Hypertension prevalence as a function of different guidelines, India

Bull World Health Organ 2019;97:799–809 | doi: http://dx.doi.org/10.2471/BLT.19.234500 Research 799 Introduction With developments in technology and the expansion of treat- ment options and modalities, the field of clinical care guide- lines is constantly evolving. Although clinical care guidelines are only recommendations, the decision to follow a specific set of guidelines by a health-care provider should be based on the local context of need, availability and affordability, especially in low- and middle-income countries.1 The availability of dif- ferent guidelines, with inconsistencies in recommendations of when medical treatment should be initiated, can cause friction between health-care provider and patient.2,3 Blood pressure measurement is one of the most common non-invasive clinical practice tools used to assess the cardio- vascular status of an individual and predict the likelihood of future cardiovascular events. An individual’s blood pressure can change quickly and regularly, and is influenced by respi- ration, temperature, bladder distension, pain levels, emotion, diet, time since last exercise and whether alcohol has recently been consumed.4 A simple method of obtaining an accurate blood pressure measurement is to take repeated readings over multiple visits. Compared with diagnoses of hypertension based on a single measurement of blood pressure, studies have demonstrated as much as 12% reduction in the prevalence of hypertension if repeated readings over multiple visits are considered.5,6 By considering multiple readings, up to 35% of patients were reclassified within a lower category of blood pressure.5,6 However, even after obtaining a more accurate blood pressure measurement, clinical care guidelines differ with respect to the precise blood pressure at which a patient is diagnosed as hypertensive and begins treatment.7–12 This lack of uniformity between the various available guidelines diminishes the value of measuring blood pressure. Over the past 25 years, the availability of health-care services have increased in India, and the country has ad- opted a universal health coverage programme.13 Although the availability of health-care services has risen, the quality of treatment received from different health-care providers is not consistent.1,14–16 The causes of this inconsistency in quality across India include variations in clinical practice, poor diagnostic facilities, a lack of expertise, unnecessary use of medicines (e.g. antibiotics, analgesics and steroids) and substandard treatment.1 India is currently experiencing an increase in the prevalence of noncommunicable diseases, such as hypertension and diabetes, and the accompanying premature mortality.17–21 Inconsistent guidelines introduce uncertainty in the accuracy of hypertension diagnoses and increase the likelihood of poor health outcomes.22 Poor health- care literacy, high self-medication rate, poor blood pressure control and inconsistent hypertension management guidelines intensify the problem in India.23 Here we have analysed the impact of inconsistent practices on the calculated prevalence of hypertension. We have focused on the particular blood pressure measurements at which hy- pertension is diagnosed and whether a single reading or the recommended number of readings was taken, for six different hypertension guidelines. Objective To determine the effect of different hypertension management guidelines and of basing diagnosis on a single reading of blood pressure on the hypertension prevalence in the Indian population. Methods We performed a secondary analysis of data acquired as part of the Fourth national family health survey, 2015 to 2016, over all districts in India. We calculated the proportion of the population within three different age groups (18 to 34, 35 to 49 and 18 to 49 years of age) with raised blood pressure according to six different guidelines, and how prevalence changed if diagnoses were based on a single blood pressure measurement. Findings We observed that the Government of India and the American College of Cardiology/American Heart Association guidelines consistently yielded the lowest and highest prevalence of raised blood pressure; in the combined age group, we calculated the proportion of the population categorized as having raised blood pressure as 7.5% (95% confidence interval (CI): 7.4 to 7.7) and 40.1% (95% CI: 39.7 to 40.7), respectively. When basing diagnosis on a single reading of blood pressure only, a total of 56 million individuals would be erroneously categorized as hypertensive following the Government of India guidelines. We also showed that prevalence of hypertension in India varies with guidelines adhered to; in the combined age group, the national hypertension prevalence was three times higher when following the American College of Cardiology/American Heart Association compared with the Government of India guidelines. Conclusion To optimize current clinical practice, health-care providers need to follow universally agreed, evidence-based methods of diagnosing hypertension. a World Food Programme, New Delhi, India. b Indian Institute of Foreign Trade, New Delhi, India. c Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Plot No. 47, Sector 44, Institutional Area, Gurugram, 122002, India. Correspondence to Ashish Awasthi (email: ashish.awasthi@phfi.org). (Submitted: 3 April 2019 – Revised version received: 23 August 2019 – Accepted: 23 August 2019 – Published online: 17 September 2019 ) Hypertension prevalence as a function of different guidelines, India Manisha Dubey,a Sanjay Rastogib & Ashish Awasthic Researc 800 Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in India Manisha Dubey et al. Methods Data source We used data from the most recent large-scale health survey, the Fourth National Family Health Survey,24 con- ducted over 2015 to 2016 in India. The Fourth National Family Health Survey was conducted over all 640 districts of India (according to Census of India 2011 listing),25 and included men aged 15 to 54 years and women aged 15 to 49 years. For consistency in our study, we in- cluded participants aged 18 to 49 years. Households within each district were selected to participate in the survey by two-stage cluster random sampling, stratified by rural versus urban areas. Primary sampling units, selected using probability proportional to population size, were defined as villages in rural areas and census enumeration blocks in urban areas. After sitting calmly for 5 minutes, the blood pressure of partici- pants was measured three times, with at least 5 minutes between each measure- ment, in the left upper arm using the Omron HEM-8712 monitor. All blood pressure measurements were recorded in millimetres of mercury (mm Hg). Hypertension guidelines The six different guidelines that we used in this study for the calculation of hypertension prevalence are published by the European Society of Cardiology,7 the Government of India,8 the American College of Cardiology/American Heart Association,9 the National Institute for Health and Clinical Excellence/British and Irish Hypertension Society,10 the Eighth Joint National Committee11 and the International Society of Hyperten- sion.12 The latter two guidelines are identical in terms of diagnosis of raised blood pressure. All six guidelines are used in India for the diagnosis and treatment of hypertension; although the exact proportion of health-care providers across India that adhere to any particular guideline is not known, the proportion of health-care provid- ers adhering to specific guidelines was investigated within a single private hospital26 and among attendees of a cardiology conference.27 The number of readings taken, the number of visits required by the patient and the blood pressure at which hyper- tension is diagnosed (and pharmaco- logical antihypertensive treatment initi- ated) for each of these six guidelines are listed in Table 1. Although all the listed guidelines recommend the measure- ment of blood pressure from at least two or three readings, it is general practice in India to take only a single blood pressure reading.28 A patient is defined as having raised blood pressure if their blood pres- sure is categorized as Stage 1 or Grade 1 hypertension or higher according to the different guidelines in Table 1. A patient is defined as hypertensive if they have raised blood pressure, have confirmed at the time of the survey that they were taking prescribed medicine to control blood pressure, or if they had previously received at least two diagnoses of raised blood pressure or hypertension. Statistical analysis From the sample, we excluded par- ticipants having at least one missing blood pressure measurement or having unfeasible (i.e. systolic blood pres- sure < 30 mm Hg or < diastolic blood pressure) readings. We calculated the proportion of individuals within vari- ous blood pressure categories for age groups 18 to 34, 35 to 49 and 18 to 49 years of age for all six guidelines. We applied sampling weights and ad- justed confidence intervals (CIs) at the primary sampling unit level to obtain nationally representative estimates with precise CIs. To calculate prevalence, we defined participants having hypertension if they had stage I/grade I or higher blood pres- sure, taking prescribed medicine to con- trol blood pressure or being informed at least twice by the health professional that they had raised blood pressure or hypertension. We estimated the total population within each age group from Census of India 2011 age distribution data,25 multiplied by World Bank Indian population estimates for the year 2017.29 We calculated the number of in- dividuals across India within each cat- egory for each guideline by multiplying the proportion within each blood pres- sure category according to the Fourth National Family Health Survey by the calculated population within each age group. To confirm that the exclusion of participants did not cause significant difference in terms of age, sex and place of residence in the final data set, we per- formed a sensitivity analysis by compar- ing prevalence estimates from the clean data set with those from the full data set. We performed all analyses using Stata software, version 15.0 (StataCorp, Col- lege Station, United States of America). Ethics The Fourth National Family Health Sur- vey obtained ethical clearance from the Ethics Committee of the International Institute for Population Sciences.24 No specific permission was required for our study, as we conducted a secondary analysis of publicly available data. Results We obtained data on 797 161 individu- als from the survey. We excluded 45 691 patients with missing data and 1594 participants with unusual blood pres- sure measurements.24 Of the 749 876 eligible participants, 651 605 (86.9%) were women and 98 271 (13.1%) were men, and 529 899 (70.7%) of individuals resided in rural areas. Our study sample comprises 439 414 (58.6%) individuals 18 to 34 years of age and 310 462 (41.4%) individuals 35 to 49 years of age. The sensitivity analysis showed that the exclusion of participants with missing or unfeasible readings did not cause a difference in the final data set. We observe that the Government of India and the American College of Car- diology/American Heart Association guidelines consistently yield the lowest and highest prevalence of measured raised blood pressure, respectively (Table 2). For the combined age group, in order of increasing prevalence the weighted proportion of the popula- tion classified as having raised blood pressure is: 7.5% (95% CI: 7.4 to 7.7; Government of India guidelines); 10.1% (95% CI: 10.0 to 10.2; European Society of Cardiology/European Society of Hypertension guidelines); 13.1% (95% CI: 13.1 to 13.3; Eighth Joint National Committee and International Society of Hypertension guidelines); 19.4% (95% CI: 19.3 to 19.6; National Insti- tute for Health and Clinical Excellence/ British and Irish Hypertension Society guidelines); and 40.1% (95% CI: 39.7 to 40.7; American College of Cardiology/ American Heart Association guidelines; Table 2). Among the group18 to 34 years of age, the Government of India and 801Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in IndiaManisha Dubey et al. the American College of Cardiology/ American Heart Association guidelines yielded proportions of the population with raised blood pressure of 3.4% (95% CI: 3.3 to 3.5) and 30.3% (95% CI: 30.2 to 30.5), respectively. Among the older age group, the lowest and highest proportions were calculated as 13.8% (95% CI: 13.7 to 14.0; Government of India guidelines) and 55.3% (95% CI: 55.2 to 55.5; American College of Car- diology/American Heart Association guidelines), respectively. Following the guidelines set by the Government of In- dia, we estimate 48 million Indians have raised blood pressure; if the American College of Cardiology/American Heart Association guidelines are followed, this number is 253 million (Table 3). We also observe an increase in the weighted proportion of the population classified as having raised blood pres- sure when only a single blood pressure reading (i.e. the first reading taken) is Table 1. Guidelines for definition of raised blood pressure used in comparison study, India No. of readings by guideline Reading considered Hypertension diagnosis Blood pressure categorya Blood pressure (mm Hg) Systolic Diastolic European Society of Cardiology/European Society of Hypertension7 At least three (if different by ≥ 10 mm Hg, at least four) Average of last two readings Other than Grade 3, two visits required Optimalb < 120 < 80 Normal 120 to 129 80 to 84 High normal 130 to 139 85 to 89 Grade 1 hypertension 140 to 159 90 to 99 Grade 2 hypertension 160 to 179 100 to 109 Grade 3 hypertension ≥ 180 ≥ 110 Isolated systolic hypertension ≥ 140 < 90 Government of India8 At least two (if different by ≥ 5 mm Hg, at least three) Lowest Other than Grade 3, two visits required Optimalb < 120 < 80 Normal 120 to 129 80 to 84 High normal 130 to 139 85 to 89 Grade 1 hypertension 140 to 159 90 to 99 Grade 2 hypertension 160 to 179 100 to 109 Grade 3 hypertension ≥ 180 ≥ 110 Isolated systolic hypertensionb ≥ 140 < 90 Hypertensive urgency > 180 > 110 Hypertensive emergency > 180 > 110 to 120 American College of Cardiology/American Heart Association9 At least two Average Two visits or more Normalb < 120 < 80 Elevatedb 120 to 129 < 80 Stage 1 hypertensionc 130 to 139 80 to 89 Stage 2 hypertension ≥ 140 ≥ 90 National Institute for Health and Clinical Excellence/British and Irish Hypertension Society10 At least two (if readings different, at least three) Average of last two readings Two visits or more Normalb < 135 < 85 Stage 1 hypertension ≥ 135 ≥ 85 Stage 2 hypertension ≥ 150 ≥ 95 Severe hypertension ≥ 180 ≥ 110 Eighth Joint National Committee11 At least two Average Two visits or more Normalb < 120 < 80 Prehypertension 120 to 139 80 to 89 Stage 1 hypertension 140 to 159 90 to 99 Stage 2 hypertension ≥ 160 ≥ 100 International Society of Hypertension12 At least two Average Two visits or more Normalb < 120 < 80 Prehypertension 120 to 139 80 to 89 Stage 1 hypertension 140 to 159 90 to 99 Stage 2 hypertension ≥ 160 ≥ 100 Hg: mercury. a Bold formatting indicates the blood pressure category at which medical treatment is initiated. b Categories for which both systolic and diastolic blood pressure measurements of less than threshold are required; patients are assigned to other categories if either of their systolic or diastolic blood pressure measurement is within the given limit. c Medical treatment initiated only if the patient has a Framingham risk score (risk of developing cardiovascular disease over the next 10 years) of ≥ 10%. 802 Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in India Manisha Dubey et al. Ta bl e 2. Pr op or tio n of p op ul at io n w ith a b lo od p re ss ur e le ve l a cc or di ng to ca te go ry , g ui de lin e an d re ad in g, In di a, 2 01 5– 20 16 Bl oo d pr es su re ca te go ry b y g ui de lin e W ei gh te d % (9 5% CI )a If gu id el in es fo llo w ed If on ly fi rs t r ea di ng co ns id er ed 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar s 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar s Eu ro pe an S oc ie ty o f C ar di ol og y/ Eu ro pe an S oc ie ty o f H yp er te ns io n7 O pt im al 66 .0 (6 5. 7 to 6 6. 2) 41 .5 (4 1. 1 to 4 1. 8) 56 .4 (5 6. 1 to 5 6. 6) 53 .3 (5 3. 0 to 5 3. 6) 31 .4 (3 1. 1 to 3 1. 7) 44 .7 (4 4. 5 to 4 5. 0) N or m al 20 .4 (2 0. 1 to 2 0. 6) 24 .7 (2 4. 5 to 2 5. 0) 22 .1 (2 1. 9 to 2 2. 3) 23 .1 (2 2. 9 to 2 3. 3) 22 .8 (2 2. 5 to 2 3. 1) 23 .0 (2 2. 8 to 2 3. 2) H ig h no rm al 8. 4 (8 .3 to 8 .6 ) 16 .1 (1 5. 9 to 1 6. 4) 11 .5 (1 1. 3 to 1 1. 6) 13 .4 (1 3. 2 to 1 3. 6) 19 .5 (1 9. 3 to 1 9. 8) 15 .8 (1 5. 7 to 1 6. 0) Gr ad e 1 hy pe rt en sio n 3. 9 (3 .8 to 4 .0 ) 11 .3 (1 1. 1 to 1 1. 5) 6. 8 (6 .7 to 6 .9 ) 7. 3 (7 .1 to 7 .4 ) 16 .2 (1 6. 0 to 1 6. 4) 10 .7 (1 0. 6 to 1 0. 9) Gr ad e 2 hy pe rt en sio n 0. 6 (0 .6 to 0 .7 ) 3. 1 (3 .0 to 3 .2 ) 1. 6 (1 .6 to 1 .7 ) 1. 2 (1 .2 to 1 .3 ) 4. 8 (4 .6 to 4 .9 ) 2. 6 (2 .6 to 2 .7 ) Gr ad e 3 hy pe rt en sio n 0. 1 (0 .1 to 0 .2 ) 1. 2 (1 .1 to 1 .2 ) 0. 5 (0 .5 to 0 .6 ) 0. 4 (0 .4 to 0 .5 ) 2. 0 (1 .9 to 2 .1 ) 1. 0 (1 .0 to 1 .1 ) Iso la te d sy st ol ic h yp er te ns io n 0. 6 (0 .5 to 0 .6 ) 2. 0 (2 .0 to 2 .1 ) 1. 1 (1 .1 to 1 .2 ) 1. 3 (1 .2 to 1 .3 ) 3. 3 (3 .2 to 3 .4 ) 2. 1 (2 .0 to 2 .1 ) G ov er nm en t o f I nd ia 8 O pt im al 73 .7 (7 3. 4 to 7 3. 9) 49 .2 (4 8. 8 to 4 9. 5) 64 .1 (6 3. 8 to 6 4. 3) 53 .3 (5 3. 0 to 5 3. 6) 31 .4 (3 1. 1 to 3 1. 7) 44 .7 (4 4. 5 to 4 5. 0) N or m al 17 .1 (1 6. 9 to 1 7. 3) 23 .9 (2 3. 6 to 2 4. 1) 19 .7 (1 9. 5 to 1 9. 9) 23 .1 (2 2. 9 to 2 3. 3) 22 .8 (2 2. 5 to 2 3. 1) 23 .0 (2 2. 8 to 2 3. 2) H ig h no rm al 5. 8 (5 .7 to 5 .9 ) 13 .1 (1 2. 9 to 1 3. 3) 8. 7 (8 .5 to 8 .8 ) 13 .4 (1 3. 2 to 1 3. 6) 19 .5 (1 9. 3 to 1 9. 8) 15 .8 (1 5. 7 to 1 6. 0) Gr ad e 1 hy pe rt en sio n 2. 6 (2 .6 to 2 .7 ) 8. 8 (8 .7 to 9 .0 ) 5. 1 (5 .0 to 5 .2 ) 7. 3 (7 .1 to 7 .4 ) 16 .2 (1 6. 0 to 1 6. 4) 10 .7 (1 0. 6 to 1 0. 9) Gr ad e 2 hy pe rt en sio n 0. 4 (0 .4 to 0 .4 ) 2. 4 (2 .3 to 2 .5 ) 1. 2 (1 .1 to 1 .2 ) 1. 2 (1 .2 to 1 .3 ) 4. 8 (4 .6 to 4 .9 ) 2. 6 (2 .6 to 2 .7 ) Gr ad e 3 hy pe rt en sio n 0. 1 (0 .1 to 0 .1 ) 0. 8 (0 .8 to 0 .9 ) 0. 4 (0 .4 to 0 .4 ) 0. 4 (0 .4 to 0 .5 ) 2. 0 (1 .9 to 2 .1 ) 1. 0 (1 .0 to 1 .1 ) Iso la te d sy st ol ic h yp er te ns io n 0. 3 (0 .3 to 0 .3 ) 1. 8 (1 .7 to 1 .9 ) 0. 9 (0 .9 to 0 .9 ) 1. 3 (1 .2 to 1 .3 ) 3. 3 (3 .2 to 3 .4 ) 2. 1 (2 .0 to 2 .1 ) A m er ic an C ol le ge o f C ar di ol og y/ A m er ic an H ea rt A ss oc ia ti on 9 N or m al 63 .3 (6 3. 0 to 6 3. 6) 38 .7 (3 8. 3 to 3 9. 0) 53 .6 (5 3. 4 to 5 3. 9) 53 .3 (5 3. 0 to 5 3. 6) 31 .4 (3 1. 1 to 3 1. 7) 44 .7 (4 4. 5 to 4 5. 0) El ev at ed 6. 4 (6 .3 to 6 .5 ) 6. 1 (5 .9 to 6 .2 ) 6. 3 (6 .2 to 6 .4 ) 7. 2 (7 .0 to 7 .3 ) 5. 9 (5 .8 to 6 .1 ) 6. 7 (6 .6 to 6 .8 ) St ag e 1 hy pe rt en sio n 24 .5 (2 4. 3 to 2 4. 8) 36 .2 (3 5. 9 to 3 6. 5) 29 .1 (2 8. 9 to 2 9. 3) 29 .4 (2 9. 1 to 2 9. 6) 36 .4 (3 6. 1 to 3 6. 7) 32 .1 (3 1. 9 to 3 2. 3) St ag e 2 hy pe rt en sio n 5. 8 (5 .7 to 5 .9 ) 19 .1 (1 8. 8 to 1 9. 3) 11 .0 (1 0. 9 to 1 1. 1) 10 .2 (1 0. 0 to 1 0. 3) 26 .3 (2 6. 0 to 2 6. 5) 16 .5 (1 6. 3 to 1 6. 6) St ag e 1 w ith F ra m in gh am ri sk sc or e of ≥ 1 0% b 8. 4 (8 .3 to 8 .6 ) 54 .1 (5 3. 7 to 5 4. 4) 30 .4 (3 0. 1 to 3 0. 6) 10 .9 (1 0. 7 to 1 1. 1) 61 .2 (6 0. 8 to 6 1. 5) 36 .3 (3 6. 0 to 3 6. 6) N at io na l I ns ti tu te fo r H ea lt h an d Cl in ic al E xc el le nc e/ Br it is h an d Ir is h H yp er te ns io n So ci et y1 0 N or m al 87 .9 (8 7. 7 to 8 8. 1) 69 .2 (6 8. 9 to 6 9. 5) 80 .6 (8 0. 4 to 8 0. 8) 78 .6 (7 8. 3 to 7 8. 8) 57 .2 (5 6. 9 to 5 7. 5) 70 .2 (7 0. 0 to 7 0. 4) St ag e 1 hy pe rt en sio n 10 .1 (9 .9 to 1 0. 3) 22 .0 (2 1. 7 to 2 2. 2) 14 .7 (1 4. 6 to 1 4. 9) 17 .1 (1 6. 9 to 1 7. 3) 28 .7 (2 8. 5 to 2 9. 0) 21 .6 (2 1. 5 to 2 1. 8) St ag e 2 hy pe rt en sio n 1. 9 (1 .8 to 1 .9 ) 7. 7 (7 .5 to 7 .8 ) 4. 1 (4 .1 to 4 .2 ) 3. 9 (3 .8 to 4 .0 ) 12 .0 (1 1. 8 to 1 2. 2) 7. 1 (7 .0 to 7 .2 ) Se ve re h yp er te ns io n 0. 2 (0 .1 to 0 .2 ) 1. 2 (1 .1 to 1 .3 ) 0. 6 (0 .5 to 0 .6 ) 0. 5 (0 .4 to 0 .5 ) 2. 0 (2 .0 to 2 .1 ) 1. 1 (1 .0 to 1 .1 ) (c on tin ue s. . . ) 803Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in IndiaManisha Dubey et al. considered, compared with measuring blood pressure from several readings as recommended by the guidelines (Ta- ble 2). If the proportion is based on first reading only, the guidelines published by the European Society of Cardiology/Eu- ropean Society for Hypertension and by the Government of India yield the same results. The increase in the proportion is higher in the younger compared with the older age group for all guidelines. Specifically, when we consider only the first reading for blood pressure categori- zation, the proportion of the population in the combined age group with raised blood pressure according to the Govern- ment of India guidelines increases by 8.9 percentage-points to 16.5% (95% CI: 16.5 to 16.7). According to the American College of Cardiology/American Heart Association guidelines, the proportion increases by 8.5 percentage-points to 48.6% (95% CI: 48.5 to 48.8) when only the first blood pressure reading is considered. By neglecting to follow any guide- lines precisely and by basing diagnosis on a single reading of blood pressure only, a total of 56 million would be er- roneously categorized as hypertensive instead of normotensive following the American College of Cardiology/ American Heart Association guidelines (Table 3). The largest increase in patients misdiagnosed with raised blood pres- sure from a single reading (65 million; Table 3) is observed for the National Institute for Health and Clinical Excel- lence/British and Irish Hypertension Society guidelines. Table 4 shows the national hyper- tension prevalence according to vari- ous guidelines. For the combined age group, following the American College of Cardiology/American Heart Asso- ciation guidelines yields a hypertension prevalence (44.7%, 95% CI: 44.4 to 45.0) three times higher than that calculated according to the Government of India guidelines (15.8%, 95% CI: 15.5 to 16.0). Discussion This study compares the difference in hypertension prevalence when using six hypertension management guidelines in India. Our findings, that prevalence of hypertension varies according to guidelines followed and according to the number of blood pressure readings taken, are in concordance with other studies.6,30,31 Bl oo d pr es su re ca te go ry b y g ui de lin e W ei gh te d % (9 5% CI )a If gu id el in es fo llo w ed If on ly fi rs t r ea di ng co ns id er ed 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar s 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar s Ei gh th Jo in t N at io na l C om m it te e1 1 N or m al 59 .5 (5 9. 2 to 5 9. 8) 35 .8 (3 5. 5 to 3 6. 2) 50 .3 (5 0. 0 to 5 0. 5) 53 .5 (5 3. 2 to 5 3. 8) 31 .5 (3 1. 2 to 3 1. 8) 44 .9 (4 4. 7 to 4 5. 2) Pr eh yp er te ns io n 33 .1 (3 2. 9 to 3 3. 4) 42 .1 (4 1. 8 to 4 2. 5) 36 .7 (3 6. 4 to 3 6. 9) 36 .3 (3 6. 0 to 3 6. 5) 42 .1 (4 1. 8 to 4 2. 4) 38 .6 (3 8. 3 to 3 8. 8) St ag e 1 hy pe rt en sio n 6. 2 (6 .1 to 6 .3 ) 16 .4 (1 6. 2 to 1 6. 6) 10 .2 (1 0. 1 to 1 0. 3) 8. 4 (8 .3 to 8 .5 ) 19 .3 (1 9. 0 to 1 9. 5) 12 .6 (1 2. 5 to 1 2. 8) St ag e 2 hy pe rt en sio n 1. 1 (1 .1 to 1 .2 ) 5. 6 (5 .5 to 5 .8 ) 2. 9 (2 .8 to 2 .9 ) 1. 8 (1 .7 to 1 .9 ) 7. 1 (6 .9 to 7 .3 ) 3. 9 (3 .8 to 4 .0 ) In te rn at io na l S oc ie ty o f H yp er te ns io n1 2 N or m al 59 .5 (5 9. 2 to 5 9. 8) 35 .8 (3 5. 5 to 3 6. 2) 50 .3 (5 0. 0 to 5 0. 5) 53 .5 (5 3. 2 to 5 3. 8) 31 .5 (3 1. 2 to 3 1. 8) 44 .9 (4 4. 7 to 4 5. 2) Pr eh yp er te ns io n 33 .1 (3 2. 9 to 3 3. 4) 42 .1 (4 1. 8 to 4 2. 5) 36 .7 (3 6. 4 to 3 6. 9) 36 .3 (3 6. 0 to 3 6. 5) 42 .1 (4 1. 8 to 4 2. 4) 38 .6 (3 8. 3 to 3 8. 8) St ag e 1 hy pe rt en sio n 6. 2 (6 .1 to 6 .3 ) 16 .4 (1 6. 2 to 1 6. 6) 10 .2 (1 0. 1 to 1 0. 3) 8. 4 (8 .3 to 8 .5 ) 19 .3 (1 9. 0 to 1 9. 5) 12 .6 (1 2. 5 to 1 2. 8) St ag e 2 hy pe rt en sio n 1. 1 (1 .1 to 1 .2 ) 5. 6 (5 .5 to 5 .8 ) 2. 9 (2 .8 to 2 .9 ) 1. 8 (1 .7 to 1 .9 ) 7. 1 (6 .9 to 7 .3 ) 3. 9 (3 .8 to 4 .0 ) CI : c on fid en ce in te rv al ; H g m er cu ry . a So m e co lu m ns d o no t a dd u p to 1 00 % b ec au se o f r ou nd in g of in di vi du al p er ce nt ag es to a si ng le d ec im al p oi nt . b Fr am in gh am ri sk sc or e (ri sk o f d ev el op in g ca rd io v as cu la r d ise as e w ith in 1 0 ye ar s) o f ≥ 10 % a s w el l a s s ys to lic b lo od p re ss ur e ≥ 13 0 m m H g or d ia st ol ic b lo od p re ss ur e ≥ 80 m m H g. (. . . co nt in ue d) 804 Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in India Manisha Dubey et al. Ta bl e 3. Nu m be r o f p eo pl e ca te go riz ed b y b lo od p re ss ur e le ve l, gu id el in es a nd re ad in gs , I nd ia , 2 01 5– 20 16 Bl oo d pr es su re ca te go ry by g ui de lin e Po pu la tio n in m ill io ns (9 5% CI ) Di ffe re nc e in m ill io ns If gu id el in es fo llo w ed If on ly fi rs t r ea di ng co ns id er ed 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa Eu ro pe an S oc ie ty o f C ar di ol og y/ Eu ro pe an S oc ie ty o f H yp er te ns io n7 O pt im al 25 6 (2 54 to 2 57 ) 10 1 (1 00 to 1 02 ) 35 6 (3 54 to 3 57 ) 20 7 (2 05 to 2 08 ) 76 (7 6 to 7 7) 28 2 (2 80 to 2 84 ) − 49 − 25 − 73 N or m al 79 (7 8 to 8 0) 60 (6 0 to 6 1) 13 9 (1 38 to 1 40 ) 89 (8 9 to 9 0) 55 (5 5 to 5 6) 14 5 (1 44 to 1 46 ) 11 − 5 6 H ig h no rm al 33 (3 2 to 3 3) 39 (3 9 to 4 0) 72 (7 1 to 7 3) 52 (5 1 to 5 3) 48 (4 7 to 4 8) 10 0 (9 9 to 1 01 ) 19 8 27 Gr ad e 1 hy pe rt en sio n 15 (1 5 to 1 6) 27 (2 7 to 2 8) 43 (4 2 to 4 4) 28 (2 8 to 2 9) 39 (3 9 to 4 0) 68 (6 7 to 6 9) 13 12 25 Gr ad e 2 hy pe rt en sio n 2 (2 to 3 ) 8 (7 to 8 ) 10 (1 0 to 1 0) 5 (5 to 5 ) 12 (1 1 to 1 2) 16 (1 6 to 1 7) 2 4 6 Gr ad e 3 hy pe rt en sio n 1 (1 to 1 ) 3 (3 to 3 ) 3 (3 to 4 ) 2 (1 to 2 ) 5 (5 to 5 ) 6 (6 to 7 ) 1 2 3 Iso la te d sy st ol ic hy pe rt en sio n 2 (2 to 2 ) 5 (5 to 5 ) 7 (7 to 7 ) 5 (5 to 5 ) 8 (8 to 8 ) 13 (1 3 to 1 3) 3 3 6 G ov er nm en t o f I nd ia 8 O pt im al 28 5 (2 84 to 2 86 ) 12 0 (1 19 to 1 20 ) 40 4 (4 02 to 4 06 ) 20 7 (2 05 to 2 08 ) 76 (7 6 to 7 7) 28 2 (2 80 to 2 84 ) − 79 − 43 − 12 2 N or m al 66 (6 5 to 6 7) 58 (5 7 to 5 9) 12 4 (1 23 to 1 26 ) 89 (8 9 to 9 0) 55 (5 5 to 5 6) 14 5 (1 44 to 1 46 ) 23 − 3 21 H ig h no rm al 23 (2 2 to 2 3) 32 (3 1 to 3 2) 55 (5 4 to 5 5) 52 (5 1 to 5 3) 48 (4 7 to 4 8) 10 0 (9 9 to 1 01 ) 29 16 45 Gr ad e 1 hy pe rt en sio n 10 (1 0 to 1 1) 21 (2 1 to 2 2) 32 (3 1 to 3 3) 28 (2 8 to 2 9) 39 (3 9 to 4 0) 68 (6 7 to 6 9) 18 18 36 Gr ad e 2 hy pe rt en sio n 2 (1 to 2 ) 6 (6 to 6 ) 7 (7 to 8 ) 5 (5 to 5 ) 12 (1 1 to 1 2) 16 (1 6 to 1 7) 3 6 9 Gr ad e 3 hy pe rt en sio n 0 (0 to 0 ) 2 (2 to 2 ) 2 (2 to 3 ) 2 (1 to 2 ) 5 (5 to 5 ) 6 (6 to 7 ) 1 3 4 Iso la te d sy st ol ic hy pe rt en sio n 1 (1 to 1 ) 4 (4 to 5 ) 6 (5 to 6 ) 5 (5 to 5 ) 8 (8 to 8 ) 13 (1 3 to 1 3) 4 4 7 A m er ic an C ol le ge o f C ar di ol og y/ A m er ic an H ea rt A ss oc ia ti on 9 N or m al 24 5 (2 44 to 2 46 ) 94 (9 3 to 9 5) 33 8 (3 37 to 3 40 ) 20 7 (2 05 to 2 08 ) 76 (7 6 to 7 7) 28 2 (2 80 to 2 84 ) − 38 − 18 − 56 El ev at ed 25 (2 4 to 2 5) 15 (1 4 to 1 5) 40 (3 9 to 4 0) 28 (2 7 to 2 8) 14 (1 4 to 1 5) 42 (4 1 to 4 3) 3 0 3 St ag e 1 hy pe rt en sio n 95 (9 4 to 9 6) 88 (8 7 to 8 9) 18 3 (1 82 to 1 85 ) 11 4 (1 13 to 1 15 ) 89 (8 8 to 8 9) 20 2 (2 01 to 2 04 ) 19 1 19 St ag e 2 hy pe rt en sio n 22 (2 2 to 2 3) 46 (4 6 to 4 7) 69 (6 8 to 7 0) 39 (3 9 to 4 0) 64 (6 3 to 6 5) 10 4 (1 03 to 1 05 ) 17 17 34 St ag e 1 w ith Fr am in gh am ri sk sc or e of ≥ 1 0% b 33 (3 2 to 3 3) 13 2 (1 31 to 1 32 ) 19 1 (1 90 to 1 93 ) 42 (4 1 to 4 3) 14 9 (1 48 to 15 0) 22 9 (2 27 to 2 31 ) 9 17 37 N at io na l I ns ti tu te fo r H ea lt h an d Cl in ic al E xc el le nc e/ Br it is h an d Ir is h H yp er te ns io n So ci et y1 0 N or m al 34 0 (3 40 to 3 41 ) 16 8 (1 68 to 1 69 ) 50 8 (5 07 to 5 09 ) 30 4 (3 03 to 3 05 ) 13 9 (1 38 to 14 0) 44 3 (4 41 to 4 44 ) − 36 − 29 − 65 St ag e 1 hy pe rt en sio n 39 (3 8 to 4 0) 53 (5 3 to 5 4) 93 (9 2 to 9 4) 66 (6 5 to 6 7) 70 (6 9 to 7 1) 13 6 (1 35 to 1 38 ) 27 17 44 St ag e 2 hy pe rt en sio n 7 (7 to 8 ) 19 (1 8 to 1 9) 26 (2 6 to 2 7) 15 (1 5 to 1 5) 29 (2 9 to 3 0) 44 (4 4 to 4 5) 8 11 18 Se ve re h yp er te ns io n 1 (1 to 1 ) 3 (3 to 3 ) 4 (3 to 4 ) 2 (2 to 2 ) 5 (5 to 5 ) 7 (7 to 7 ) 1 2 3 (c on tin ue s. . . ) 805Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in IndiaManisha Dubey et al. Another recent study30 compared hypertension prevalence in India ac- cording to the Seventh Joint National Committee and the American College of Cardiology/American Heart Asso- ciation guidelines. Their observation is in concordance with ours, that is, that hypertension prevalence more than doubles when calculated according to the American College of Cardiology/ American Heart Association guidelines compared with Eight Joint National Committee guidelines.30 The other study investigated hypertension prevalence in the age group 30 to 74 years and ob- tained a prevalence of 52.3% (95% CI; 51.9 to 52.8) according to the American College of Cardiology/American Heart Association guidelines,30 similar to our observation of 44.7%. Our findings also show that 30.4% (95% CI: 30.1 to 30.6) of individuals 18 to 49 years of age with Stage 1 hypertension (accord- ing to American College of Cardiology/ American Heart Association guidelines) have a 10-year risk of developing car- diovascular disease equal to or more than 10%; this figure was calculated as 40.3% for the age group 30 to 74 years in the recent study.30 Our study is more versatile, however, with a comparison of six guidelines for hypertension preva- lence using both single and repetitive measurements. Our study had several limitations. We may have overestimated hyperten- sion prevalence by our definition of hypertension being based on blood pres- sure measurements taken during one occasion; a clinical diagnosis of hyper- tension requires raised blood pressure on at least two different occasions.32 The lower age of participants in this sample is also largely responsible for the lower hypertension prevalence observed here compared with the nationally represen- tative study among an older sample.18 Another limitation of our study is the lack of nationally representative data regarding use of hypertension guidelines by health-care providers in India. Fi- nally, the questions asked in the Fourth National Family Health Survey did not allow us to investigate any connection between the prevalence of hypertension and lifestyle. Our results show that the current use of several different guidelines in India results in inconsistent prevalence data, which could result in poor health outcomes. We therefore urge global bod- ies to discuss and propose a universal Bl oo d pr es su re ca te go ry by g ui de lin e Po pu la tio n in m ill io ns (9 5% CI ) Di ffe re nc e in m ill io ns If gu id el in es fo llo w ed If on ly fi rs t r ea di ng co ns id er ed 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa Ei gh th Jo in t N at io na l C om m it te e1 1 N or m al 23 1 (2 29 to 2 32 ) 87 (8 6 to 8 8) 31 7 (3 15 to 3 19 ) 20 7 (2 06 to 2 09 ) 77 (7 6 to 7 7) 28 3 (2 82 to 2 85 ) − 23 − 11 − 34 Pr eh yp er te ns io n 12 8 (1 27 to 1 29 ) 10 2 (1 02 to 1 03 ) 23 1 (2 30 to 2 33 ) 14 1 (1 39 to 1 42 ) 10 2 (1 02 to 10 3) 24 3 (2 42 to 2 45 ) 12 0 12 St ag e 1 hy pe rt en sio n 24 (2 4 to 2 5) 40 (3 9 to 4 0) 64 (6 4 to 6 5) 33 (3 2 to 3 3) 47 (4 6 to 4 7) 80 (7 9 to 8 1) 8 7 15 St ag e 2 hy pe rt en sio n 4 (4 to 5 ) 14 (1 3 to 1 4) 18 (1 8 to 1 9) 7 (7 to 7 ) 17 (1 7 to 1 8) 24 (2 4 to 2 5) 3 4 6 In te rn at io na l S oc ie ty o f H yp er te ns io n1 2 N or m al 23 1 (2 29 to 2 32 ) 87 (8 6 to 8 8) 31 7 (3 15 to 3 19 ) 20 7 (2 06 to 2 09 ) 77 (7 6 to 7 7) 28 3 (2 82 to 2 85 ) − 23 − 11 − 34 Pr eh yp er te ns io n 12 8 (1 27 to 1 29 ) 10 2 (1 02 to 1 03 ) 23 1 (2 30 to 2 33 ) 14 1 (1 39 to 1 42 ) 10 2 (1 02 to 10 3) 24 3 (2 42 to 2 45 ) 12 0 12 St ag e 1 hy pe rt en sio n 24 (2 4 to 2 5) 40 (3 9 to 4 0) 64 (6 4 to 6 5) 33 (3 2 to 3 3) 47 (4 6 to 4 7) 80 (7 9 to 8 1) 8 7 15 St ag e 2 hy pe rt en sio n 4 (4 to 5 ) 14 (1 3 to 1 4) 18 (1 8 to 1 9) 7 (7 to 7 ) 17 (1 7 to 1 8) 24 (2 4 to 2 5) 3 4 6 CI : c on fid en ce in te rv al ; H g m er cu ry . a Th e po pu la tio n in so m e co m bi ne d ag e gr ou ps d o no t a lw ay s e qu al th e su m o f t he p op ul at io n in th e tw o su bg ro up s b ec au se o f r ou nd in g to a si ng le d ec im al p oi nt . b Fr am in gh am ri sk sc or e (ri sk o f d ev el op in g ca rd io v as cu la r d ise as e w ith in 1 0 ye ar s) o f ≥ 10 % a s w el l a s s ys to lic b lo od p re ss ur e ≥ 13 0 m m H g or d ia st ol ic b lo od p re ss ur e ≥ 80 m m H g. (. . . co nt in ue d) 806 Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in India Manisha Dubey et al. guideline, similar to the cut-off for body mass index, malnutrition and anaemia. In our opinion, the European Society of Hypertension guidelines are most suited for India; these guidelines have the same definitions of blood pressure categories as the Government of India guidelines, but diagnosis is made from the last two readings (out of three) instead of the lowest reading (out of two or three). This recommendation is supported by two different studies.30,33 To optimize current clinical prac- tice in India, health-care providers need to follow universally agreed, evidence- based methods of diagnosing hyper- tension. The importance of multiple measurements and its impact on health management must be emphasized to health-care professionals. Once such guidelines have been agreed upon, their display at prominent locations within hospitals could help to improve the health literacy of the general popula- tion. ■ Acknowledgements MD and SR contributed equally to this work. Funding: Ashish Awasthi is supported by the Department of Science and Technol- ogy, Government of India, New Delhi through INSPIRE Faculty program. No financial assistance was received in sup- port of this study. Competing interests: None declared. Ta bl e 4. Na tio na l h yp er te ns io n pr ev al en ce b y a ge g ro up a nd g ui de lin es , I nd ia , 2 01 5– 20 16 Gu id el in e W ei gh te d % (9 5% CI ) Po pu la tio n in m ill io ns (9 5% CI ) If gu id el in es fo llo w ed If on ly fi rs t r ea di ng co ns id er ed If gu id el in es fo llo w ed If on ly fi rs t r ea di ng co ns id er ed 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar s 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar s 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa 18 to 3 4 ye ar s 35 to 4 9 ye ar s 18 to 4 9 ye ar sa Eu ro pe an S oc ie ty o f Ca rd io lo gy / E ur op ea n So ci et y of H yp er te ns io n7 12 .2 (1 1. 9 to 1 2. 5) 26 .8 (2 6. 5 to 2 7. 2) 17 .9 (1 7. 7 to 1 8. 2) 16 .7 (1 6. 4 to 16 .9 ) 34 .2 (3 3. 8 to 3 4. 5) 23 .5 (2 3. 2 to 23 .8 ) 47 (4 6 to 48 ) 65 (6 4 to 66 ) 11 3 (1 11 to 11 5) 65 (6 3 to 66 ) 83 (8 2 to 84 ) 14 8 (1 46 to 15 0) G ov er nm en t o f I nd ia 8 10 .6 (1 0. 3 to 1 0. 9) 23 .8 (2 3. 5 to 2 4. 2) 15 .8 (1 5. 5 to 1 6. 0) 16 .7 (1 6. 4 to 16 .9 ) 34 .2 (3 3. 8 to 3 4. 5) 23 .5 (2 3. 2 to 23 .8 ) 41 (4 0 to 42 ) 58 (5 7 to 59 ) 99 (9 8 to 10 1) 65 (6 3 to 66 ) 83 (8 2 to 84 ) 14 8 (1 46 to 15 0) Am er ic an C ol le ge o f Ca rd io lo gy / A m er ic an H ea rt As so ci at io n9 35 .2 (3 4. 9 to 3 5. 5) 59 .6 (5 9. 2 to 5 9. 9) 44 .7 (4 4. 4 to 4 5. 0) 43 .7 (4 3. 4 to 44 .0 ) 66 .2 (6 5. 9 to 6 6. 5) 52 .5 (5 2. 2 to 52 .8 ) 13 6 (1 35 to 1 38 ) 14 5 (1 44 to 1 46 ) 28 2 (2 80 to 28 4) 16 9 (1 68 to 1 71 ) 16 1 (1 60 to 1 62 ) 33 1 (3 29 to 33 3) N at io na l I ns tit ut e fo r H ea lth an d Cl in ic al E xc el le nc e/ Br iti sh a nd Ir ish H yp er te ns io n So ci et y1 0 18 .4 (1 8. 1 to 1 8. 7) 38 .0 (3 7. 6 to 3 8. 3) 26 .0 (2 5. 8 to 2 6. 3) 27 .0 (2 6. 7 to 27 .3 ) 48 .5 (4 8. 2 to 4 8. 9) 35 .4 (3 5. 2 to 35 .7 ) 71 (7 0 to 72 ) 92 (9 1 to 93 ) 16 4 (1 62 to 16 6) 10 5 (1 04 to 1 06 ) 11 8 (1 17 to 1 19 ) 22 3 (2 22 to 22 5) Ei gh th Jo in t N at io na l Co m m itt ee 11 14 .1 (1 3. 8 to 1 4. 4) 30 .1 (3 0. 0 to 3 0. 9) 20 .5 (2 0. 2 to 2 0. 8) 16 .7 (1 6. 5 to 17 .0 ) 34 .3 (3 3. 9 to 3 4. 7) 23 .6 (2 3. 3 to 23 .9 ) 55 (5 3 to 56 ) 73 (7 3 to 75 ) 12 9 (1 28 to 13 1) 65 (6 4 to 66 ) 83 (8 2 to 84 ) 14 9 (1 47 to 15 1) In te rn at io na l S oc ie ty o f H yp er te ns io n1 2 14 .1 (1 3. 8 to 1 4. 4) 30 .1 (3 0. 0 to 3 0. 9) 20 .5 (2 0. 2 to 2 0. 8) 16 .7 (1 6. 5 to 17 .0 ) 34 .3 (3 3. 9 to 3 4. 7) 23 .6 (2 3. 3 to 23 .9 ) 55 (5 3 to 56 ) 73 (7 3 to 75 ) 12 9 (1 28 to 13 1) 65 (6 4 to 66 ) 83 (8 2 to 84 ) 14 9 (1 47 to 15 1) CI : c on fid en ce in te rv al . a Th e po pu la tio n in so m e co m bi ne d ag e gr ou ps d o no t a lw ay s e qu al th e su m o f t he p op ul at io n in th e tw o su bg ro up s b ec au se o f r ou nd in g to a si ng le d ec im al p oi nt . 807Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in IndiaManisha Dubey et al. 摘要 不同指南下的印度高血压患病率 目的 旨在确定不同高血压管理指南和基于单一血压读 数的诊断对印度人群高血压患病率的影响。 方法 我们对印度所有地区 2015-2016 年第四次全国家 庭健康调查的数据进行了次级分析。根据六个不同 指南，我们计算了在三个不同年龄组（18 至 34 岁、 35 至 49 岁和 18 至 49 岁）中血压升高人群的比例， 以及如果诊断是基于单一血压测量的话，患病率是如 何变化的。 结果 我们发现，印度政府和美国心脏病学院 / 美国 心脏协会指南得出的血压升高的最低患病率和最高 患病率数据一致 ；在综合年龄组中，我们计算出血 压升高人群的比例分别为 7.5% （95% 置信区间 ：7.4- 7.7）和 40.1% （95% 置信区间 ：39.7-40.7）。根据印度政 府指南，当仅根据单次血压读数进行诊断时，共计会 有 5600 万人会被错误归为高血压人群。我们还发现， 印度的高血压患病率因遵循不同指南而变化 ；在综合 年龄组中，当遵循美国心脏病学院 / 美国心脏协会指 南时，全国范围内的高血压患病率要比遵循印度政府 的准则时的患病率高出三倍。 结论 为了优化目前的临床实践，医护人员应遵循世界 公认、基于证据的方法进行高血压的诊断。 Résumé Prévalence de l'hypertension en fonction de différentes directives, Inde Objectif Déterminer l'effet de différentes directives de gestion de l'hypertension et de l'établissement d'un diagnostic à partir d'une seule mesure de la tension artérielle sur la prévalence de l'hypertension dans la population indienne. Méthodes Nous avons effectué une analyse secondaire des données collectées lors de la quatrième enquête nationale sur la santé des familles, de 2015 à 2016, dans tous les districts d'Inde. Nous avons calculé la part de la population, dans trois tranches d'âge différentes (18-34 ans, 35-49 ans et 18-49 ans), qui présentait une tension artérielle élevée selon six directives différentes, et la manière dont la prévalence changeait si le diagnostic se fondait sur une seule mesure de la tension artérielle. Résultats Nous avons observé que les directives du gouvernement indien et celles de l'American College of Cardiology/American Heart Association donnaient systématiquement la prévalence la plus faible et la prévalence la plus élevée d'hypertension artérielle; dans la tranche d'âge combinée, nous avons calculé que la part de la population classée comme souffrant d'hypertension s'élevait respectivement à 7,5% (intervalle de confiance (IC) de 95%: 7,4 à 7,7) et à 40,1% (IC de 95%: 39,7 à 40,7). En fondant le diagnostic uniquement sur une mesure de la tension artérielle, un total de 56 millions de personnes seraient classées à tort comme hypertendues selon les directives du gouvernement indien. Nous avons également montré que la prévalence de l'hypertension en Inde varie en fonction des directives auxquelles on se réfère; dans la tranche d'âge combinée, la prévalence nationale de l'hypertension était trois fois plus élevée si l'on suivait les directives de l'American College of Cardiology/American Heart Association que celles du gouvernement indien. Conclusion Pour optimiser la pratique clinique, les prestataires de soins doivent suivre des méthodes de diagnostic de l'hypertension éprouvées et universellement admises. صخلم دنلها ،ةفلتخلما ةيهيجوتلا ئدابملل ةجيتنك مدلا طغض عافترا راشتنا طغض عافترا ةرادلإ ةفلتخلما ةيهيجوتلا ئدابلما يرثأت ديدتح ضرغلا ،مدلا طغضل ةدحاو ةءارق لىع دمتعلما صيخشتلا كلذكو ،مدلا .دنلها في ناكسلا ينب عفترلما مدلا طغض راشتنا لىع اهيلع لوصلحا مت يتلا تانايبلل يوناث ليلتح ءارجإب مق ةقيرطلا لىإ 2015 للاخ ،ةسرلأا ةحصل عبارلا ينطولا حسلما نم ءزجك في ناكسلا ةبسن باسحب انمق .دنلها في قطانلما عيجم في ،2016 ،ةنس 49 لىإ 35و ،ةنس 34 لىإ 18) ةفلتمخ ةيرمع تائف ثلاث اقفو كلذو ،مدلا طغض عافترا نم نياعت يتلاو ،(ةنس 49 لىإ 18و اذإ راشتنلاا في يرغتلا ىدم نع ًلاضف ،ةفلتمخ ةيهيجوت ئدابم ةتسل .ةدحاو ةرم مدلا طغض سايق لىع ًادمتعم صيخشتلا ناك ،ةيدنلها ةموكلحا نم لكل ةيهيجوتلا ئدابلما نأ انظحلا جئاتنلا ،ةيكيرملأا بلقلا ةيعجم/بلقلا ضارملأ ةيكيرملأا ةيعملجاو مدلا طغض راشتنلا لدعم لىعأو ىندأ لىإ قستم لكشب تدأ دق ناكسلا ةبسن باسحب انمق ،ةعمجلما ةيرمعلا ةئفلا في ؛عفترلما ةبسنب مدلا طغض في عافترا نم نوناعي منهأب مهفينصت مت نيذلا لصاف) 40.1%و (7.7 لىإ 7.4 :95% ةقثلا لصاف) 7.5% صيخشتلا دماتعا دنع .لياوتلا لىع ،(40.7 لىإ 39.7 :95% ةقث 56 لياجمإ فينصت متي فوسف ،مدلا طغضل طقف ةدحاو ةءارق لىع ًاقفو مدلا طغض عافتراب ينباصم منهأب ئطاخ لكشب ةمسن نويلم طغض راشتنا نأ انحضوأ ماك .ةيدنلها ةموكحلل ةيهيجوتلا ئدابملل ةئفلا في ؛ةعبتلما ةيهيجوتلا ئدابملل ًاقفو فلتيخ دنلها في عفترلما مدلا ينطولا ىوتسلما لىع مدلا طغض عافترا نإف ،ةعمجلما ةيرمعلا ضارملأ ةيكيرملأا ةيعملجا عابتا دنع هنع تارم ثلاث لىعأ ناك ةيهيجوتلا ئدابلماب ًةنراقم ،ةيكيرملأا بلقلا ةيعجم/بلقلا .ةيدنلها ةموكحلل ةياعرلا ومدقم جاتيح ،ةيلالحا ةيريسرلا ةسرمالما ينسحتل جاتنتسلاا ،ةلدلأا لىع ةدمتعلماو ،ًايلماع اهيلع قفتلما قرطلا عابتا لىإ ةيحصلا .مدلا طغض عافتراب ةباصلإا صيخشتل 808 Bull World Health Organ 2019;97:799–809| doi: http://dx.doi.org/10.2471/BLT.19.234500 Research Hypertension in India Manisha Dubey et al. Резюме Зависимость уровня распространенности гипертонии в Индии от различных руководящих принципов Цель Определение влияния различных руководящих принципов по ведению больных с артериальной гипертонией и постановки диагноза по однократному измерению артериального давления на показатели распространенности гипертонии среди населения Индии. Методы Авторы провели дополнительный анализ данных, полученных в рамках четвертого национального опроса о здоровье семьи, который проводился в 2015–2016 годах во всех регионах Индии. Была рассчитана доля лиц с повышенным артериальным давлением в популяции трех возрастных групп (от 18 до 34 лет, от 35 до 49 лет и от 18 до 49 лет) в соответствии с шестью различными руководящими принципами, а также продемонстрировано изменение показателя распространенности гипертонии, если диагностика опиралась на однократное измерение артериального давления. Результаты Авторы обнаружили, что руководящие принципы Правительства Индии и Американской коллегии кардиологов или Американской ассоциации сердца в результате неизменно дают минимальный и максимальный показатели распространенности повышенного артериального давления; в комбинированной возрастной группе, по расчетам авторов, доля популяции с повышенным артериальным давлением составила соответственно 7,5% (95%-й ДИ: 7,4–7,7) и 40,1% (95%-й ДИ: 39,7–40,7). В случае постановки диагноза на основании однократного измерения артериального давления 56 миллионам людей был бы ошибочно поставлен диагноз гипертонии на основании руководящих принципов Правительства Индии. Авторы также доказали, что уровень распространенности гипертонии в Индии зависит от того, каким руководящим принципам следуют врачи: в комбинированной возрастной группе национальный уровень распространенности гипертонии был в три раза выше при использовании руководящих принципов Американской коллегии кардиологов или Американской ассоциации сердца, чем при использовании руководящих принципов Правительства Индии. Вывод Для оптимизации текущей клинической практики работники здравоохранения должны следовать всесторонне согласованным и научно обоснованным методам диагностики гипертонии. Resumen Prevalencia de hipertensión en función de las diferentes directrices, India Objetivo Determinar el efecto de las diferentes directrices para el tratamiento de la hipertensión y de basar el diagnóstico en una sola lectura de la presión arterial sobre la prevalencia de la hipertensión en la población india. Métodos Se realizó un análisis secundario de los datos adquiridos como parte de la Cuarta Encuesta Nacional de Salud Familiar, 2015-2016, en todos los distritos de la India. Se calculó la proporción de la población dentro de tres grupos de edad diferentes (de 18 a 34 años, de 35 a 49 años y de 18 a 49 años) con presión arterial elevada de acuerdo con seis directrices diferentes, y cómo la prevalencia cambió si el diagnóstico se basó en una sola medición de la presión arterial. Resultados Se observó que las directrices del Gobierno de la India y del Colegio Americano de Cardiología/Asociación Americana del Corazón arrojaron sistemáticamente la prevalencia más baja y más alta de presión arterial elevada; en el grupo de edad combinado, se calculó que la proporción de la población categorizada como con presión arterial elevada era de 7,5 % (intervalo de confianza [IC] del 95 %: 7,4 a 7,7) y 40,1 % (IC del 95 %: 39,7 a 40,7), respectivamente. Al basar el diagnóstico en una sola lectura de la presión arterial, un total de 56 millones de personas serían erróneamente clasificadas como hipertensivas según las directrices del Gobierno de la India. También se demostró que la prevalencia de la hipertensión en la India varía según las directrices a las que se adhieren; en el grupo de edad combinado, la prevalencia nacional de la hipertensión era tres veces mayor cuando se seguía las directrices del Colegio Americano de Cardiología/Asociación Americana del Corazón en comparación con las del Gobierno de la India. Conclusión Para optimizar la práctica clínica actual, los profesionales de la atención de la salud deben seguir métodos universalmente acordados y basados en la evidencia para diagnosticar la hipertensión. References 1. Mehndiratta A, Sharma S, Gupta NP, Sankar MJ, Cluzeau F. Adapting clinical guidelines in India-a pragmatic approach. BMJ. 2017 11 17;359:j5147. doi: http://dx.doi.org/10.1136/bmj.j5147 PMID: 29150419 2. 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