Hypertension is the leading cause of cardiovascular disease and premature death worldwide. Owing to the widespread use of antihypertensive medications, global mean blood pressure (BP) has remained constant or has decreased slightly over the past four decades. By contrast, the prevalence of hypertension has increased, especially in low- and middle-income countries (LMICs). Estimates suggest that 31.1% of adults (1.39 billion) worldwide had hypertension in 2010. The prevalence of hypertension among adults was higher in LMICs (31.5%, 1.04 billion people) than in high-income countries (28.5%, 349 million people). Variations in the levels of risk factors for hypertension, such as high sodium intake, low potassium intake, obesity, alcohol consumption, physical inactivity and unhealthy diet, may explain some of the regional heterogeneity in hypertension prevalence. Despite the increasing prevalence, the proportions of hypertension awareness, treatment and BP control are low, particularly in LMICs, and few comprehensive assessments of the economic impact of hypertension exist. Future studies are warranted to test implementation strategies for hypertension prevention and control, especially in low-income populations, and to accurately assess the prevalence and financial burden of hypertension worldwide.
Hypertension is the leading modifiable risk factor for cardiovascular disease and premature death worldwide.
The prevalence and absolute burden of hypertension is rising globally, especially in low- and middle-income countries (LMICs).
Awareness, treatment and control of hypertension are unacceptably low worldwide, particularly in LMICs.
Reductions in risk factors, including high sodium intake, low potassium intake, obesity, alcohol consumption, physical inactivity and unhealthy diet, are recommended for the prevention and control of hypertension.
Multifaceted implementation strategies for hypertension prevention and control are needed to address barriers at the patient, provider, system and community levels.
Comprehensive assessments are needed to evaluate the economic impact of hypertension worldwide.
Subscribe to Journal
Get full journal access for 1 year
only $4.92 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Stanaway, J. D. et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet 392, 1923–1994 (2018).
GBD 2017 Causes of Death Collaborators, G. A. et al. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the global burden of disease study 2017. Lancet 392, 1736–1788 (2018).
Mills, K. T. et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation 134, 441–450 (2016).
Zhou, B. et al. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants. Lancet 389, 37–55 (2017).
Falaschetti, E., Mindell, J., Knott, C. & Poulter, N. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet 383, 1912–1919 (2014).
Ezzati, M. et al. Contributions of risk factors and medical care to cardiovascular mortality trends. Nat. Rev. Cardiol. 12, 508–530 (2015).
Laatikainen, T., Nissinen, A., Kastarinen, M., Jula, A. & Tuomilehto, J. Blood pressure, sodium intake, and hypertension control: lessons from the North Karelia project. Glob. Heart 11, 191–199 (2016).
Ibrahim, M. M. & Damasceno, A. Hypertension in developing countries. Lancet 380, 611–619 (2012).
Hogerzeil, H. V. et al. Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration. Lancet 381, 680–689 (2013).
BeLue, R. et al. An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective. Global. Health 5, 10 (2009).
Chow, C. K. et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 310, 959–968 (2013).
Forouzanfar, M. H. et al. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm Hg, 1990–2015. JAMA 317, 165–182 (2017).
Kearney, P. M. et al. Global burden of hypertension: analysis of worldwide data. Lancet 365, 217–223 (2005).
Whelton, P. K. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation 138, e484–e594 (2018).
Lewington, S., Clarke, R., Qizilbash, N., Peto, R. & Collins, R. 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 360, 1903–1913 (2002).
Guo, X. et al. Association between pre-hypertension and cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Curr. Hypertens. Rep. 15, 703–716 (2013).
SPRINT Research Group et al. A randomized trial of intensive versus standard blood-pressure control. N. Engl. J. Med. 373, 2103–2116 (2015).
Bundy, J. D. et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2, 775–781 (2017).
Bundy, J. D. et al. Estimating the association of the 2017 and 2014 hypertension guidelines with cardiovascular events and deaths in US Adults: an analysis of national data. JAMA Cardiol. 3, 572–581 (2018).
Wang, Z. et al. Status of hypertension in China. Circulation 137, 2344–2356 (2018).
Muntner, P. et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension 73, e35–e66 (2019).
Ataklte, F. et al. Burden of undiagnosed hypertension in sub-Saharan Africa. Hypertension 65, 291–298 (2015).
Martin, M. J., Hulley, S. B., Browner, W. S., Kuller, L. H. & Wentworth, D. Serum cholesterol, blood pressure, and mortality: implications from a cohort of 361,662 men. Lancet 2, 933–936 (1986).
Stamler, J., Stamler, R. & Neaton, J. D. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. Arch. Intern. Med. 153, 598–615 (1993).
Gu, D. et al. Blood pressure and risk of cardiovascular disease in Chinese men and women. Am. J. Hypertens. 21, 265–272 (2008).
Anderson, A. H. et al. Time-updated systolic blood pressure and the progression of chronic kidney disease: a cohort study. Ann. Intern. Med. 162, 258–265 (2015).
Klag, M. J. et al. Blood pressure and end-stage renal disease in men. N. Engl. J. Med. 334, 13–18 (1996).
Reynolds, K. et al. A population-based, prospective study of blood pressure and risk for end-stage renal disease in China. J. Am. Soc. Nephrol. 18, 1928–1935 (2007).
Turnbull, F. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 362, 1527–1535 (2003).
Ettehad, D. et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 387, 957–967 (2016).
Xie, X. et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet 387, 435–443 (2016).
Cheung, A. K. et al. Effects of intensive BP control in CKD. J. Am. Soc. Nephrol. 28, 2812–2823 (2017).
Malhotra, R. et al. Effects of intensive blood pressure lowering on kidney tubule injury in CKD: a longitudinal subgroup analysis in SPRINT. Am. J. Kidney Dis. 73, 21–30 (2019).
Williamson, J. D. et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years. JAMA 315, 2673 (2016).
ACCORD Study Group et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N. Engl. J. Med. 362, 1575–1585 (2010).
Margolis, K. L. et al. Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial. Diabetes Care 37, 1721–1728 (2014).
Kitagawa, K. et al. Effect of standard vs intensive blood pressure control on the risk of recurrent stroke: a randomized clinical trial and meta-analysis. JAMA Neurol. 76, 1309 (2019).
US National Library of Medicine. ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT04040634 (2019).
US National Library of Medicine. ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT04036409 (2019).
US National Library of Medicine. ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT03808311 (2019).
US National Library of Medicine. ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT03585595 (2019).
Singh, G. M. et al. The age associations of blood pressure, cholesterol, and glucose: analysis of health examination surveys from international populations. Circulation 125, 2204–2211 (2012).
Dorans, K. S., Mills, K. T., Liu, Y. & He, J. Trends in prevalence and control of hypertension according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline. J. Am. Heart Assoc. 7, e008888 (2018).
Kaufman, J. S., Dolman, L., Rushani, D. & Cooper, R. S. The contribution of genomic research to explaining racial disparities in cardiovascular disease: a systematic review. Am. J. Epidemiol. 181, 464–472 (2015).
Whelton, P. K. et al. Research needs to improve hypertension treatment and control in African Americans. Hypertension 68, 1066–1072 (2016).
Whelton, P. K. et al. Primary prevention of hypertension: clinical and public health advisory from the national high blood pressure education program. JAMA 288, 1882–1888 (2002).
Powles, J. et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 3, e003733 (2013).
National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium (National Academies Press, 2019).
He, J. & Whelton, P. K. Salt intake, hypertension and risk of cardiovascular disease: an important public health challenge. Int. J. Epidemiol. 31, 322–327 (2002).
Elliott, P. et al. Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group. BMJ 312, 1249–1253 (1996).
He, J., Tell, G. S., Tang, Y. C., Mo, P. S. & He, G. Q. Relation of electrolytes to blood pressure in men. The Yi people study. Hypertension 17, 378–385 (1991).
Mente, A. et al. Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. Lancet 392, 496–506 (2018).
Sacks, F. M. et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N. Engl. J. Med. 344, 3–10 (2001).
Midgley, J. P., Matthew, A. G., Greenwood, C. M. & Logan, A. G. Effect of reduced dietary sodium on blood pressure: a meta-analysis of randomized controlled trials. JAMA 275, 1590–1597 (1996).
Cutler, J. A., Follmann, D. & Allender, P. S. Randomized trials of sodium reduction: an overview. Am. J. Clin. Nutr. 65, 643S–651S (1997).
Graudal, N. A., Galloe, A. M., Garred, P., Galløe, A. M. & Garred, P. Effects of sodium restriction on blood pressure, renin, aldosterone, catecholamines, cholesterols, and triglyceride: a meta-analysis. JAMA 279, 1383–1391 (1998).
He, F. J., Li, J. & MacGregor, G. A. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. Br. Med. J. 346, f1325 (2013).
Newberry, S. J. et al. Sodium and Potassium Intake: Effects on Chronic Disease Outcomes and Risks (US Agency for Healthcare Research and Quality, 2018).
Cook, N. R., Appel, L. J. & Whelton, P. K. Lower levels of sodium intake and reduced cardiovascular risk. Circulation 129, 981–989 (2014).
He, J. et al. Urinary sodium and potassium excretion and CKD progression. J. Am. Soc. Nephrol. 27, 1202–1212 (2016).
Mills, K. T. et al. Sodium excretion and the risk of cardiovascular disease in patients with chronic kidney disease. JAMA 315, 2200–2210 (2016).
Stolarz-Skrzypek, K. et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA 305, 1777–1785 (2011).
O’Donnell, M. J. et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA 306, 2229–2238 (2011).
O’Donnell, M. et al. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N. Engl. J. Med. 371, 612–623 (2014).
Mente, A. et al. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet 388, 465–475 (2016).
Pfister, R. et al. Estimated urinary sodium excretion and risk of heart failure in men and women in the EPIC-Norfolk study. Eur. J. Heart Fail. 16, 394–402 (2014).
Olde Engberink, R. H. G. G. et al. Use of a single baseline versus multiyear 24-hour urine collection for estimation of long-term sodium intake and associated cardiovascular and renal risk. Circulation 136, 917–926 (2017).
Nomura, K., Asayama, K., Jacobs, L., Thijs, L. & Staessen, J. A. Renal function in relation to sodium intake: a quantitative review of the literature. Kidney Int. 92, 67–78 (2017).
Cobb, L. K. et al. Methodological issues in cohort studies that relate sodium intake to cardiovascular disease outcomes: a science advisory from the American Heart Association. Circulation 129, 1173–1186 (2014).
Iwahori, T. et al. Urinary sodium-to-potassium ratio and intake of sodium and potassium among men and women from multiethnic general populations: the INTERSALT study. Hypertens. Res. 42, 1590–1598 (2019).
Weaver, C. M., Stone, M. S., Lobene, A. J., Cladis, D. P. & Hodges, J. K. What is the evidence base for a potassium requirement? Nutr. Today 53, 1 (2018).
Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ 297, 319–328 (1988).
Cappuccio, F. P. & MacGregor, G. A. Does potassium supplementation lower blood pressure? A meta-analysis of published trials. J. Hypertens. 9, 465–473 (1991).
Whelton, P. K. et al. Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA 277, 1624–1632 (1997).
Poorolajal, J. et al. Oral potassium supplementation for management of essential hypertension: a meta-analysis of randomized controlled trials. PLOS ONE 12, e0174967 (2017).
Filippini, T., Violi, F., D’Amico, R. & Vinceti, M. The effect of potassium supplementation on blood pressure in hypertensive subjects: a systematic review and meta-analysis. Int. J. Cardiol. 230, 127–135 (2017).
Manthey, J. et al. Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study. Lancet 393, 2493–2502 (2019).
Klatsky, A. L., Friedman, G. D., Siegelaub, A. B. & Gérard, M. J. Alcohol consumption and blood pressure. Kaiser-permanente multiphasic health examination data. N. Engl. J. Med. 296, 1194–1200 (1977).
Fuchs, F. D., Chambless, L. E., Whelton, P. K., Nieto, F. J. & Heiss, G. Alcohol consumption and the incidence of hypertension: the Atherosclerosis Risk in Communities Study. Hypertension 37, 1242–1250 (2001).
Millwood, I. Y. et al. Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. Lancet 393, 1831–1842 (2019).
Xin, X. et al. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 38, 1112–1117 (2001).
Roerecke, M. et al. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis. Lancet Public Health 2, e108–e120 (2017).
Guthold, R., Stevens, G. A., Riley, L. M. & Bull, F. C. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet Glob. Health 6, e1077–e1086 (2018).
Lesniak, K. T. & Dubbert, P. M. Exercise and hypertension. Curr. Opin. Cardiol. 16, 356–359 (2001).
Hayashi, T. et al. Walking to work and the risk for hypertension in men: the Osaka Health Survey. Ann. Intern. Med. 131, 21–26 (1999).
Whelton, S. P., Chin, A., Xin, X. & He, J. Effect of aerobic exercise on blood pressure. Ann. Intern. Med. 136, 493 (2002).
Ishikawa, K., Ohta, T., Zhang, J., Hashimoto, S. & Tanaka, H. Influence of age and gender on exercise training-induced blood pressure reduction in systemic hypertension. Am. J. Cardiol. 84, 192–196 (1999).
Kelley, G. A. & Kelley, K. S. Progressive resistance exercise and resting blood pressure: a meta-analysis of randomized controlled trials. Hypertension 35, 838–843 (2000).
NCD Risk Factor Collaboration (NCD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet 387, 1377–1396 (2016).
Huang, Z. et al. Body weight, weight change, and risk for hypertension in women. Ann. Intern. Med. 128, 81 (1998).
He, J. et al. Body mass and blood pressure in a lean population in southwestern China. Am. J. Epidemiol. 139, 380–389 (1994).
Mertens, I. L. & van Gaal, L. F. Overweight, obesity, and blood pressure: the effects of modest weight reduction. Obes. Res. 8, 270–278 (2000).
Forman, J. P., Stampfer, M. J. & Curhan, G. C. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA 302, 401 (2009).
Garrison, R. J., Kannel, W. B., Stokes, J. & Castelli, W. P. Incidence and precursors of hypertension in young adults: the Framingham offspring study. Prev. Med. 16, 235–251 (1987).
Neter, J. E., Stam, B. E., Kok, F. J., Grobbee, D. E. & Geleijnse, J. M. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 42, 878–884 (2003).
Whelton, S. P. et al. Effect of dietary fiber intake on blood pressure: a meta-analysis of randomized, controlled clinical trials. J. Hypertens. 23, 475–481 (2005).
Streppel, M. T., Arends, L. R., van’t Veer, P., Grobbee, D. E. & Geleijnse, J. M. Dietary fiber and blood pressure: a meta-analysis of randomized placebo-controlled trials. Arch. Intern. Med. 165, 150–156 (2005).
Liu, L., Ikeda, K., Sullivan, D. H., Ling, W. & Yamori, Y. Epidemiological evidence of the association between dietary protein intake and blood pressure: a meta-analysis of published data. Hypertens. Res. 25, 689–695 (2002).
Rebholz, C. M. et al. Dietary protein intake and blood pressure: a meta-analysis of randomized controlled trials. Am. J. Epidemiol. 176, S27–S43 (2012).
Margetts, B. M., Beilin, L. J., Armstrong, B. K., Vandongen, R. & Croft, K. D. Dietary fat intake and blood pressure: a double blind controlled trial of changing polyunsaturated to saturated fat ratio. J. Hypertens. Suppl. 2, S201–S203 (1984).
Puska, P. et al. Controlled, randomised trial of the effect of dietary fat on blood pressure. Lancet 1, 1–5 (1983).
Imamura, F. et al. Dietary quality among men and women in 187 countries in 1990 and 2010: a systematic assessment. Lancet. Glob. Heal. 3, e132–e142 (2015).
Appel, L. J. et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N. Engl. J. Med. 336, 1117–1124 (1997).
Yokoyama, Y. et al. Vegetarian diets and blood pressure. JAMA Intern. Med. 174, 577 (2014).
Nordmann, A. J. et al. Meta-analysis comparing mediterranean to low-fat diets for modification of cardiovascular risk factors. Am. J. Med. 124, 841–851.e2 (2011).
Baer, L. & Radichevich, I. Cigarette smoking in hypertensive patients. Blood pressure and endocrine responses. Am. J. Med. 78, 564–568 (1985).
Rhee, M.-Y., Na, S.-H., Kim, Y.-K., Lee, M.-M. & Kim, H.-Y. Acute effects of cigarette smoking on arterial stiffness and blood pressure in male smokers with hypertension. Am. J. Hypertens. 20, 637–641 (2007).
Wang, Y. et al. Relationship between duration of sleep and hypertension in adults: a meta-analysis. J. Clin. Sleep Med. 11, 1047–1056 (2015).
Bazzano, L. A., Khan, Z., Reynolds, K. & He, J. Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea. Hypertension 50, 417–423 (2007).
Virdis, A., Giannarelli, C., Fritsch Neves, M., Taddei, S. & Ghiadoni, L. Cigarette smoking and hypertension. Curr. Pharm. Des. 16, 2518–2525 (2010).
Halperin, R. O., Michael Gaziano, J. & Sesso, H. D. Smoking and the risk of incident hypertension in middle-aged and older men. Am. J. Hypertens. 21, 148–152 (2008).
Cai, Y. et al. Associations of short-term and long-term exposure to ambient air pollutants with hypertension. Hypertension 68, 62–70 (2016).
Yang, B.-Y. et al. Global association between ambient air pollution and blood pressure: a systematic review and meta-analysis. Environ. Pollut. 235, 576–588 (2018).
Liu, M.-Y., Li, N., Li, W. A. & Khan, H. Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurol. Res. 39, 573–580 (2017).
Manohar, S., Thongprayoon, C., Cheungpasitporn, W., Mao, M. A. & Herrmann, S. M. Associations of rotational shift work and night shift status with hypertension: a systematic review and meta-analysis. J. Hypertens. 35, 1929–1937 (2017).
Kempen, E., van, Casas, M., Pershagen, G. & Foraster, M. WHO environmental noise guidelines for the European region: a systematic review on environmental noise and cardiovascular and metabolic effects: a summary. Int. J. Environ. Res. Public. Health 15, 379 (2018).
Dzhambov, A. M. & Dimitrova, D. D. Residential road traffic noise as a risk factor for hypertension in adults: systematic review and meta-analysis of analytic studies published in the period 2011–2017. Environ. Pollut. 240, 306–318 (2018).
Bowman, T. S., Gaziano, J. M., Buring, J. E. & Sesso, H. D. A prospective study of cigarette smoking and risk of incident hypertension in women. J. Am. Coll. Cardiol. 50, 2085–2092 (2007).
Gerace, T. A., Hollis, J., Ockene, J. K. & Svendsen, K. Smoking cessation and change in diastolic blood pressure, body weight, and plasma lipids. MRFIT Research Group. Prev. Med. 20, 602–620 (1991).
Huang, K. et al. Long-term exposure to fine particulate matter and hypertension incidence in China. Hypertension 73, 1195–1201 (2019).
Yusuf, S. et al. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet https://doi.org/10.1016/S0140-6736(19)32008-2 (2019).
Nagele, E. et al. Clinical effectiveness of stress-reduction techniques in patients with hypertension: systematic review and meta-analysis. J. Hypertens. 32, 1936–1944 discussion 1944 (2014).
Whelton, P. K. et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 279, 839–846 (1998).
Cook, N. R. et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ 334, 885–888 (2007).
Beaney, T. et al. May measurement month 2017: an analysis of blood pressure screening results worldwide. Lancet Glob. Health 6, e736–e743 (2018).
Borzecki, A. M., Oliveria, S. A. & Berlowitz, D. R. Barriers to hypertension control. Am. Heart J. 149, 785–794 (2005).
Khatib, R. et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLOS ONE 9, e84238 (2014).
Mills, K. T. et al. Comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis. Ann. Intern. Med. 168, 110–120 (2018).
He, J. et al. Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: a randomized clinical trial. JAMA 318, 1016–1025 (2017).
Piper, M. A. et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the US. Preventive services task force. Ann. Intern. Med. 162, 192 (2015).
Yang, W.-Y. et al. Association of office and ambulatory blood pressure with mortality and cardiovascular outcomes. JAMA 322, 409 (2019).
Siu, A. L. Screening for high blood pressure in adults: US. Preventive services task force recommendation statement. Ann. Intern. Med. 163, 778 (2015).
Agarwal, R., Bills, J. E., Hecht, T. J. W. & Light, R. P. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control. Hypertension 57, 29–38 (2011).
Olsen, M. H. et al. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet commission on hypertension. Lancet 388, 2665–2712 (2016).
Bao, W., Threefoot, S. A., Srinivasan, S. R. & Berenson, G. S. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study. Am. J. Hypertens. 8, 657–665 (1995).
Zhang, T. et al. Trajectories of childhood blood pressure and adult left ventricular hypertrophy. Hypertension 72, 93–101 (2018).
Li, S., Chen, W., Srinivasan, S. R. & Berenson, G. S. Childhood blood pressure as a predictor of arterial stiffness in young adults. Hypertension 43, 541–546 (2004).
Gaziano, T. A., Bitton, A., Anand, S. & Weinstein, M. C. International Society of Hypertension. The global cost of nonoptimal blood pressure. J. Hypertens. 27, 1472–1477 (2009).
Kirkland, E. B. et al. Trends in healthcare expenditures among US adults with hypertension: National Estimates, 2003–2014. J. Am. Heart Assoc. 7, e008731 (2018).
Zhang, D., Wang, G., Zhang, P., Fang, J. & Ayala, C. Medical expenditures associated with hypertension in the US, 2000–2013. Am. J. Prev. Med. 53, S164–S171 (2017).
Wang, G., Fang, J. & Ayala, C. Hypertension-associated hospitalizations and costs in the United States, 1979–2006. Blood Press. 23, 126–133 (2014).
Wang, G., Yan, L., Ayala, C., George, M. G. & Fang, J. Hypertension-associated expenditures for medication among US adults. Am. J. Hypertens. 26, 1295–1302 (2013).
Heidenreich, P. A. et al. Forecasting the future of cardiovascular disease in the United States. Circulation 123, 933–944 (2011).
Nakamura, K. et al. Treated and untreated hypertension, hospitalization, and medical expenditure: an epidemiological study in 314622 beneficiaries of the medical insurance system in Japan. J. Hypertens. 31, 1032–1042 (2013).
Arredondo, A. & Zuniga, A. Epidemiologic changes and economic burden of hypertension in Latin America: evidence from Mexico. Am. J. Hypertens. 19, 553–559 (2006).
Arredondo, A. & Aviles, R. Hypertension and its effects on the economy of the health system for patients and society: suggestions for developing countries. Am. J. Hypertens. 27, 635–636 (2014).
Global Burden of Disease Health Financing Collaborator Network et al. Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050. Lancet 393, 2233–2260 (2019).
Woolf, S. H. A closer look at the economic argument for disease prevention. JAMA 301, 536–538 (2009).
Park, C., Wang, G., Durthaler, J. M. & Fang J. Cost-effectiveness analyses of antihypertensive medicines: a systematic review. Am. J. Prev. Med. 53, S131–S142 (2017).
Bress, A. P. et al. Cost-effectiveness of intensive versus standard blood-pressure control. N. Engl. J. Med. 377, 745–755 (2017).
Gu, D. et al. The cost-effectiveness of low-cost essential antihypertensive medicines for hypertension control in China: a modelling study. PLOS Med. 12, e1001860 (2015).
Lakdawalla, D. N. et al. Defining elements of value in health care — a health economics approach: an ISPOR special task force report . Value Health 21, 131–139 (2018).
Marzorati, C. & Pravettoni, G. Value as the key concept in the health care system: how it has influenced medical practice and clinical decision-making processes. J. Multidiscip. Healthc. 10, 101–106 (2017).
GBD 2013 DALYs and HALE Collaborators, C. J. L. et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet 386, 2145–2191 (2015).
Blacher, J., Levy, B. I., Mourad, J.-J., Safar, M. E. & Bakris, G. From epidemiological transition to modern cardiovascular epidemiology: hypertension in the 21st century. Lancet 388, 530–532 (2016).
He, J. et al. Major causes of death among men and women in China. N. Engl. J. Med. 353, 1124–1134 (2005).
Bi, Y. et al. Status of cardiovascular health in Chinese adults. J. Am. Coll. Cardiol. 65, 1013–1025 (2015).
Yang, W. et al. Prevalence of diabetes among men and women in China. N. Engl. J. Med. 362, 1090–1101 (2010).
The authors’ work is supported by the National Institute of General Medical Sciences of the National Institutes of Health (NIH) under Award Number P20GM109036 and by the National Heart, Lung, and Blood Institute of NIH under Award Number R01HL133790. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
The authors declare no competing interests.
Peer review information
Nature Reviews Nephrology thanks G. Mancia, K. Rahimi and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- Pooled analyses
Meta-analyses in which investigators have access to and analyse the original individual level data from the participating studies.
- Regression dilution
In an epidemiological study, regression dilution refers to underestimation of the regression slope between a response and predictor variable when the predictor variable is measured imprecisely.
- Network meta-analysis
A type of meta-analysis in which multiple treatments are compared using both direct comparisons of interventions within randomized controlled trials and indirect comparisons across trials based on a common comparator.
- Crossover design
A type of clinical trial in which each participant is randomly assigned to a sequence of two or more treatments; the participant can, therefore, be used as his or her own control.
- Dietary Approaches to Stop Hypertension diet
(DASH diet). A diet that emphasizes fruits, vegetables and low-fat dairy foods (including whole grains, poultry, fish and nuts) and limits red meat, sweets and sugar-containing beverages.
- Weighted mean
A type of mean in which some data points contribute more to the final average than others.
- Dose–response relationship
A relationship in which a change in amount, intensity or duration of an exposure is associated with either an increase or a decrease in risk of the outcome.
- Convenience samples
A type of non-probability sample in which the study participants are taken from a group of people who are easy to contact or reach.
- Quality-adjusted life year
(QALY). A measure of the burden of disease on a defined population that equals the sum of years of life lost (YLLs) and years lived with disability (YLDs). One DALY equals one lost year of healthy life.
- Incremental cost-effectiveness ratio
(ICER). A measure of the cost-effectiveness of new health-care interventions defined as the ratio of the difference in cost between two possible interventions divided by the difference in their effect.
About this article
Cite this article
Mills, K.T., Stefanescu, A. & He, J. The global epidemiology of hypertension. Nat Rev Nephrol 16, 223–237 (2020). https://doi.org/10.1038/s41581-019-0244-2
Circulation Research (2021)
Influence of Dietary Components and Traditional Chinese Medicine on Hypertension: A Potential Role for Gut Microbiota
Evidence-Based Complementary and Alternative Medicine (2021)
Predicting psychological factors affecting regular physical activity in hypertensive patients: Application of health action process approach model
Nursing Open (2021)
Canadian Liver Journal (2021)
The Prevalence of Inorganic Mercury in Human Kidneys Suggests a Role for Toxic Metals in Essential Hypertension