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Hypertension in China

2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 22 Linguagem: Inglês

10.1161/circulationaha.118.034028

1524-4539

Norman R.C. Campbell, Xinhua Zhang,

Cardiovascular Health and Risk Factors

HomeCirculationVol. 137, No. 22Hypertension in China Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBHypertension in ChinaTime to Transition From Knowing the Problem to Implementing the Solution Norman R.C. Campbell, MD and Xin-Hua Zhang, MD, PhD Norman R.C. CampbellNorman R.C. Campbell Departments of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (N.R.C.C.). and Xin-Hua ZhangXin-Hua Zhang Beijing Hypertension League Institute, China (X.-H.Z.). Originally published29 May 2018https://doi.org/10.1161/CIRCULATIONAHA.118.034028Circulation. 2018;137:2357–2359Article, see p 2344The Global Burden of Disease Study estimated that increased blood pressure was the world's leading risk for death, contributing to >10 million deaths in 2016.1 Hypertension is very common, with 40% of those >25 years of age having high blood pressure, representing ≈1.4 billion people worldwide.2 Almost half of those with hypertension are unaware, and although many of those who are aware are treated with antihypertensive drugs, most do not have their blood pressure lowered to recommended targets.3How does China, the most populous nation in the world, fare? Wang et al4 report in this issue of Circulation results from a large population blood pressure survey providing up-to-date data for China. The survey methods included stratified multistage random sampling to provide data representative of the Chinese population >15 years of age and the assessment of blood pressure using a standardized technique with a validated electronic manometer. Specifically, the survey was designed to examine blood pressure in 14 age-sex groups, in rural and urban settings, and in all 31 provinces of China. The survey methodology and the overall response rate of 66.4% are similar to those of other high-quality population blood pressure surveys. The survey data largely reflect global data in many regards, but in such a large population, the numbers are staggering4: Almost 250 million people have hypertension, >125 million are unaware, close to 150 million are not on antihypertensive drug therapy (59.3%), and "only" 37 million (15.3%) are controlled.4 Just over 435 million (40%) adult Chinese had prehypertension. Minority ethnic populations had lower rates of awareness (36.9% versus 48.0%), treatment (29.5% versus 42.0%), and control (8.4% versus 16.1%) compared with urban populations of Han ethnicity.4Recently, the American College of Cardiology/American Heart Association hypertension guidelines were released, with 2 major features being a change in the definition of hypertension from 140/90 to 130/80 mm Hg and a recommendation to treat those at high cardiovascular risk who meet or exceed 130/80 mm Hg.5 Almost 50% of adults in China meet the new definition for hypertension, but a relatively small increment (≈2%) meet the new criteria to be prescribed hypertension pharmacotherapy.6 Nevertheless, the current task of identifying those who have hypertension by the 140/90 mm Hg criterion is enormous and likely to exceed primary care capacity for many years to come. Adoption of the 130/80 mm Hg criterion is likely to occur over time with a focus on identification of those at high cardiovascular risk.6The needless human morbidity and suffering from chronic disease led by hypertension-related diseases have been viewed as a major threat to global economic development.7 As a result, the World Health Assembly agreed to 9 targets to reduce chronic noncommunicable disease, including a target to reduce uncontrolled blood pressure by 25% by the year 2025.7 Clinical and public health organizations are starting to mobilize, developing and implementing strategies and tools to help prevent and control hypertension (and other noncommunicable diseases). The World Health Organization with partners is developing HEARTS (healthy-lifestyle counselling, evidence-based treatment protocols, access to essential medicines and technology, risk based charts, team-based care, systems for monitoring, implementation), a population-based program focused on clinical interventions to control hypertension, limit tobacco use, and reduce dietary salt.8 Throughout 2018, HEARTS plans to release various tools and resources to aid clinical programs control hypertension. RESOLVE (with funding from the Bloomberg, Zuckerberg, and Gates Foundations) aims to save 100 million lives over 10 years mainly by interventions to enhance hypertension control and to reduce dietary salt and dietary trans fats.9 At a regional level, several other programs, including one from the Pan American Health Organization (PAHO), have been active in the effort to control hypertension.10 The World Hypertension League (a coalition of national hypertension organizations) has also been advocating strategic approaches to hypertension control and developing resources.3The hypertension interventions proposed by HEARTS, RESOLVE, PAHO, and the World Hypertension League advocate changes to current programmatic and clinical approaches to hypertension control. An increase in the capacity of primary health care is recommended to be accomplished, in part, by reallocating some or all of the management of hypertension to nonphysician healthcare professionals and people who are not healthcare professionals (task sharing or shifting). Other recommended changes include the use of highly simplified protocols for the diagnosis and treatment of hypertension and implementation of hypertension registries with performance reporting.9 Standardized education programs that focus on the key tasks required to screen, diagnose, treat, and control hypertension are important.11 At a health-systems level, work is ongoing to facilitate the availability of high-quality, low-cost, long-acting antihypertensive medications, as well as regulations to allow task sharing.10The HEARTS, RESOLVE, PAHO, and World Hypertension League proposals are built on prior successes in controlling hypertension and several chronic infectious diseases (eg, HIV, tuberculosis). Kaiser Permanente, a large integrated healthcare provider in the United States, was able to increase hypertension control to 90% in a program based on task sharing, standardized care algorithms, and registries with performance reporting.12 Other integrated healthcare organizations in the United States have also achieved high levels of hypertension control using systematic approaches. In Canada, an intensely implemented national education program based on highly simplified evidence-based recommendations was associated with an increase in hypertension control from 13% to >65%.11 The HEARTS, RESOLVE, PAHO, and World Hypertension League proposals, while built on past successes, promote adaptation to the local contexts. Led by PAHO, adapted hypertension control programs are currently being implemented in Barbados, Cuba, Colombia, and Chile, with plans to expand. Much more implementation research from evolving programs is needed on how to effectively adapt global best clinical practices for hypertension. However, at this time, healthcare professional and scientific organizations can play very important roles supporting and helping to adopt the global best practices for hypertension control using current knowledge. Specifically, the low rates of awareness, treatment, and control of hypertension in China highlight the urgency to improve the capacity of primary healthcare services and to reduce regional and ethnic disparity.Surprisingly, there is little research on the causes of hypertension at a population level. Hunter-gatherer populations mostly have a very low prevalence of hypertension, and people in these populations have little to no increase in blood pressure with age. In 2010, the Institute of Medicine summarized the limited data available, indicating that most hypertension is caused by diets high in salt (sodium) and low in potassium, by obesity, and by physical inactivity.13 Older reports indicate that the ratio of dietary saturated fats to unsaturated fats can have a large impact on blood pressure.14 Excess alcohol consumption can increase blood pressure in populations and may be important in populations in which high consumption is common.13 There is high variability in national rates of hypertension, a fact that is currently poorly understood, and hence a careful examination of causes of hypertension at a population level should be a global research priority.2Although the Chinese national hypertension survey did not assess dietary sodium consumption, which is typically high in China, salt reduction should be a priority for prevention and control of hypertension, together with efforts to improve diet, enhance physical activity, reduce obesity, and reduce excess alcohol consumption, as recommended by the World Health Organization.4 To enhance the political will for action, public policies to reduce the incidence of hypertension should be strongly supported and advocated for by clinicians because they can also have a major impact on the control of hypertension. In a model of dietary salt consumption in Canada, it was estimated that the current high levels of consumption accounted for approximately one third of hypertension and that reducing to recommended levels would double the hypertension control rate.15Although additional research is needed, it is critical that clinicians and those in public health work collaboratively and prioritize and implement interventions to prevent and control hypertension. To accelerate hypertension control, it is of great importance to share insights learned by successful and less successful programs. This is of greater importance in low- and middle-income countries, which have the highest burden of hypertension-related disease, fewer resources to prevent and control hypertension, and the least context-specific research with which to guide programs.2 It is critical that hypertension surveys be used to stimulate much-needed changes in the prevention and control of hypertension.DisclosuresDr Campbell was a consultant to the Novartis Foundation (2016-2017) to support their program to improve hypertension control in low- to middle-income countries, which includes travel support for site visits and a contract to develop a survey. Dr Campbell has provided paid consultative advice on accurate blood pressure assessment to Midway Corp and is an unpaid member of World Action on Salt and Health. Dr Zhang reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.http://circ.ahajournals.orgNorman R.C. Campbell, MD, GE-86, Libin Cardiovascular Institute of Alberta, University of Calgary, 3280 Hospital Dr NW, Calgary AB, Canada T2N 4Z6. E-mail [email protected]References1. Institute for Health Metrics and Evaluation. Global burden of disease arrow diagram.http://www.healthdata.org/gbd/data-visualizations. Accessed February 21, 2018.Google Scholar2. Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, Chen J, He J. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries.Circulation. 2016; 134:441–450. doi: 10.1161/CIRCULATIONAHA.115.018912.LinkGoogle Scholar3. Campbell NR, Khalsa T, Lackland DT, Niebylski ML, Nilsson PM, Redburn KA, Orias M, Zhang XH, Burrell L, Horiuchi M, Poulter NR, Prabhakaran D, Ramirez AJ, Schiffrin EL, Touyz RM, Wang JG, Weber MA; World Hypertension League Executive; International Society of Hypertension Executive; World Stroke Organization; International Diabetes Federation; International Council of Cardiovascular Prevention and Rehabilitation; International Society of Nephrology. High blood pressure 2016: why prevention and control are urgent and important: the World Hypertension League, International Society of Hypertension, World Stroke Organization, International Diabetes Foundation, International Council of Cardiovascular Prevention and Rehabilitation, International Society of Nephrology.J Clin Hypertens (Greenwich). 2016; 18:714–717. doi: 10.1111/jch.12840.MedlineGoogle Scholar4. Wang Z, Chen Z, Zhang L, Wang X, Hao G, Zhang Z, Shao L, Tian Y, Dong Y, Zheng C, Wang J, Zhu M, Weintraub WS, Gao R; on behalf of the China Hypertension Survey Investigators. Status of hypertension in China: results from the China Hypertension Survey, 2012–2015.Circulation. 2018; 137:2344–2356. doi: 10.1161/CIRCULATIONAHA.117.032380.LinkGoogle Scholar5. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD, Wright JT. 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 [published online ahead of print November 13, 2017].Hypertension. doi: 10.1161/HYP.0000000000000067. http://hyper.ahajournals.org.Google Scholar6. Wang JG, Liu L. 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Saving 100 million lives by improving global treatment of hypertension and reducing cardiovascular disease risk factors.J Clin Hypertens (Greenwich). 2018; 20:208–211. doi: 10.1111/jch.13195.CrossrefMedlineGoogle Scholar10. Patel P, Ordunez P, DiPette D, Escobar MC, Hassell T, Wyss F, Hennis A, Asma S, Angell S; Standardized Hypertension Treatment and Prevention Network. Improved blood pressure control to reduce cardiovascular disease morbidity and mortality: the Standardized Hypertension Treatment and Prevention Project.J Clin Hypertens (Greenwich). 2016; 18:1284–1294. doi: 10.1111/jch.12861.CrossrefMedlineGoogle Scholar11. Campbell NR, Sheldon T. The Canadian effort to prevent and control hypertension: can other countries adopt Canadian strategies?Curr Opin Cardiol. 2010; 25:366–372. doi: 10.1097/HCO.0b013e32833a3632.CrossrefMedlineGoogle Scholar12. Jaffe MG, Young JD. The Kaiser Permanente Northern California story: improving hypertension control from 44% to 90% in 13 years (2000 to 2013).J Clin Hypertens (Greenwich). 2016; 18:260–261. doi: 10.1111/jch.12803.CrossrefMedlineGoogle Scholar13. Institute of Medicine of the National Academies. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension: Brief Report. Washington, DC: National Academy Press; 2010. Report 1-4.Google Scholar14. Huttunen JK, Pietinen P, Nissinen A, Puska P. Dietary factors and hypertension.Acta Med Scand Suppl. 1985; 701:72–82.MedlineGoogle Scholar15. Joffres MR, Campbell NR, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada.Can J Cardiol. 2007; 23:437–443.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Yin R, Yin L, Li L, Silva-Nash J, Tan J, Pan Z, Zeng J and Yan L (2021) Hypertension in China: burdens, guidelines and policy responses: a state-of-the-art review, Journal of Human Hypertension, 10.1038/s41371-021-00570-z, 36:2, (126-134), Online publication date: 1-Feb-2022. Chan A, Chan S, Khanam M and Kinsman L (2022) Factors affecting reductions in dietary salt consumption in people of Chinese descent: An integrative review, Journal of Advanced Nursing, 10.1111/jan.15237, 78:7, (1919-1937), Online publication date: 1-Jul-2022. 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