ObjectiveComparison of recent national survey data on prevalence, awareness, treatment and control of hypertension in England, the USA and Canada, and correlation of these parameters with each country stroke and ischaemic heart disease (IHD) mortality.DesignNon-institutionalised population surveys.Setting and participantsEngland (2006 n=6873), the USA (2007–2010 n=10 003) and Canada (2007–2009 n=3485) aged 20–79 years.OutcomesStroke and IHD mortality rates were plotted against countries’ specific prevalence data.ResultsMean systolic blood pressure (SBP) was higher in England than in the USA and Canada in all age–gender groups. Mean diastolic blood pressure (DBP) was similar in the three countries before age 50 and then fell more rapidly in the USA, being the lowest in the USA. Only 34% had a BP under 140/90 mm Hg in England, compared with 50% in the USA and 66% in Canada. Prehypertension and stages 1 and 2 hypertension prevalence figures were the highest in England. Hypertension prevalence (≥140 mm Hg SBP and/or ≥90 mm Hg DBP) was lower in Canada (19·5%) than in the USA (29%) and England (30%). Hypertension awareness was higher in the USA (81%) and Canada (83%) than in England (65%). England also had lower levels of hypertension treatment (51%; USA 74%; Canada 80%) and control (<140/90 mm Hg; 27%; the USA 53%; Canada 66%). Canada had the lowest stroke and IHD mortality rates, England the highest and the rates were inversely related to the mean SBP in each country and strongly related to the blood pressure indicators, the strongest relationship being between low hypertension awareness and stroke mortality.ConclusionsWhile the current prevention efforts in England should result in future-improved figures, especially at younger ages, these data still show important gaps in the management of hypertension in these countries, with consequences on stroke and IHD mortality.

Background— In the United States and Canada, folic acid fortification of enriched grain products was fully implemented by 1998. The resulting population-wide reduction in blood homocysteine concentrations might be expected to reduce stroke mortality if high homocysteine levels are an independent risk factor for stroke. Methods and Results— In this population-based cohort study with quasi-experimental intervention, we used segmented log-linear regression to evaluate trends in stroke-related mortality before and after folic acid fortification in the United States and Canada and, as a comparison, during the same period in England and Wales, where fortification is not required. Average blood folate concentrations increased and homocysteine concentrations decreased in the United States after fortification. The ongoing decline in stroke mortality observed in the United States between 1990 and 1997 accelerated in 1998 to 2002 in nearly all population strata, with an overall change from −0.3% (95% CI, −0.7 to 0.08) to −2.9 (95% CI, −3.5 to −2.3) per year ( P =0.0005). Sensitivity analyses indicate that changes in other major recognized risk factors are unlikely to account for the reduced number of stroke-related deaths in the United States. The fall in stroke mortality in Canada averaged −1.0% (95% CI, −1.4 to −0.6) per year from 1990 to 1997 and accelerated to −5.4% (95% CI, −6.0 to −4.7) per year in 1998 to 2002 ( P ≤0.0001). In contrast, the decline in stroke mortality in England and Wales did not change significantly between 1990 and 2002. Conclusions— The improvement in stroke mortality observed after folic acid fortification in the United States and Canada but not in England and Wales is consistent with the hypothesis that folic acid fortification helps to reduce deaths from stroke.