Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Hypertension in China: burdens, guidelines and policy responses: a state-of-the-art review

Abstract

Hypertension is a leading risk factor of cardiovascular disease and it is becoming increasingly prevalent globally. Correspondingly, the Chinese government and public health institutions have issued a series of policy documents and guidelines for hypertension. However, no comprehensive review of such documents has been conducted. Hence, this review aims to provide an up-to-date and comprehensive assessment of not only the disease burden, but also hypertension management policies and guidelines in China. A total of 15 epidemiological studies based on national population surveys, 15 Chinese Hypertension Guidelines, and seven policy documents were identified. We found a larger burden of hypertension in men, while the awareness, treatment, and control rates have remained low in both sexes. The ranges of hypertension prevalence, awareness, treatment, and control rate among hypertensive patients were 18.0–44.7%, 23.6–56.2%, 14.2–48.5%, and 4.2–30.1% respectively. Chinese hypertension guidelines provide evidence-based instructions to healthcare practitioners over hypertension management in which primary healthcare is increasingly emphasized. Finally, the policy documents set national goals for hypertension management and standardized the services provided in primary healthcare. The findings highlight the importance of integrating new guidelines into hypertension management provided by primary healthcare practitioners and the need to evaluate the implementation of guidelines and policies.

Introduction

High blood pressure is one of the leading risk factors for cardiovascular disease (CVD) and premature deaths worldwide [1, 2]. In 2010, it was estimated that 1.39 billion adults had hypertension globally, with higher prevalence in Low- and Middle- Income Countries (LMICs) [3]. China has also experienced an increasing prevalence of hypertension over the decades according to a systematic review published in 2014 [4]. Although the awareness, treatment and control of hypertension are crucial to prevent complications, these rates in China remained low compared with those in developed countries [5]. A few observational studies over hypertension in China have been conducted using nationally representative samples [6, 7], but research that systematically examined their changes over time is limited.

Clinical guidelines provide up to date guidance for preventing and managing diseases. Periodically, China publishes and updates national hypertension guidelines, based on international guidelines but with substantiated China-specific findings. Since 1999, five national hypertension guidelines have been developed [8,9,10,11,12]. Although a previous review published in 2015 described the development of guidelines in China [13], two more national guidelines and subgroup specific guidelines, focusing on the elderly and community-based efforts, have been published since then. Therefore, it is timely to provide a systematic and comprehensive overview of hypertension guidelines in China.

In response to the rapid increase in hypertension disease burden, the Chinese government and public health institutions have increased efforts to develop policies aimed to improve hypertension management [14]. Noncommunicable disease (NCD) prevention and control has been increasingly emphasized in political agendas, especially after China’s healthcare reform in 2009 [15]. In that same year, the Basic Public Health Services (BPHS) policy was released and set out to provide affordable and equitable care for diabetes and hypertension, thus potentially improving the management of hypertension [16]. Several Chinese policies on hypertension are embedded in national broad health-related policies, but this review will focus on the hypertension-specific content in effort to increase our understanding of policy response in China to address the rising burden of hypertension.

In this state-of-the-art review, we aim to provide an updated and comprehensive assessment of the following three areas: (1) a systematic review of the prevalence, awareness, treatment, and control of hypertension since 2000; (2) national clinical guidelines on hypertension since 1999; and (3) policies and guidelines in relation to hypertension management in China.

Materials and methods

Corresponding to the three aims stated above, we describe the methods used in the sections below.

Disease burden of hypertension

Search strategy

The search terms used in PubMed were: “hypertension,” “hypertensive,” “hyperpiesis,” “hyperplasia,” “high blood pressure,” “elevated blood pressure,” “normotension,” “raised blood pressure,” OR “prehypertension” in Title, AND “China,” “Chinese,” “Mainland,” OR “PRC” in Title/Abstract, AND “prevalence,” OR “aware” AND “treatment” AND “control” in Title/Abstract. Criteria for inclusion were: [1] The study must have been published between January 2000 and June 2020; [2] based on a nationally representative adult population living in mainland China; [3] study focuses on hypertension; [4] the full text was written in English. Studies that met the following criteria were excluded: [1] targeted population was a specific subgroup of Chinese residents, such as specific occupations, ethnic groups, or co-morbid diseases, etc; [2] total sample size of less than 1000 individuals; [3] study samples restricted to a single geographic region in China, such as Northern, Southern, Eastern, Western China, or fewer than 6 provinces; [4] failure to report data concerning hypertension prevalence, awareness, treatment, or control; [5] the study was a systematic review or meta-analysis; and [6] multiple papers from a same database.

Hypertension was defined as systolic blood pressure over 140 mmHg, diastolic blood pressure over 90 mmHg, or taking antihypertensive medicine [17]. Prevalence was the proportion of people with hypertension in the whole population. Awareness was considered as the proportion of those who had been diagnosed by a doctor to have hypertension or self-reported to be hypertensive. The proportion of people with hypertension who were treated with antihypertensive medication was defined as treatment rate. Control was the proportion of those whose blood pressure was under control (systolic blood pressure <140 mm Hg or/and diastolic blood pressure <90 mm Hg) [16, 18]. The hypertension awareness, treatment and control rates were formed using persons with hypertension as the denominator to increase comparability across studies, which also applies to studies that defined controlled hypertension as associated with pharmacological treatment [7, 19,20,21,22]. One study reported the control rate among those who were aware of their diagnosis, but we recalculated it using persons with hypertension as the denominator [7].

Screening and data extraction

Two reviewers independently conducted the literature search, screening and data extraction. A designated third reviewer was consulted to resolve any incongruities.

Quality and bias assessment

We followed the “NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” for quality assessment of included cohort and cross-sectional studies [23]. Studies were then ranked as “Good,” “Fair,” or “Poor” by two reviewers. A third reviewer was involved to resolve any discrepancies.

Data analysis

The overall hypertension prevalence in the general population and awareness, treatment, control rates among participants with hypertension were illustrated in histograms, while sex-specific data were displayed in clustered histograms. Reference lines of the awareness, treatment and control rates among people with hypertension in developed countries in 2000 were extracted from a systematic analysis of 90 countries and shown in the figure, which are 58.8%, 44.5% and 17.9% [24].

Chinese hypertension guidelines

The search for Chinese hypertension guidelines was conducted using the China National Knowledge Infrastructure digital database (CNKI). The search terms used in CNKI was “Hypertension” AND “Guidelines”. The Website of National Center for Cardiovascular Diseases was also searched to identify released guidelines that were not published in journals. Only documents released by the Chinese Hypertension League, National Center for Cardiovascular Diseases, or the Chinese Society of Medicine aiming at guiding the comprehensive clinical and community primary hypertension management were included in this review. All retrieved papers were written in Chinese and examined by Chinese - English speaking reviewers.

We identified 15 guidelines for hypertension management published between 1999 and 2020 [8,9,10,11,12, 25,26,27,28,29,30,31,32,33,34]. Based on the selection criteria, this review extracted data from nine major guidelines that provide comprehensive instructions for general clinical hypertension management and the community hypertension management.

Chinese policy documents for hypertension

We searched the State Council website with keyword “NCDs” or “hypertension” or “diabetes” or “primary healthcare.” A total of 74 documents were found. The inclusion criteria were: (1) it must be a policy targeting all groups (some policies are for the minorities or the poor); (2) it must have specific clauses related to hypertension management. After reviewing the full texts, 27 polices were included. Seven policies published by the State Council were presented using a table while the other 20 government documents were reviewed and summarized.

Results

Disease burden of hypertension

As demonstrated in (Fig. 1), 545 papers were retrieved from PubMed. The publication titles and abstracts were screened using the eligibility criteria, and 516 of them were excluded. Thirty-one publications were selected into full text review. For those studies derived from the same databases, those that reported the prevalence, awareness, treatment, and control rate of hypertension were included. After excluding 16 articles according to the pre-specified criteria, a total of 15 articles were included in the review [7, 16, 19,20,21,22, 35,36,37,38,39,40,41,42,43].

Fig. 1
figure1

Flow chart of literature search and screening of the epidemiological studies on burden of hypertension in China.

The characteristics of the studies included were shown in Table 1. Sample sizes ranged from 4,987 to 1,738,886 and all participants were 18 years of age or older. The response rate varied from 66.4 to 99.65%. The last year of data collection ranged from 1997 to 2017, and all studies included nine or more provinces.

Table 1 The characteristics of included studies on hypertension in China.

Figure 2 shows the disease burden of hypertension according to the data collection year. The range of hypertension prevalence among the general population, and the awareness, treatment, and control rates in people with hypertension were 18.0–44.7%, 23.6–56.2%, 14.2–48.5%, and 4.2–30.1%, respectively [7, 16, 19,20,21,22, 35,36,37,38,39,40,41,42,43] (Fig. 2a, b, and Supplementary Table 1). Variations in burden of hypertension among the included studies were due to many factors such as inconsistencies in age ranges, age-standardization methods, years of data collection, and sampling schemes. For instance, on account of different age ranges, in Wu’s [7] study the prevalence of hypertension was 18.0% with participants aged 18 years or older, whereas the prevalence in Lu et. al [40] was 56.1% with participants aged between 35 and 75 years. The awareness and treatment rates increased over time, but the hypertension control rate remained low. As per sex differences (Fig. 2c, d), generally a higher prevalence was found in men than that in women, and women were more likely to have higher rates of awareness, treatment, and control.

Fig. 2: Disease burden of hypertension in China.
figure2

a Prevalence of hypertension in China. b Awareness, treatment and control rates of hypertension in China. c Prevalence of hypertension in China by sex. d Awareness, treatment and control rates of hypertension in China by sex.

Guidelines

Figure 3 shows the timeline of guidelines publication from 1999 to 2020. Out of 15 guidelines depicted in this timeline, 12 were published after 2010 and 7 were published within 2017–2019. Six guidelines did not meet the inclusion criteria. Table 2 summarizes the changes over time and reflects the trend of hypertension management [8,9,10,11,12, 25, 28, 32, 34]. These national documents aimed to provide evidence-based instruction for hypertension management to health care providers, to translate new research results into clinical practice, and to promote management and prevention of hypertension and other chronic diseases in China. The first Chinese Guidelines for the Management of Hypertension was published in 1999, introducing a 6-level blood pressure classification (Supplementary Table 2). This was largely based on WHO/ISH and the Joint National Committee (JNC) 5 recommendations [8]. The second guideline was issued in 2005 [9], whereby modifications included a 5-level blood pressure classification and removal of “optimal” blood pressures for age groups (Supplementary Table 2). The definition and classification of hypertension changed again in the 2010 guidelines and control of hypertension risk factors was addressed for the first time. The risk factors recognized in the 2010 guidelines include high sodium and low potassium intake, being overweight or obese, alcohol consumption, long term mental stress, age, family history of hypertension, physical inactive, smoking, dyslipidemia, and diabetes [10]. In addition, the 2010 guidelines modified risk factors and risk stratification for cardiovascular diseases (Supplementary Table 3). In the 2018 guidelines [11], blood pressure goals for diabetes and renal diseases were lower than those in previous guidelines. Other guidelines on specific topics included medications for hypertension, health education for hypertensive patients, and blood pressure measurement instructions for healthcare providers.

Fig. 3
figure3

Publication Timeline of Hypertension Guidelines in China.

Table 2 Blood pressure goals, prevention and management strategies in hypertension guidelines in China.

Community-based hypertension management has been increasingly emphasized in subsequent editions since the 1999 guideline (Table 2). In 2009, as a response to the national BPHS policy, the Chinese Hypertension League issued a guideline focusing on community management for general physicians working at the community level [28]. The awareness, control and management rates were promoted as criteria for hypertension management assessment. In 2014, the second edition of community-based guidelines was published. The classification of hypertension patients changed into two levels and an emphasis on self-management and management in rural areas emerged [25]. The 2017 community guidelines standardized medical equipment, healthcare workforce and medication possession in the community clinics [34]. Following the 2017 version, guidelines for primary care of hypertension were published in 2019 with specified blood pressure goals for patients with respective comorbidities [32]. This guideline standardized the follow-up visit procedures and emphasized the treatment of acute hypertension.

Policy responses for hypertension prevention and control in China

Table 3 shows the key messages from seven documents published by the State Council. The State Council introduced chronic disease prevention in the 2007 National Disease Control System, and as one of the leading risk factors for chronic diseases, hypertension has since gained increased attention [44]. However, it was not until 2009, when major medical and health system reforms were initiated, that prevention and treatment of hypertension was directly mentioned in the plan for Healthcare System Reform [45]. Standards for hypertension management were revised in the Twelfth Five-Year Plan for Health Service Development [46]. For example, blood pressure measurements were required for people aged over 35 years when they were visiting medical institutions. Most recently, the Thirteenth Five-Year Plan for Hygiene and Health required that Basic Public Health Services (BPHS) be delivered to high-risk populations for chronic diseases at the primary care level, including individual health profiles, physical examination, regular follow-up visits, and guidance over healthy lifestyle [47, 48]. Other primary tasks proposed in 2017 were to further develop an integrated prevention and control system for NCDs focusing on grassroots healthcare facilities [47].

Table 3 Summary of national five-year plans and relevant policy documents for hypertension prevention and control published by the State Council, China.

In total, 20 additional documents regarding the implementation of BPHS and NCD control are summarized here [49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68]. BPHS was first released in 2009 [49]. The Opinions on Gradual Equalization to Promote BPHS specified mandatory public health services, including providing blood pressure measurements for people aged over 35 at their first visits to the hospital and management for hypertensive and diabetic patients [49]. Goals for hypertension management were gradually increased in later documents. For example, the target rate of standardized management in hypertensive patients rose from 35% in 2013 to over 60% in 2017 [51, 53,54,55]. Meanwhile, the BPHS Service Code began to promote new patient goals, such as BMI control and blood pressure control for overweight/obese people with hypertension, and expanded the service coverage to cover patients and other high-risk individuals [60, 61]. The Chinese National Health Commission and the State Council have also issued plans on NCD control, including the Healthy China 2030 Plan published in 2016 that further stressed the comprehensive prevention and control of NCDs and set the goal of achieving population-wide and whole lifecycle health management of NCDs by 2030. Two documents that focused on special topics addressed other core pillars of the health system including finance and the utilization of information technology [67, 68].

Discussion

This review summarized the changes in the burden of hypertension in China, the development of hypertension management guidelines, and the policy responses to these changes. A larger burden of hypertension was observed in men than in women, while the overall control rate in both sexes remained low. The Chinese government responded by increasing emphasis on prevention and management of hypertension and other chronic diseases in national policies. In addition, since the release of the first Chinese national hypertension guidelines in 1999, newer guidelines have been revised according to new scientific and empirical evidence. In recent years, more guidelines were published on specific topics and hypertension management at the primary healthcare level.

The awareness, treatment, and control rates in China have remained low, although an upward trend has been observed. A higher prevalence of hypertension was found in males, which is consistent with previous systematic reviews on hypertension prevalence in China [4, 5]. This may be explained by the larger proportion of men with smoking and drinking habits compared to women [69]. Improvements in awareness, treatment and control of hypertension might be credited to the enhanced financial support to hypertension management [5], the dramatic expansion of health insurance coverage [16, 70], and the implementation of national hypertension programs that led to the transition from institutional service to community care [71]. However, the control rates in China were still far from optimal compared with that in developed countries [24, 72]. For example, according to the National Health and Nutrition Examination Survey, the control rate of hypertension in the United States increased significantly from 31.6% in 1999–2000 to 48.3% in 2009–2010 among hypertensive patients, with a stable rate of hypertension of around 29.0% [73]. Alternatively, a national survey in China reported a slight increase in the control rate of hypertension among people with hypertension from 6.1% in 2002 [7] to 11.2% in 2010 [74].

Chinese hypertension guidelines have been constantly updated with emerging evidence-based solutions and better access to antihypertensive medications [9]. The Chinese guidelines are similar to the guidelines issued by the JNC in the United States, the European Society of Hypertension and the European Society of Cardiology (ESH/ESC), and the Canadian Hypertension Education Program (CHEP) in many aspects [75]. For example, the Chinese guidelines published in 2010 and the JNC report similarly emphasized risk management, such as blood lipid and blood glucose control, and antiplatelet therapy [10]. In addition, the ESH/ESC guidelines gradually placed more importance to home blood pressure monitoring (HBPM) for cardiovascular risk prevention since 2003 [75]. Likewise, the Chinese Hypertension League issued a specific Guideline on HBPM in 2019. However, studies show that physicians would prescribe medications beyond the recommended list of drugs in the guidelines [40, 76]. This indicated that the guidelines need further promotion among clinical practitioners to increase their knowledge of and willingness to adhere to updated hypertension guidelines [40].

Over the years, China has attached more importance on hypertension management by specifying goals and treatment plans in its policies. These health polices showed a significant continuity in terms of hypertension management strategies. For instance, China has steadily promoted the hierarchical medical system, national demonstration areas for NCDs management, and family doctor empanelment to enhance the quality of care. China has also allocated more funding and provided policy support for strengthening the grassroots healthcare system with the focus on NCDs prevention and management [77]. In addition, the strong intersectoral collaboration seen in recent policies, such as the joint release of the National Plan on NCD Prevention and Treatment (2012–2015) by 15 Chinese ministries and commissions, suggests cohesiveness and shared commitment to stop the growth of NCD [78]. China’s policies corresponded with the proposals by WHO that urge governments to create and implement national policies for NCD risk and burden reduction, generally through increased access to healthcare and establishment of healthy environments [79].

The coronavirus disease (COVID-19) started in late 2019 and quickly swept across the whole world. The unprecedented pandemic has revealed the inadequacy of health systems and society at large to tackle rapidly emerging infectious diseases. Measures to contain COVID-19 such as social distancing and lock-downs and prioritizing limited medical resources to treat COVID-19 cases have led to reduced access or lower quality of care for patients with NCDs. Furthermore, people with NCDs such as hypertension and related diseases, are at higher risk of contracting and dying from COVID-19, exacerbating the joint consequences of NCDs and the pandemic. While low-cost and effective vaccine is the ultimate weapon against COVID-19, successful development of vaccines must be coupled with efficient delivery of vaccinations to vulnerable populations including NCD patients in low-and middle-income countries to win this battle. Such delivery will require a well-functioning primary care system and workforce.

Strengths and limitations

A strength of this review is its wide research scope and inclusion of various literature types. Part one, or the investigation of the burden of hypertension in China, was based on nationally representative samples and captures changes in disease burden overtime. For parts two and three, national guidelines and policy document series were reviewed in a chronological fashion, thereby describing the progression and development of the national responses to hypertension. Not only did we include specific documents regarding hypertension management, but we also collected key information from policies with larger scope, such as the national five-year plans issued by the State Council.

Nevertheless, this study has some limitations. The first part on disease burden only utilized one database and one language (English), but this review was systematic and included all national and regional studies we could find. Our knowledge of Chinese literature on hypertension indicated that national studies were published in English not Chinese journals. Second, given the already broad scope of our review, we did not include information on risk factors for hypertension or hypertension-related diseases such as cardiovascular and renal disease. Third, we did not include evaluation studies on implementation and impacts of the guidelines and policies, which are important topics for future research but beyond the scope of this paper. Lastly, due to the heterogeneity of the included studies, we were unable to conclude an estimate of the prevalence of hypertension in China over time.

Conclusion

This review shows the increase of hypertension disease burden in China, the development of hypertension management guidelines, and the policy responses to these changes. National clinical guidelines were developed and updated over time with increasing specificity within guidelines. Prevention and management of hypertension has been featured in the National Health Commission policies and in national plans such as the five-year development plan and Healthy China 2030. The BPHS policies initiated in 2009 included hypertension management as one of the service packages and promoted nation-wide uptake of hypertension management especially at the primary care level. Our findings highlighted the importance of integrating new guidelines into hypertension management provided by primary healthcare practitioners. Future research is warranted to examine the implementation of guidelines and policies regarding hypertension management.

References

  1. 1.

    Bromfield S, Muntner P. High blood pressure: the leading global burden of disease risk factor and the need for worldwide prevention programs. Curr Hypertens Rep. 2013;15:134–6.

    Article  Google Scholar 

  2. 2.

    Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323.

    Article  Google Scholar 

  3. 3.

    Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16:223–37.

    CAS  Article  Google Scholar 

  4. 4.

    Fang L, Song J, Ma Z, Zhang L, Jing C, Chen D. Prevalence and characteristics of hypertension in mainland Chinese adults over decades: a systematic review. J Hum Hypertens. 2014;28:649–56.

    CAS  Article  Google Scholar 

  5. 5.

    Wang Y, Peng X, Nie X, Chen L, Weldon R, Zhang W, et al. Burden of hypertension in China over the past decades: Systematic analysis of prevalence, treatment and control of hypertension Eur J Prev Cardiol. 2016;23:792–800.

    Article  Google Scholar 

  6. 6.

    Li Y, Wang L, Feng X, Zhang M, Huang Z, Deng Q, et al. Geographical variations in hypertension prevalence, awareness, treatment and control in China: findings from a nationwide and provincially representative survey. J Hypertens. 2018;36:178–87.

    CAS  Article  Google Scholar 

  7. 7.

    Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002. Circulation. 2008;118:2679–86.

    Article  Google Scholar 

  8. 8.

    Chinese Hypertension League, Chinese Ministry of Health. 1999 Chinese Guidelines for the Management of Hypertension.

  9. 9.

    Chinese Hypertension League, Chinese Ministry of Health. 2005 Chinese Guidelines for the Management of Hypertension.

  10. 10.

    Chinese Hypertension League, National Center for Cardiovascular Diseases. 2010 Guidelines for the Management of Hypertension.

  11. 11.

    Chinese Hypertension League, National Center for Cardiovascular Diseases. 2018 Chinese Guidelines for the Management of Hypertension.

  12. 12.

    National Center for Cardiovascular Diseases, Chinese Center for Disease Control and Prevention, Chinese Society of Cardiology. National guideline for hypertension management in China (2019).

  13. 13.

    Wang JG. Chinese hypertension guidelines. Pulse (Basel). 2015;3:14–20.

    Article  Google Scholar 

  14. 14.

    Campbell NRC, Zhang XH. Hypertension in China: time to transition from knowing the problem to implementing the solution. Circulation 2018;137:2357–9.

    Article  Google Scholar 

  15. 15.

    Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in China. Lancet 2005;366:1821–4.

    Article  Google Scholar 

  16. 16.

    Feng XL, Pang M, Beard J. Health system strengthening and hypertension awareness, treatment and control: data from the China Health and Retirement Longitudinal Study. Bull World Health Organ. 2014;92:29–41.

    Article  Google Scholar 

  17. 17.

    World Health Organization. Global status report on noncommunicable diseases 2010. 2011.

  18. 18.

    Walker RW, McLarty DG. Hypertension and stroke in developing countries. Lancet. 1995;346:778.

    CAS  Article  Google Scholar 

  19. 19.

    Gao Y, Chen G, Tian H, Lin L, Lu J, Weng J, et al. Prevalence of hypertension in china: a cross-sectional study. PLoS One. 2013;8:e65938.

    CAS  Article  Google Scholar 

  20. 20.

    Lewington S, Lacey B, Clarke R, Guo Y, Kong XL, Yang L, et al. The burden of hypertension and associated risk for cardiovascular mortality in China. JAMA Intern Med. 2016;176:524–32.

    Article  Google Scholar 

  21. 21.

    Li W, Gu H, Teo KK, Bo J, Wang Y, Yang J, et al. Hypertension prevalence, awareness, treatment, and control in 115 rural and urban communities involving 47 000 people from China. J Hypertens. 2016;34:39–46.

    Article  Google Scholar 

  22. 22.

    Wang J, Zhang L, Wang F, Liu L, Wang H. Prevalence, awareness, treatment, and control of hypertension in China: results from a national survey. Am J Hypertens. 2014;27:1355–61.

    CAS  Article  Google Scholar 

  23. 23.

    National Heart L, Institute B. Quality assessment tool for observational cohort and cross-sectional studies. Bethesda: National Institutes of Health, Department of Health and Human Services. 2014.

  24. 24.

    Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-Based Studies From 90 Countries. Circulation 2016;134:441–50.

    Article  Google Scholar 

  25. 25.

    National Health and Family Planning Commission of the People’s Republic of China, National Center for Cardiovascular Diseases, Chinese Hypertension League. Chinese Guidelines for the Management of Hypertension in the Community (2014 revised version). 2014.

  26. 26.

    National Center for Cardiovascular Diseases, Chinese Center for Disease Control and Prevention, Chinese Society of Cardiology. 2019 Chinese Guidelines for the Management of Hypertension in the Elderly. 2019.

  27. 27.

    Chinese Hypertension League. 2019 Chinese Hypertension League Guideline on Home Blood Pressure Monitoring. 2019中国家庭血压监测指南2019.

  28. 28.

    Chinese Hypertension League, Chinese Ministry of Health. Chinese Guidelines for the Management of Hypertension in the Community. 2009.

  29. 29.

    China Blood Pressure Measurement Working Group. Guidelines for Blood Pressure Measurement. 2012.

  30. 30.

    Professional Committee on Hypertension, Chinese Medical Doctor Association. Guidelines for Hypertension Medication. 高血压合理用药指南2015.

  31. 31.

    National Health and Family Planning Commission of the People’s Republic of China, Professional Committee on Hypertension, Chinese Medical Doctor Association. Guidelines for Hypertension Medication (the second version). 高血压合理用药指南 (第2版) 2017.

  32. 32.

    Chinese Medical Association, Chinese Medical Journals Publishing House, Chinese Society of General Practice, Editorial Board of Chinses Journal of General Practice. Guidelines for Primary Care of Hypertension. 2019.

  33. 33.

    Chinese Hypertension League. Guidelines for the Education of Hypertensive Patients. 中国高血压患者教育指南2013.

  34. 34.

    National Center for Cardiovascular Diseases, National Basic Public Health Service Project. National Guidelines for the Management of Hypertension in the Community 2017.

  35. 35.

    Feng YJ, Wang HC, Li YC, Zhao WH. Hypertension screening and follow-up management by primary health care system among Chinese population aged 35 years and above. Biomed Environ Sci. 2015;28:330–40.

    PubMed  Google Scholar 

  36. 36.

    Gu D, Reynolds K, Wu X, Chen J, Duan X, Muntner P, et al. Prevalence, awareness, treatment, and control of hypertension in China. Hypertension 2002;40:920–7.

    CAS  Article  Google Scholar 

  37. 37.

    Guo J, Zhu YC, Chen YP, Hu Y, Tang XW, Zhang B. The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011. J Hypertens 2015;33:1688–96.

    CAS  Article  Google Scholar 

  38. 38.

    He M, Yu S, Liu R, Yang X, Zhao G, Qiao X, et al. Elevated blood pressure and headache disorders in China–associations, under-treatment and implications for public health. J Headache Pain. 2015;16:86.

    Article  Google Scholar 

  39. 39.

    Li Y, Yang L, Wang L, Zhang M, Huang Z, Deng Q, et al. Burden of hypertension in China: a nationally representative survey of 174,621 adults. Int J Cardiol. 2017;227:516–23.

    Article  Google Scholar 

  40. 40.

    Lu J, Lu Y, Wang X, Li X, Linderman GC, Wu C, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project). Lancet 2017;390:2549–58.

    Article  Google Scholar 

  41. 41.

    Wang Y, Chen J, Wang K, Edwards CL. Education as an important risk factor for the prevalence of hypertension and elevated blood pressure in Chinese men and women. J Hum Hypertens. 2006;20:898–900.

    CAS  Article  Google Scholar 

  42. 42.

    Wang Z, Chen Z, Zhang L, Wang X, Hao G, Zhang Z, et al. Status of Hypertension in China: Results From the China Hypertension Survey, 2012-2015. Circulation 2018;137:2344–56.

    Article  Google Scholar 

  43. 43.

    You Y, Teng W, Wang J, Ma G, Ma A, Wang J, et al. Hypertension and physical activity in middle-aged and older adults in China. Sci Rep. 2018;8:16098.

    Article  Google Scholar 

  44. 44.

    State Council (China). Outline of the Eleventh Five-year Plan for Health Service Development. 2007.

  45. 45.

    State Council (China). Plan on Recent Priorities in Carrying out the Healthcare System Reform (2009-2011). 2009.

  46. 46.

    State Council (China). Outline of the Twelfth Five-Year Plan for Health Service Development. 2012.

  47. 47.

    State Council (China). Thirteenth Five-Year Plan for Hygiene and Health. 2017.

  48. 48.

    State Council (China). The Thirteenth Five-Year Plan to Promote Equalization of Basic Public Health Services. 2017.

  49. 49.

    National Health and Family Planning Commission (China). Opinions on Gradually Promoting the Equalization of Basic Public Health Services. 2009.

  50. 50.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2018.

  51. 51.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2017.

  52. 52.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2016.

  53. 53.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2015.

  54. 54.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2014.

  55. 55.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2013.

  56. 56.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2011.

  57. 57.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2019.

  58. 58.

    National Health and Family Planning Commission (China). Notice on Successful Implementation of National Basic Public Health Services in 2020.

  59. 59.

    National Health and Family Planning Commission (China). National Basic Public Health Service Code (2009).

  60. 60.

    National Health and Family Planning Commission (China). National Basic Public Health Service Code (2011).

  61. 61.

    National Health and Family Planning Commission (China). National Basic Public Health Service Code (the Third Edition). 2017.

  62. 62.

    National Health and Family Planning Commission (China). China National Plan for NCD Prevention and Treatment (2012-2015). 2012.

  63. 63.

    National Health and Family Planning Commission (China). Guidance for Construction of National Demonstration Area for Comprehensive Prevention and Control of NCDs. 2016.

  64. 64.

    State Council (China). Healthy China 2030 Plan. 2016.

  65. 65.

    State Council (China). China’s Medium-to-Long Term Plan for NCD Prevention and Treatment (2017-2025). 2017.

  66. 66.

    State Council (China). Guidance on Promoting the Construction of a Hierarchical Medical System. 2017.

  67. 67.

    State Council (China). Guidance on further deepening the reform of basic medical insurance payment method. 2017.

  68. 68.

    State Council (China). Opinions on Promoting the Development of mHealth. 2018.

  69. 69.

    Yang G, Kong L, Zhao W, Wan X, Zhai Y, Chen LC, et al. Emergence of chronic non-communicable diseases in China. Lancet. 2008;372:1697–705.

    Article  Google Scholar 

  70. 70.

    Yip WC, Hsiao WC, Chen W, Hu S, Ma J, Maynard A. Early appraisal of China’s huge and complex health-care reforms. Lancet. 2012;379:833–42.

    Article  Google Scholar 

  71. 71.

    Li H, Liu F, Xi B. Control of hypertension in China: challenging. Int J Cardiol. 2014;174:797.

    Article  Google Scholar 

  72. 72.

    McAlister FA, Wilkins K, Joffres M, Leenen FH, 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.

    Article  Google Scholar 

  73. 73.

    Cheryl D. Fryar, Yechiam Ostchega, Craig M. Hales, Guangyu Zhang, Deanna Kruszon-Moran. Hypertension Prevalence and Control Among Adults: United States, 2015–2016. In: Services USDoHaH, editor. 2017.

  74. 74.

    Li D, Lv J, Liu F, Liu P, Yang X, Feng Y, et al. Hypertension burden and control in mainland China: Analysis of nationwide data 2003-2012. Int J Cardiol. 2015;184:637–44.

    Article  Google Scholar 

  75. 75.

    Kotchen TA. Developing hypertension guidelines: an evolving process. Am J Hypertens. 2014;27:765–72.

    Article  Google Scholar 

  76. 76.

    Su M, Zhang Q, Bai X, Wu C, Li Y, Mossialos E, et al. Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey. Lancet. 2017;390:2559–68.

    Article  Google Scholar 

  77. 77.

    Li X, Krumholz HM, Yip W, Cheng KK, De Maeseneer J, Meng Q, et al. Quality of primary health care in China: challenges and recommendations. Lancet. 2020;395:1802–12.

    CAS  Article  Google Scholar 

  78. 78.

    Ministy of Health, National Development and Reform Commission, Ministry of Education, Ministry of Science and Technology, Ministry of Civil Affairs, Ministry of Finance, et al. National Plan on NCD Prevention and Treatment (2012-2015). 2012.

  79. 79.

    World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. 2013.

Download references

Acknowledgements

We hereby express our gratitude to Lei Guo, Yuewen Sun, Quanyue Li, and Kamila Pinter for participating in the initial search of this review.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Lijing L. Yan.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Yin, R., Yin, L., Li, L. et al. Hypertension in China: burdens, guidelines and policy responses: a state-of-the-art review. J Hum Hypertens (2021). https://doi.org/10.1038/s41371-021-00570-z

Download citation

Search

Quick links