Variation in the Proportion of Adults in Need of Blood Pressure-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries A Cross-Sectional Study of 1 037 215 Individuals From 50 Nationally Representative Surveys

Sudharsanan N. Theilmann M. Kirschbaum T.K. Manne-Goehler J. Azadnajafabad S. Bovet P. Chen S. Damasceno A. De Neve J.-W. Dorobantu M. Ebert C. Farzadfar F. Gathecha G. Gurung M.S. Jamshidi K. Jørgensen J.M.A. Labadarios D. Lemp J. Lunet N. Mwangi J.K. Moghaddam S.S. Bahendeka S.K. Zhumadilov Z. Bärnighausen T. Vollmer S. Atun R. Davies J.I. Geldsetzer P.
9 March 2021 Lippincott Williams and Wilkins

Circulation
2021 #143 Issue 10 991 - 1001 pp.

BACKGROUND: Current hypertension guidelines vary substantially in their definition of who should be offered blood pressure-lowering medications. Understanding the effect of guideline choice on the proportion of adults who require treatment is crucial for planning and scaling up hypertension care in low- and middle-income countries. METHODS: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults 30 to 70 years of age from nationally representative surveys in 50 low- and middle-income countries (N = 1037215). We aimed to determine the effect of hypertension guideline choice on the proportion of adults in need of blood pressure-lowering medications. We considered 4 hypertension guidelines: the 2017 American College of Cardiology/American Heart Association guideline, the commonly used 140/90 mmHg threshold, the 2016 World Health Organization HEARTS guideline, and the 2019 UK National Institute for Health and Care Excellence guideline. RESULTS: The proportion of adults in need of blood pressure-lowering medications was highest under the American College of Cardiology/American Heart Association, followed by the 140/90 mmHg, National Institute for Health and Care Excellence, and World Health Organization guidelines (American College of Cardiology/American Heart Association: women, 27.7% [95% CI, 27.2-28.2], men, 35.0% [95% CI, 34.4-35.7]; 140/90 mmHg: women, 26.1% [95% CI, 25.5-26.6], men, 31.2% [95% CI, 30.6-31.9]; National Institute for Health and Care Excellence: women, 11.8% [95% CI, 11.4-12.1], men, 15.7% [95% CI, 15.3-16.2]; World Health Organization: women, 9.2% [95% CI, 8.9-9.5], men, 11.0% [95% CI, 10.6-11.4]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood pressure-lowering medications were largest in the oldest (65-69 years) age group (American College of Cardiology/American Heart Association: women, 60.2% [95% CI, 58.8-61.6], men, 70.1% [95% CI, 68.8-71.3]; World Health Organization: women, 20.1% [95% CI, 18.8-21.3], men, 24.1.0% [95% CI, 22.3-25.9]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood pressure-lowering medicines, whereas the South and Central Americas had the lowest. CONCLUSIONS: There was substantial variation in the proportion of adults in need of blood pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policy makers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.

health policy , hypertension , therapeutics

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Heidelberg Institute of Global Health, Heidelberg University, Germany
Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, United States
Tehran University of Medical Sciences, Iran
Institute of Social and Preventive Medicine, Bern, Switzerland
Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
Cardiology Department, Emergency Hospital of Bucharest, Romania
RWI-Leibniz Institute for Economic Research, Essen, Germany
Division of NonCommunicable Diseases, Ministry of Health, Nairobi, Kenya
Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan
D-Tree International, Norwell, MA, United States
Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
Department of Public and Forensic Health Sciences and Medical Education, Faculty of Medicine, University of Porto, Portugal
Department of Strategic National Public Health Programs, Ministry of Health, Nairobi, Kenya
Saint Francis Hospital, Kampala, Uganda
National Laboratory Astana, University Medical Centre, Nazarbayev University, Kazakhstan
Department of Economics, Centre for Modern Indian Studies, University of Göttingen, Germany
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
Institute of Applied Health Research, University of Birmingham, United Kingdom
Division of Primary Care and Population Health, Department of Medicine, Stanford University, CA, United States

Heidelberg Institute of Global Health
Division of Infectious Diseases
Tehran University of Medical Sciences
Institute of Social and Preventive Medicine
Faculty of Medicine
Cardiology Department
RWI-Leibniz Institute for Economic Research
Division of NonCommunicable Diseases
Health Research and Epidemiology Unit
D-Tree International
Faculty of Medicine and Health Sciences
Department of Public and Forensic Health Sciences and Medical Education
Department of Strategic National Public Health Programs
Saint Francis Hospital
National Laboratory Astana
Department of Economics
Department of Global Health and Population
Institute of Applied Health Research
Division of Primary Care and Population Health

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