Background: Current hypertension guidelines vary substantially in their definition of who should be offered blood-pressure-lowering medications. Understanding the impact of guideline choice on the proportion of adults who require treatment will be crucial for planning and scaling up hypertension care in low- and middle-income countries (LMICs). Methods: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults ages 30-70 from nationally representative surveys in 50 LMICs (N = 1,037,215). Our main objective was to determine the impact of hypertension guideline choice on the proportion of adults in need of blood-pressure-lowering medications. We considered four hypertension guidelines: the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline, the commonly used 140/90 mmHg threshold, the 2016 World Health Organization HEARTS guideline (WHO), and the 2019 United Kingdom National Institute for Health and Care Excellence (NICE) guideline. Results: The proportion of adults in need of blood-pressure-lowering medications was highest under the ACC/AHA followed by the 140/90, NICE, and WHO guidelines (ACC/AHA: women, 27.7% [95% CI: 27.2%, 28.2%], men, 35.0% [34.4%, 35.7%]; 140/90: women: 26.1% [25.5%, 26.6%], men, 31.2% [30.6%, 31.9%]; NICE: women, 11.8% [11.4%, 12.1%]; men, 15.7% [15.3%, 16.2%]; WHO: women, 9.2% [8.9%, 9.5%], men, 11.0% [10.6%,11.4%]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood-pressure-lowering medications were largest in the oldest, 65-69, age group (ACC/AHA: women, 60.2% [58.8%, 61.6%], men, 70.1% [68.8%, 71.3%]; WHO: women, 20.1% [18.8%, 21.3%], men, 24.1.0% [22.3%, 25.9%]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood-pressure-lowering medicines while the South and Central Americas had the lowest. Conclusions: There was substantial variation in the proportion of adults in need of blood-pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policymakers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.
Background As screening programs in low‐ and middle‐income countries (LMICs) often do not have the resources to screen the entire population, there is frequently a need to target such efforts to easily identifiable priority groups. This study aimed to determine (1) how hypertension prevalence in LMICs varies by age, sex, body mass index, and smoking status, and (2) the ability of different combinations of these variables to accurately predict hypertension. Methods and Results We analyzed individual‐level, nationally representative data from 1 170 629 participants in 56 LMICs, of whom 220 636 (18.8%) had hypertension. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or reporting to be taking blood pressure–lowering medication. The shape of the positive association of hypertension with age and body mass index varied across world regions. We used logistic regression and random forest models to compute the area under the receiver operating characteristic curve in each country for different combinations of age, body mass index, sex, and smoking status. The area under the receiver operating characteristic curve for the model with all 4 predictors ranged from 0.64 to 0.85 between countries, with a country‐level mean of 0.76 across LMICs globally. The mean absolute increase in the area under the receiver operating characteristic curve from the model including only age to the model including all 4 predictors was 0.05. Conclusions Adding body mass index, sex, and smoking status to age led to only a minor increase in the ability to distinguish between adults with and without hypertension compared with using age alone. Hypertension screening programs in LMICs could use age as the primary variable to target their efforts.
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