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The aggregated outcome was assumed to include death and morbidity. Cohort studies and a meta-analysis of clinical trials of blood pressure—lowering drugs found improved outcomes due to blood pressure lowering were similar across the range of to mm Hg SBP levels at pretreatment. Citation information for the data sources used for RRs are provided by the Global Health Data Exchange in a searchable web tool. The GBD comparative risk assessment framework is based on the observation that risk caused by a given exposure begins at a certain level and then ascends as exposure increases above that level.
This counterfactual level is referred to as the theoretical minimum-risk exposure level which, when compared with an observed level of SBP, allows for estimation of the PAF. The theoretical minimum-risk exposure level of SBP was estimated to range from to mm Hg based on pooled prospective cohort studies that show risk of mortality increases for SBP above that level.
Some studies, such as the Framingham cohort, have found an increase in SBP with increasing age and it has been suggested that the theoretical minimum-risk exposure level should also follow this age pattern.
Based on the current evidence, 43 we determined that a difference in theoretical minimum-risk exposure level by age group was not sufficiently supported and decided to retain a single level across age groups. Further investigations in the form of cohorts or pooled cohort studies are needed to determine if varying the theoretical minimum-risk exposure level for SBP with age group is justified. To include the uncertainty in the theoretical minimum-risk exposure level, random draws from the uniform distribution of the interval between and mm Hg were taken; unertainty in the theoretical minimum-risk exposure level was propagated by sampling between the and mm Hg interval each time the population-attributable burden was calculated.
The equation in this section describes the formula used for computing a PAF for a continuous risk factor; the PAF for SBP in an age-sex-country-year for a cause o is defined as follows:. RR oas x is the relative risk as a function of exposure level x for SBP, cause o , age group a and sex s. The lowest level of exposure l and the highest level of exposure possible u mm Hg are also described in this equation. Total all-causes burden related to SBP of at least to mm Hg was calculated by the following:.
Hypertensive heart disease and hypertensive chronic kidney disease were treated as conditions that would not have occurred without elevated systolic blood pressure, and all disease burden for these causes was attributed to this risk factor. A Monte Carlo simulation approach was used to propagate uncertainty from all sources in the final burden estimations.
These intervals incorporated sampling uncertainty in the examination surveys, parameter estimation in the spatiotemporal Gaussian process regression model for blood pressure mean, the RRs for each outcome from the analysis of pooled cohort studies, the theoretical minimum-risk exposure level, and the deaths and DALYs estimated for each age, sex, country, year, and cause.
The draws of the posterior distribution of mean SBP and outcomes by country, age, and sex were calculated independently so the variance of estimation for the aggregate groups eg, all-age, both sexes, or global burden were more likely to be underestimated because of possible covariance between different risk levels and outcome, countries, or sexes. Despite efforts to incorporate all sources of uncertainty, uncertainties from some intermediate predictive steps were not propagated due to existing data and methodological constraints.
Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015
Therefore, the UIs presented may be optimistic estimates. Analyses and computations were completed using Stata version The associated estimated annual deaths for SBP of at least to mm Hg and of mm Hg or higher increased from The projected number of individuals with SBP of at least to mm Hg increased from 1. The downward change in the age-standardized rate of deaths was 0. Age-standardized DALYs per capita decreased from 4.
Figure 1 shows 2 views of global trends for individuals with SBP of mm Hg or higher. Although the rate initially decreased between and , the initial trend was followed by an increase to Panel B shows that after controlling for changes in population aging, the age-standardized rate increased after eFigure 2 and eFigure 3 in the Supplement. At all levels of SBP, ischemic heart disease was the most important contributor to SBP-related deaths followed by hemorrhagic stroke and then ischemic stroke. SBP of at least to mm Hg was associated with all hypertensive heart disease deaths, Overall, SBP of mm Hg or higher was associated with The total burden is greater in men than women except after age 75, when more burden is observed in women because of longer life expectancy.
Regions were ordered by life expectancy. Age-standardized DALY rates varied substantially—from The relative contributions of different outcomes to the global age-standardized DALY rate associated with SBP of at least to mm Hg varied by region. In sub-Saharan Africa, cerebrovascular diseases predominated, while in Oceania, Central Asia, and Eastern Europe, ischemic heart disease predominated.
Table 4 and Table 5 provide deaths and DALYs associated with SBP to mm Hg and of mm Hg or higher for all ages and both sexes combined, by region, and for the 25 most populous countries in the world from to The last column in Table 4 and Table 5 lists the number of individuals measured for each country for all included data sources.
Estimates for all countries can be found in eTables 2, 3, and 4 in the Supplement. In China, the total burden of SBP has increased since , and SBP levels increased after but were offset by decreases in mortality until , at which point the overall age-standardized burden started increasing.
Quiz Ref ID In this study, we used an expanded set of blood pressure prevalence surveys to assess, for the first time to our knowledge, the full distribution of the population by level of SBP and the burden of mortality and DALYs associated with each level of SBP for countries and territories.
Compared with all other specific risks quantified in the GBD, SBP of at least to mm Hg was the leading global contributor to preventable death in This analysis, the first to be performed at a comprehensive global scale, found considerable variation among the countries and territories and 21 regions studied. Both the projected number and prevalence rate of SBP of at least to mm Hg are likely to continue to increase globally. These findings support increased efforts to control the burden of SBP of at least to mm Hg to reduce disease burden.
A broad range of other conditions contributed to health loss associated with SBP of at least to mm Hg, with chronic kidney disease notable for contributing almost as many DALYs globally in as hypertensive heart disease. There have been claims that the burden of SBP of at least to mm Hg is an increasing problem globally.
Quiz Ref ID Although the drivers of trends in hypertension were not quantified in this study, other research has documented that dietary salt intake, fruit and vegetable consumption, overweight and obesity, and physical activity have also changed substantially over the same time period. With population growth and aging and the fact that SBP levels increase with age, the number of persons with hypertension and related adverse health outcomes are expected to increase in the world.
The difference in trends between exposure to SBP of at least to mm Hg and the rates of related outcomes is likely related to background trends downward in global age-specific cardiovascular death rates. Previous studies have attributed those declines in CVD death rates to changes in risk factors such as tobacco as well as improved access to treatment. The results of the current study are informed by, but do not help to resolve, the significant debate about appropriate clinical use and targets for blood pressure—lowering medications.
Meta-analyses performed by Law et al and Ettehad et al showed cardiovascular mortality benefits for a target SBP as low as mm Hg. Quiz Ref ID These results support the model assumption that elevated SBP is a modifiable risk factor for mortality even though the precise subpopulation and SBP target for blood pressure—lowering medications remains less clear. The purpose of this study was to estimate the full extent of health burden lost related to elevated SBP and not to determine the optimum SBP level for the current population.
This estimation is an essential step in understanding the contribution of SBP as a risk factor for global health loss. Quantification of the modifiable health loss due to SBP, given scale-up of the technologies currently available for SBP lowering, would require an alternate estimation strategy than used for this study. However in , 7. It is likely that more evidence will be needed to define the role of pharmacotherapy in reducing the burden associated with SBP of at least mm Hg and less than an SBP of mm Hg.
This study has important limitations. First, the burden of high diastolic blood pressure, including cases of isolated high diastolic blood pressure, was not included. Second, burden was only associated with SBP for individuals aged 25 years and older, except for hypertensive heart disease, which included all ages. Third, estimates of population mean SBP were based on studies in countries. For 41 countries with no examination survey data, estimates of blood pressure levels were based on spatiotemporal Gaussian process regression statistical models; there is a need for population-based health surveys in these countries as well as broader implementation of surveys that track access to treatment.
Fourth, measured standard deviations of blood pressure were converted to narrower ranges of usual blood pressure using a single correction factor based on cohort studies in 5 countries. This intertemporal variation may well vary across countries. Moreover, uncertainty in this correction was not captured in this study. The meta-analyses by Lv et al and by Law et al of all blood pressure—lowering trials support this assumption; showing that there was no statistically different RR as a function of starting level of SBP.
While acknowledging these limitations, this study was based on the largest available set of data and applied the same methods to previous years to provide a consistent analysis of time trends from to This article was corrected on January 19, , for incorrect values in the Abstract and for missing units of measure in Table 1. Drs Murray and Forouzanfar had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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Acquisition, analysis, or interpretation of data: Drafting of the manuscript: Critical revision of the manuscript for important intellectual content: Administrative, technical, or material support: Scientific oversight as former chair of the Cardiovascular Disease Expert Panel: Study rationale checking and future directions for research, practice, and policy: Conflict of Interest Disclosures: Dr Ng reports receipt of grants from the Bill and Melinda Gates Foundation during the conduct of the study and receipt of personal fees from IBM Watson Health outside the submitted work.
Dr Hankey reports receipt of honoraria from AC Immune for chairing the data safety monitoring committee, Bayer for lecturing, and Medscape Web MD for participating in a discussion outside the submitted work. Dr Lotufo reports receipt of honoraria for lectures from Abbvie Brazil outside the submitted work. Dr Schutte reports receipt of personal fees from Boehringer-Ingelheim for developing educational material and Omron Healthcare and Aspen Pharmaceuticals for presentations outside the submitted work.
Dr Thrift reports receipt of grants from the National Health and Medical Research Council during the conduct of the study. Dr Vos reports receipt of a grant from the Bill and Melinda Gates Foundation during the conduct of the study. The remaining authors report no disclosures. This research was supported by funding from the Bill and Melinda Gates Foundation.
The Bill and Melinda Gates Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Overview and Methods eTable 1. Relative Risks Used by Age eTable 2.
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