age, sex, current smoking, and physician specialty indicated that, compared with US patients, European patients had higher latest systolic BP levels (by 5.3-10.2 mm Hg across countries examined) and diastolic BP levels (by 1.9-5.3 mm Hg), a smaller likelihood of hypertension control (odds ratios, 0.27-0.50), and a smaller likelihood of medication increase for inadequately controlled hypertension (odds ratios, 0.29-0.65) …
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