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Original Investigation |

The Burden of Hypertension and Associated Risk for Cardiovascular Mortality in China

Sarah Lewington, DPhil1; Ben Lacey, FFPH1; Robert Clarke, FRCP1; Yu Guo, MSc2; Xiang Ling Kong, MSc1; Ling Yang, PhD1; Yiping Chen, DPhil1; Zheng Bian, MD2; Junshi Chen, MD3; Jinhuai Meng, BSc4; Youping Xiong, BSc5; Tianyou He, BSc6; Zengchang Pang, BSc7; Shuo Zhang, BSc8; Rory Collins, FRS1; Richard Peto, FRS1; Liming Li, PhD2,9; Zhengming Chen, DPhil1 ; for the China Kadoorie Biobank Consortium
[+] Author Affiliations
1Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England
2Department of Epidemiology, School of Public Health, Peking University Health Science Centre, Beijing, China
3China National Centre for Food Safety Risk Assessment, Chaoyang District, Beijing, China
4Liuzhou Centre for Disease Control, Liuzhou, China
5Liuyang Centre for Disease Control, Baiyikengdao, Liuyang, China
6Huixian Centre for Disease Control, Huixian, China
7Qingdao Centre for Disease Control, Qingdao, China
8Suzhou Centre for Disease Control, Jiangsu, China
9Head Office, Chinese Academy of Medical Science, Beijing, China
JAMA Intern Med. 2016;176(4):524-532. doi:10.1001/jamainternmed.2016.0190.
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Importance  Hypertension is a leading cause of premature death in China, but limited evidence is available on the prevalence and management of hypertension and its effect on mortality from cardiovascular disease (CVD).

Objectives  To examine the prevalence, diagnosis, treatment, and control of hypertension and to assess the CVD mortality attributable to hypertension in China.

Design, Setting and Participants  This prospective cohort study (China Kadoorie Biobank Study) recruited 500 223 adults, aged 35 to 74 years, from the general population in China. Blood pressure (BP) measurements were recorded as part of the baseline survey from June 25, 2004, to August 5, 2009, and 7028 deaths due to CVD were recorded before January 1, 2014 (mean duration of follow-up: 7.2 years). Data were analyzed from June 9, 2014, to July 17, 2015.

Exposures  Prevalence and diagnosis of hypertension (systolic BP ≥140 mm Hg, diastolic BP ≥90 mm Hg, or receiving treatment for hypertension) and treatment and control rates overall and in various population subgroups.

Main Outcomes and Measures  Cox regression analysis yielded age- and sex-specific rate ratios for deaths due to CVD comparing participants with and without uncontrolled hypertension, which were used to estimate the number of CVD deaths attributable to hypertension.

Results  The cohort included 205 167 men (41.0%) and 295 056 women (59.0%) with a mean (SD) age of 52 (10) years for both sexes. Overall, 32.5% of participants had hypertension; the prevalence increased with age (from 12.6% at 35-39 years of age to 58.4% at 70-74 years of age) and varied substantially by region (range, 22.7%-40.7%). Of those with hypertension, 30.5% had received a diagnosis from a physician; of those with a diagnosis of hypertension, 46.4% were being treated; and of those treated, 29.6% had their hypertension controlled (ie, systolic BP <140 mm Hg; diastolic BP <90 mm Hg), resulting in an overall control rate of 4.2%. Even among patients with hypertension and prior CVD, only 13.0% had their hypertension controlled. Uncontrolled hypertension was associated with relative risks for CVD mortality of 4.1 (95% CI, 3.7-4.6), 2.6 (95% CI, 2.4-2.9) and 1.9 (95% CI, 1.8-2.0) at ages 35 to 59, 60 to 69, and 70 to 79 years, respectively, and accounted for about one-third of deaths due to CVD (approximately 750 000) at 35 to 79 years of age in 2010.

Conclusions and Relevance  About one-third of Chinese adults in this national cohort population had hypertension. The levels of diagnosis, treatment, and control were much lower than in Western populations, and were associated with significant excess mortality.

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Figure 1.
Mean Systolic (SBP) and Diastolic (DBP) Blood Pressure

Mean values are standardized for region.

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Figure 2.
Prevalence of Hypertension by Age and Sex

Hypertension is defined as a measured systolic blood pressure (BP) of at least 140 mm Hg, a measured diastolic BP of at least 90 mm Hg, or treatment for hypertension. Hypertension is categorized as undiagnosed, diagnosed but not treated, treated but not controlled, or controlled. Prevalences are standardized for region and additionally for age within the group 35 to 74 years (All).

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Figure 3.
Age- and Sex-Specific Association of Hypertension With Mortality Due to Cardiovascular Disease (CVD)

A, Death rate ratios (RR) are calculated for participants with vs without uncontrolled hypertension. Rate ratios are adjusted for region and age (in 5-year bands) within each age group and exclude participants with a history of CVD disease at baseline. For each RR, the area of the data point is inversely proportional to the variance of the log risk. The overall RR (adjusted for age, sex, and region) at ages 35 to 79 years (mean age at death, 67.6 years) was 2.49 (95% CI, 2.37-2.62). B, CVD mortality due to uncontrolled hypertension in 2010 is calculated by applying population-attributable fractions (PAF) to the estimated age- and sex-specific number of CVD deaths in China for 2010 to give the number of deaths attributable to uncontrolled hypertension for that year. Hypertension is defined as a measured systolic blood pressure of at least 140 mm Hg, a measured diastolic blood pressure of at least 90 mm Hg, or treatment for hypertension. Deaths due to CVD are categorized as attributable to hypertension in persons with hypertension, not attributable to hypertension in persons with hypertension, and in persons without hypertension.

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