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Status of Hypertension in China

Results From the China Hypertension Survey, 2012–2015
Originally publishedhttps://doi.org/10.1161/CIRCULATIONAHA.117.032380Circulation. 2018;137:2344–2356

Abstract

Background:

Although the prevalence of hypertension (HTN) continues to increase in developing countries, including China, recent data are lacking. A nationwide survey was conducted from October 2012 to December 2015 to assess the prevalence of HTN in China.

Methods:

A stratified multistage random sampling method was used to obtain a nationally representative sample of 451 755 residents ≥18 years of age from 31 provinces in mainland China from October 2012 to December 2015. Blood pressure (BP) was measured after resting for 5 minutes by trained staff using a validated oscillometric BP monitor. HTN was defined as systolic BP (SBP) ≥140 mm Hg/or diastolic BP (DBP) ≥90 mm Hg or use of antihypertensive medication within 2 weeks. Pre-HTN was defined as SBP 120 to 139 mm Hg and DBP 80 to 89 mm Hg without antihypertensive medication. HTN control was defined as SBP <140 mm Hg and DBP<90 mm Hg. In addition, the prevalence of HTN (SBP ≥130 or DBP ≥80 mm Hg) and control rate (SBP <130 and DBP <80 mm Hg) of HTN were also estimated according to the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline.

Results:

Overall, 23.2% (≈244.5 million) of the Chinese adult population ≥18 years of age had HTN, and another 41.3% (≈435.3 million) had pre-HTN according to the Chinese guideline. There were no significant differences of HTN prevalence between urban and rural residents (23.4% versus 23.1%, P=0.819). Among individuals with HTN, 46.9% were aware of their condition, 40.7% were taking prescribed antihypertensive medications, and 15.3% had controlled HTN. Calcium channel blockers were the most commonly used antihypertensive medication (46.5%) as monotherapy, and 31.7% of treated hypertensive patients used ≥2 medications. The prevalence of HTN based on the 2017 American College of Cardiology/American Heart Association guideline was twice as high as that based on 2010 Chinese guideline (46.4%), whereas the control rate fell to 3.0%.

Conclusions:

In China, there is a high prevalence of HTN and pre-HTN, and awareness, treatment, and control of HTN were low. Management of medical therapy for HTN needs to improve.

Introduction

Editorial, see p 2357

Clinical Perspective

What Is New?

  • This large national representative survey indicated that 23.2% of Chinese people ≥18 years of age (≈244.5 million individuals) had hypertension (HTN).

  • The prevalence of HTN was similar in rural and urban settings, whereas 3 municipalities (Beijing, Tianjin, and Shanghai) had the highest prevalence of HTN.

  • Almost half the hypertensive population was aware of their HTN, 40.7% were treated, and only 15.3% achieved blood pressure control; among treated patients, 31.7% were prescribed ≥2 antihypertensive medications.

What Are the Clinical Implications?

  • This study revealed a considerable prevalence of HTN in Chinese adults, as well as low awareness and control rates, implying a huge potential burden of future cardiovascular disease in China.

  • The geographic pattern suggests that increased attention should be paid to these specific geographical regions with different strategies in HTN management.

Hypertension (HTN) is the leading modifiable risk factor for cardiovascular disease, which represents the top cause of death in China.1,2 The burden of HTN and cardiovascular disease in China is increasing along with urbanization, rising incomes, and aging of the population.24 The age-standardized prevalence of HTN decreased in high-income countries over the last decade, but it has increased in low- and middle-income countries.57 Although safe and effective antihypertensive medications have been available for decades, blood pressure (BP) control rates remain low in China compared with high-income countries.

It is clear that the epidemiology of HTN in China is in a dynamic phase. Several population-based epidemiological surveys have been conducted in China recently, but the results were not consistent because of small sample size or nonrepresentative sampling, with reported prevalence ranging from 26.6% to 33.6%.8,9 The present survey on the prevalence, awareness, treatment, and control of HTN in China (The China Hypertension Survey), conducted between October 2012 and December 2015, was a nationally representative cross-sectional study designed to provide reliable and evidence-based data on the current status of HTN and associated factors in Chinese adults.

Methods

The data, analytic methods, and study materials cannot be made available to other researchers for purposes of reproducing the results or replicating the procedure.

Survey Participants

The China Hypertension Survey study design was published previously.10 Briefly, a stratified multistage random sampling method was used to obtain a nationally representative sample of the general Chinese population ≥15 years of age. All 31 provinces in mainland China were covered in this survey. The first stage of sampling was to select 4 cities in urban areas and 4 counties in rural areas within each province by the probability proportional to size method. Then by a simple random sampling method, 2 districts or 2 townships were selected within each city or county, and 3 communities or villages were chosen within each district or township, respectively. In the final stage of sampling, a given number of participants from each of the 14 sex/age strata (men and women 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, ≥75 years of age) were selected from communities or villages using lists compiled from local government registers of households (Figure I in the online-only Data Supplement). A total of 500 000 permanent residents from 262 urban cities and rural counties were expected to participate in the study (Figure II in the online-only Data Supplement). To meet the designed sample size and take nonresponse into account in the survey, 733 600 subjects were randomly selected. Finally, 487 349 participants were recruited, with an overall response rate of 66.4%. After exclusion (n=7507) because of missing information on major risk factors, 479 842 were eligible and completed the survey. The participants (n=451 755) who were ≥18 years of age were included in the finally analysis.

The written informed consent was obtained from each participant. The Ethics Committee of Fuwai Hospital (Beijing, China) approved the study.

Training and Data Collection

All study investigators and staff members were trained to be familiar with both the aims of the study and the specific tools and methods used. A standardized questionnaire developed by the coordinating center, Fuwai Hospital, was administered by trained staff to obtain information on demographic characteristics and socioeconomic factors.

Body mass index was calculated as weight divided by the square of height (kg/m2). Height was measured without shoes using a standard right-angle device and a fixed measurement tape (to the nearest 0.5 cm). Body weight without heavy clothing was measured using an OMRON body fat and weight measurement device (V-body HBF-371, OMRON).

BP Measurement

BP was measured with the OMRON HBP-1300 professional portable blood pressure monitor (OMRON) 3 times on the right arm positioned at heart level after the participant was sitting at rest for 5 minutes, with 30 seconds between each measurement with an observer present. The average of the 3 readings was used for analysis. The accuracy of the Omron HBP-1300 for BP measurement had been verified in our prior study.11

Outcome Definitions

According to 2010 Chinese guidelines for the management of HTN,12 HTN was defined as systolic BP (SBP) ≥140 mm Hg, diastolic BP (DBP) ≥90 mm Hg, and use of antihypertensive medicine within 2 weeks. Stage 1 of HTN was defined as SBP 140 to 159 mm Hg and DBP 90 to 99 mm Hg, stage 2 as 160 to 179 mm Hg and 100 to 109 mm Hg, and stage 3 as ≥180 mm Hg and ≥110 mm Hg; SBP 120 to 139 mm Hg and DBP 80 to 89 mm Hg and not being on antihypertensive medication was considered pre-HTN. Awareness of HTN was defined as self-report of any previous diagnosis of HTN by a doctor, treatment as self-reported use of a prescription medication for HTN within 2 weeks at the time of the interview, control as SBP <140 mm Hg and DBP <90 mm Hg. In addition, as a post hoc analysis, the prevalence (SBP ≥130 or DBP ≥80 mm Hg) and control rate (SBP <130 and DBP <80 mm Hg) of HTN were also estimated according to the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline.13

Overweight and obesity were defined as a body mass index between 24.0 and 27.9 and of ≥28.0, respectively.14 Current smokers were defined as participants who have smoked at least 20 packets of cigarettes in their lifetime and currently smoke cigarettes, former smokers as participants who have smoked at least 20 packets of cigarettes in their lifetime and quit smoking for at least 1 month, and never smokers as participants who never smoked or smoked <20 packets of cigarettes in their entire lifetime. Drinker was defined as consuming at least 1 alcoholic beverage per week in the past month.

Medications were classified as diuretics, β-blockers, α-β-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, centrally acting drugs, vasodilators, and traditional Chinese medicine.

Single-pill combinations, which normally contain ≥2 active ingredients, were separated into their generic components. For more on Chinese traditional single-pill combinations, see Table I in the online-only Data Supplement. Each medication was classified into only 1 category. Participants who used only 1 drug were defined as receiving monotherapy, whereas those using ≥2 drugs were defined as receiving combination therapy.

Statistical Analysis

Our study was designed to provide accurate estimates of the prevalence of HTN by age, sex, and urban or rural residence in the general Chinese population ≥18 years of age. To address the multilevel stratified sampling design, rates were calculated using the PROC SURVEYFREQ procedure; the means were calculated using the PROC SURVEYMEANS; and differences or trends across groups, including age, ethnicity, sex, body mass index, education status, smoking, alcohol consumption, family history of HTN, and region (urban versus rural) were tested using PROC SURVEYLOGISTIC in SAS. Logistic regression, also applied with PROC SURVEYLOGISTIC, was used for risk factors analysis.

Survey weights were calculated based on the 2010 China population census data and the sampling scheme and included oversampling for specific age subgroups, nonresponse, and other demographic between the sample and the total population.15 Adjustment for differential probabilities of selection and the complex sampling design was used to enhance the representativeness of the survey sample population.

Variables were summarized using means with 95% confidence intervals (CI) for continuous data, and frequencies, percentages, and proportions were used for categorical data. Two-tailed Student t tests with Wilcoxon rank test when necessary and chi-squared tests were used to compare continuous and categorical variables, respectively. Logistic regression, applied with PROC SURVEYLOGISTIC, was used for risk factors analysis. All 95% CI for the parameters were estimated. P<0.05 was the threshold for statistical significance. Statistical analyses were conducted with SAS version 9.4 (SAS Institute, Inc) and Stata 12.1 (STATA Corp).

Results

Characteristics of Study Participants

A total of 451 755 participants (47.8% men and 52.2% women, 51.3% urban and 48.7% rural) completed the survey and were included in the analysis (Table 1). A significant difference was observed between men and women for all characteristics except ethnicity. Urban and rural populations were similar except for age (P=0.032) and education level (P<0.001).

Table 1. Characteristics of Study Participants, by Sex and Region

CharacteristicsRegionSexTotalP Value for RegionP Value for Sex
UrbanRuralMenWomen
N, %220 052 (48.7)231 703 (51.3)216 034 (47.8)235 721 (52.2)451 755 (100.0)
Mean age, y44.0 (43.4–44.6)43.0 (42.3–43.7)43.0 (42.5–43.6)43.7 (43.2–44.2)43.4 (42.8–43.9)0.032<0.001
Mean body mass index, kg/m223.9 (23.6–24.2)23.7 (23.4–24.0)23.9 (23.6–24.1)23.6 (23.4–23.9)23.8 (23.5–24.0)0.429<0.001
 <18.54.5 (3.7–5.4)5.0 (4.2–6.0)4.1 (3.6–4.7)5.6 (4.9–6.4)4.8 (4.2–5.5)0.514<0.001
 18.5–23.950.5 (47.3–53.6)52.0 (48.6–55.3)50.2 (47.5–52.8)52.8 (50.5–55.1)51.5 (49.1–53.8)
 24.0–27.932.4 (30.6–34.3)31.2 (29–33.4)33.8 (32.1–35.6)29.3 (27.8–30.9)31.6 (30.1–33.2)
 ≥28.012.6 (10.7–14.8)11.8 (9.9–14.1)11.9 (10.5–13.5)12.3 (10.8–14.0)12.1 (10.7–13.7)
Mean systolic blood pressure, mm Hg125.6 (124.5–126.7)126.4 (125.2–127.6)128.0 (127.3–128.8)124.2 (123.1–125.2)126.1 (125.3–127.0)0.323<0.001
Mean diastolic blood pressure, mm Hg76.0 (75.2–76.9)76.0 (75.2–76.8)77.8 (77.2–78.3)74.2 (73.5–74.8)76.0 (75.4–76.6)0.898<0.001
Ethnicity, Han, %92.7 (87.8–95.7)86.5 (74.9–93.3)88.6 (81.1–93.3)88.8 (81.7–93.4)88.7 (81.4–93.3)0.1440.314
Education attainment, %
 Elementary school22.1 (18.7–25.8)37.7 (34.2–41.3)26.0 (23.5–28.6)38.8 (36.0–41.8)32.3 (29.7–35.0)<0.001<0.001
 Elementary middle school58.1 (55.8–60.5)51.8 (48.6–55.0)59.8 (57.4–62.2)48.0 (45.6–50.3)54.0 (51.7–56.2)
 High school or above19.8 (17.2–22.6)10.6 (6.6–16.4)14.3 (11.2–18.0)13.2 (10.4–16.6)13.7 (10.8–17.3)
Smoking status, %
 Nonsmokers78.1 (75.8–80.3)76.2 (73.7–78.6)56.2 (53.0–59.4)98.2 (97.3–98.8)76.9 (75.1–78.6)0.297<0.001
 Past smokers2.6 (2.1–3.2)2.4 (1.8–3.3)4.7 (3.8–5.8)0.2 (0.2–0.4)2.5 (2.0–3.1)
 Current smokers19.3 (17.4–21.3)21.3 (19.3–23.5)39.1 (36.5–41.9)1.6 (1.1–2.4)20.6 (19.2–22.2)
Consumption of alcohol, %14.6 (12.6–16.7)16.5 (14.5–18.6)28.5 (26.0–31.1)2.8 (2.1–3.5)15.8 (14.4–17.4)0.190<0.001
Family history of hypertension, %27.0 (23.4–30.8)22.0 (18.3–26.3)23.2 (20.5–26.1)24.2 (21.5–27.3)23.7 (21.0–26.7)0.0750.004

Data are represented as value (95% confidence interval) unless otherwise indicated. All values were weighted to represent the total population of Chinese ≥18 years of age based on Chinese Census 2010.

Prevalence of HTN and Pre-HTN

The mean SBP and DBP were 126.1 (95% CI, 125.3–127.0) mm Hg and 76.0 (95% CI, 75.4–76.6) mm Hg, respectively (Table 2, Figure III in the online-only Data Supplement). Among Chinese adults ≥18 years of age, the overall crude prevalences of HTN and pre-HTN were 27.9% and 39.1%, respectively (Table II in the online-only Data Supplement); the weighted prevalence of HTN was 23.2% (≈244.5 million); and the weighted prevalence of pre-HTN was 41.3% (≈435.3 million) (Table 2). There were significant differences in weighted HTN status for each subgroup (P<0.001), except for ethnicity and region, where the weighted prevalence of HTN was similar between urban and rural residents (23.4% versus 23.1%, P=0.819) (Table 2, Figure IV in the online-only Data Supplement). The weighted prevalence of HTN was higher in men than in women (24.5% versus 21.9%, P<0.001) and was >2 times higher in obese individuals compared with those of normal weight (44.5% versus 15.4%, P<0.001).

Table 2. Weighted Blood Pressure Level and Prevalence of Prehypertension and Hypertension by Characteristics

CharacteristicsNBlood Pressure (mm Hg)Hypertension Classification (%)Hypertension Prevalence (%)
Systolic Blood PressureDiastolic Blood PressureNormalPrehypertensionStage 1Stage 2Stage 3
Overall451 755126.1 (125.3–127.0)76.0 (75.4–76.6)35.5 (33.2–37.9)41.3 (39.3–43.2)13.6 (12.8–14.4)4.5 (4.1–4.8)1.6 (1.4–1.8)23.2 (21.9–24.5)
Age, y
 18–2442 806117.4 (116.6–118.2)71.4 (70.6–72.2)56.0 (53.0–59.0)39.9 (37.4–42.6)3.6 (2.9–4.5)0.4 (0.3–0.5)0.0 (0.0–0.1)4.0 (3.3–5.0)
 25–3488 540118.9 (118.1–119.6)73.2 (72.5–73.9)50.5 (47.7–53.3)43.4 (40.8–46.0)5.0 (4.4–5.6)0.8 (0.6–1.0)0.2 (0.1–0.3)6.1 (5.4–6.9)
 35–4479 854123.0 (122.3–123.7)76.4 (75.9–76.9)39.0 (36.6–41.5)46.0 (43.7–48.4)10.3 (9.3–11.4)2.5 (2.2–2.8)0.7 (0.6–0.9)15.0 (13.6–16.5)
 45–5475 398129.0 (128.1–130.0)78.9 (78.4–79.5)27.0 (24.7–29.5)43.4 (41.3–45.5)17.5 (16.4–18.7)5.6 (5.0–6.2)1.7 (1.5–2.0)29.6 (27.7–31.6)
 55–6465 868134.8 (133.8–135.9)78.9 (78.2–79.6)18.5 (16.4–20.7)36.9 (35.1–38.7)24.5 (23.2–25.8)8.8 (8.2–9.5)3.1 (2.7–3.5)44.6 (42.4–46.9)
 65–7456 343139.8 (138.6–141.0)77.5 (76.9–78.2)12.6 (11.1–14.2)31.7 (30.3–33.2)28.0 (26.8–29.2)12.5 (11.5–13.5)5.0 (4.4–5.7)55.7 (53.5–57.9)
 ≥7542 946142.6 (141.4–143.8)75.9 (75.1–76.7)10.4 (9.4–11.5)29.4 (27.3–31.5)28.6 (27.4–29.9)14.5 (13.4–15.6)6.9 (6.2–7.6)60.2 (57.7–62.7)
P value<0.001<0.001<0.001<0.001
Ethnicity
 Others61 049125.9 (123.8–127.9)75.8 (74.6–76.9)38.2 (34.3–42.2)40.8 (36.6–45.0)13.1 (10.5–16.1)4.6 (3.3–6.2)1.7 (1.2–2.3)21.1 (16.7–26.1)
 Han390 706126.2 (125.3–127.0)76.0 (75.4–76.6)35.2 (32.8–37.7)41.3 (39.3–43.4)13.7 (12.9–14.5)4.5 (4.1–4.8)1.6 (1.4–1.7)23.5 (22.3–24.6)
P value0.7860.6670.8010.318
Sex
 Men216 034128.0 (127.3–128.8)77.8 (77.2–78.3)27.7 (25.8–29.8)47.8 (46.3–49.3)15.1 (14.2–16.1)4.6 (4.2–5.0)1.5 (1.4–1.7)24.5 (23.0–26.0)
 Women235 721124.2 (123.1–125.2)74.2 (73.5–74.8)43.6 (40.6–46.6)34.6 (32.1–37.2)12.0 (11.3–12.8)4.4 (4.0–4.7)1.6 (1.4–1.9)21.9 (20.7–23.1)
P value<0.001<0.001<0.001<0.001
Body mass index
 <18.522 518118.1 (116.9–119.3)71.4 (70.7–72.1)57.5 (53.8–61.1)31.3 (28.6–34.1)6.7 (5.8–7.6)2.4 (2.0–3.0)0.7 (0.6–0.9)11.3 (9.9–12.8)
 18.5–23.9232 324122.6 (121.7–123.5)73.9 (73.3–74.6)43.8 (41.0–46.6)40.8 (38.5–43.1)9.4 (8.7–10.2)2.8 (2.5–3.1)1.0 (0.9–1.2)15.4 (14.3–16.6)
 24.0–27.9142 741129.5 (128.7–130.3)78.0 (77.6–78.5)26.2 (24.3–28.1)44.3 (42.6–46.1)17.3 (16.3–18.3)5.7 (5.2–6.3)1.9 (1.6–2.1)29.5 (28.0–31.1)
 ≥28.054 172135.3 (134.5–136.1)81.1 (80.7–81.5)16.2 (14.9–17.6)39.2 (37.4–41.1)24.7 (23.7–25.8)9.3 (8.7–9.9)3.5 (3.1–3.9)44.5 (42.7–46.4)
P value<0.001<0.001<0.001<0.001
Education status
 Elementary school175 856132.2 (131.1–133.3)77.3 (76.6–77.9)25.1 (22.9–27.5)38.4 (36.3–40.5)20.1 (18.9–21.4)7.8 (7.2–8.5)3.1 (2.7–3.5)36.5 (34.2–38.9)
 Middle school218 696124.1 (123.3–125.0)75.9 (75.3–76.4)38.2 (35.6–40.9)43.1 (40.9–45.3)11.5 (10.6–12.6)3.2 (2.9–3.6)1.0 (0.9–1.1)18.7 (17.0–20.4)
 High school or above57 203119.5 (118.8–120.3)73.4 (72.5–74.3)49.5 (46.5–52.4)41.0 (38.6–43.4)6.5 (5.7–7.3)1.4 (1.2–1.7)0.3 (0.2–0.4)9.5 (8.5–10.8)
P value<0.001<0.001<0.001<0.001
Smoking status
 Nonsmokers352 708125.0 (124.2–125.9)75.3 (74.6–76.0)38.4 (35.9–41.1)40.4 (38.1–42.7)12.3 (11.6–13.0)4.1 (3.7–4.4)1.4 (1.2–1.6)21.2 (20.1–22.4)
 Past smokers12 891134.9 (133.6–136.3)79.6 (79.0–80.2)18.9 (16.5–21.6)35.1 (33.6–36.7)24.4 (22.7–26.2)9.0 (8.1–10.0)3.7 (3.0–4.5)46.0 (43.6–48.3)
 Current smokers86 156129.1 (128.3–129.9)78.2 (77.6–78.7)26.7 (24.7–28.8)45.5 (44.2–46.7)17.2 (16.2–18.3)5.4 (4.9–5.9)1.9 (1.6–2.1)27.9 (26.2–29.6)
P value<0.001<0.001<0.001<0.001
Consumption of alcohol
 No389 790125.4 (124.5–126.2)75.4 (74.7–76.0)37.6 (35.1–40.2)40.7 (38.5–42.9)12.6 (11.9–13.3)4.1 (3.8–4.5)1.5 (1.3–1.7)21.7 (20.5–23.0)
 Yes61 965130.2 (129.3–131.2)79.2 (78.6–79.9)24.5 (22.6–26.5)44.6 (43.3–45.9)19.1 (17.8–20.5)6.2 (5.6–6.8)2.1 (1.8–2.3)30.9 (29.0–32.9)
P value<0.001<0.001<0.001<0.001
Family history of hypertension
 No349 114125.3 (124.4–126.1)75.5 (74.8–76.1)37.0 (34.6–39.6)42.8 (40.8–44.8)12.4 (11.5–13.3)3.9 (3.6–4.3)1.4 (1.2–1.6)20.1 (18.9–21.5)
 Yes102 641128.8 (127.8–129.8)77.7 (77.1–78.3)30.7 (28.3–33.1)36.4 (34.8–37.9)17.6 (16.6–18.5)6.2 (5.7–6.7)2.1 (1.8–2.4)33.0 (31.5–34.5)
P value<0.001<0.001<0.001<0.001
Region
 Urban220 052125.6 (124.5–126.7)76.0 (75.2–76.9)35.5 (32.3–38.9)41.1 (38.7–43.5)13.4 (12.2–14.8)4.1 (3.6–4.7)1.3 (1.1–1.5)23.4 (21.3–25.6)
 Rural231 703126.4 (125.2–127.6)76.0 (75.2–76.8)35.5 (32.4–38.8)41.4 (38.6–44.2)13.7 (12.7–14.8)4.7 (4.2–5.2)1.7 (1.5–2.0)23.1 (21.5–24.8)
P value0.3230.8980.8690.819

Data are represented as mean or percentage (95% confidence interval). All values were weighted to represent the total Chinese population ≥18 years of age based on Chinese Census 2010.

It is important to note that the prevalence of HTN varied considerably among provinces (Figure 1A). Three province-level municipalities—Beijing, Tianjin, and Shanghai—ranked in the top 3 for a HTN prevalence rate of 35.9%, 34.5%, and 29.1%, respectively, and Hunan province had the lowest prevalence (15.6%) (Table III in the online-only Data Supplement). Figure 1 showed the prevalence of HTN for each province by men versus women (Figure 1B and 1C) and urban and rural areas (Figure 1D and 1E).

Figure 1.

Figure 1. Prevalence of hypertension among Chinese adults ≥18 years of age or older by province. A, Total population. B, Men. C, Women. D, Urban. E, Rural. According to tertile divided into 3 groups.

No significant difference was found between Han and other ethnicities, as well as urban and rural in the prevalence of HTN and pre-HTN (Table 2).

Awareness, Treatment, and Control of HTN

Among those with HTN, 46.9% (95% CI, 43.2-50.5) were aware of their condition, 40.7% (95% CI, 37.2-44.3) were taking prescribed medication to lower their BP, but only 15.3% (95% CI, 13.2-17.6) achieved BP control (Table 3). Among those with treated HTN, 37.5% (95% CI, 35.1-40.1) were controlled. The crude rates of awareness, treatment, and control are shown in Table IV in the online-only Data Supplement.

Table 3. Weighted Awareness, Treatment, and Control Rate, by Characteristics

CharacteristicsAwarenessTreatmentControlControl Among Treated Patients With Hypertension
Overall46.9 (43.2–50.5)40.7 (37.2–44.3)15.3 (13.2–17.6)37.5 (35.1–40.1)
Age, y
 18–245.7 (3.0–10.8)3.4 (1.1–9.9)0.6 (0.3–1.3)17.9 (3.4–57.3)
 25–3414.7 (11.4–18.8)8.4 (6.2–11.4)3.2 (1.9–5.2)37.4 (28.4–47.3)
 35–4431.7 (26.7–37.2)24.5 (20.2–29.4)9.9 (7.4–13.1)40.3 (35.5–45.3)
 45–5447.0 (43.0–51.0)40.3 (36.3–44.3)16.1 (13.9–18.7)40.1 (37.4–42.8)
 55–6453.9 (50.1–57.7)48.1 (44.3–51.9)18.6 (16.0–21.4)38.6 (35.6–41.7)
 65–7458.6 (55.6–61.7)52.8 (49.6–56.0)18.4 (16.3–20.8)34.9 (32.2–37.6)
 ≥7557.3 (53.9–60.6)52.1 (48.4–55.7)17.0 (14.8–19.5)32.7 (29.9–35.7)
P value<0.001<0.001<0.0010.004
Ethnicity
 Others36.9 (33.1–40.8)29.5 (26.1–33.2)8.4 (6.4–10.9)28.3 (22.1–35.4)
 Han48.0 (44.2–51.9)42.0 (38.3–45.8)16.1 (13.9–18.5)38.3 (35.9–40.7)
P value<0.001<0.001<0.0010.008
Sex
 Men42.5 (38.9–46.1)35.6 (32.4–39.1)13.2 (11.4–15.3)37.0 (34.5–39.7)
 Women51.9 (48.1–55.8)46.6 (42.7–50.5)17.7 (15.3–20.4)38.0 (35.3–40.7)
P value<0.001<0.001<0.0010.267
Body mass index
 <18.537.2 (32.5–42.2)31.8 (27.4–36.6)12.7 (10.4–15.4)39.9 (35.7–44.2)
 18.5–23.941.0 (37.6–44.4)35.2 (32.0–38.6)14.4 (12.2–16.8)40.8 (37.5–44.3)
 24.0–27.948.5 (44.7–52.3)42.2 (38.5–46.0)15.8 (13.5–18.4)37.4 (34.7–40.3)
 ≥28.053.7 (49.6–57.7)47.1 (43.1–51.2)16.0 (13.8–18.4)33.9 (31.5–36.3)
P value<0.001<0.0010.063<0.001
Education status
 Elementary school50.1 (46.3–53.9)43.9 (40.0–47.9)15.0 (12.7–17.7)34.2 (31.2–37.3)
 Middle school44.4 (40.1–48.9)38.3 (34.3–42.4)15.8 (13.6–18.2)41.2 (38.9–43.6)
 High school or above36.6 (31.6–42.1)31.0 (25.9–36.5)13.9 (10.7–17.8)44.8 (39.7–50.0)
P value<0.001<0.0010.476<0.001
Smoking status
 Nonsmokers48.1 (44.6–51.6)42.5 (39.0–46.0)16.1 (14.0–18.5)37.9 (35.3–40.6)
 Past smokers59.7 (56.1–63.2)52.6 (48.8–56.3)19.4 (16.9–22.2)36.9 (33.7–40.3)
 Current smokers40.8 (36.6–45.2)33.3 (29.5–37.4)12.1 (10.0–14.5)36.3 (33.3–39.4)
P value<0.001<0.001<0.0010.271
Consumption of alcohol
 No48.6 (45.1–52.2)43.1 (39.6–46.6)16.3 (14.2–18.6)37.8 (35.4–40.3)
 Yes40.2 (35.9–44.7)31.9 (27.9–36.3)11.6 (9.4–14.2)36.2 (33.0–39.6)
P value<0.001<0.0010.131
Family history of hypertension
 No39.0 (35.7–42.3)33.4 (30.2–36.8)12.1 (10.3–14.1)36.2 (33.6–38.8)
 Yes62.4 (59.5–65.2)55.1 (52.0–58.1)21.6 (19.2–24.2)39.2 (36.4–42.0)
P value<0.001<0.001<0.0010.019
Region
 Urban50.9 (45.9–56.0)45.8 (40.8–50.9)19.4 (16.4–22.8)42.4 (39.2–45.6)
 Rural44.7 (39.6–49.9)38.0 (33.1–43.2)13.1 (10.3–16.4)34.4 (30.8–38.3)
P value0.0840.0310.0060.002

Data are represented as percentage (95% confidence interval). All values were weighted to represent the total Chinese population ≥18 years of age based on Chinese Census 2010.

The awareness, treatment, and control rates of HTN were higher among women than men (51.9% versus 42.5%, 46.6% versus 35.6%, and 17.7% versus 13.2%, respectively; all P<0.001), whereas the control rate was similar between men and women taking antihypertensive medication (37.0% versus 38.0%, P=0.267) (Table 3, Figure V in the online-only Data Supplement). The control rate was higher in urban than rural patients (19.4% versus 13.1%, P=0.006).

The prevalence of HTN based on the 2017 American College of Cardiology/American Heart Association guideline was twice as high as that based on 2010 Chinese guideline (46.4%), the control rate of HTN was only 3.0%, and 14.9% among those with treated HTN (Table 4).

Table 4. Weighted Prevalence and Control Rate Based on 2010 Chinese High Blood Pressure Guideline and the 2017 ACC/AHA High Blood Pressure Guideline

CharacteristicsPrevalenceControlControl Among Treated Patients With Hypertension
2010 Chinese*2017 ACC/AHA2010 Chinese2017 ACC/AHA2010 Chinese2017 ACC/AHA
Overall23.2 (21.9–24.5)46.4 (44.2–48.7)15.3 (13.2–17.6)3.0 (2.5–3.5)37.5 (35.1–40.1)14.9 (13.4–16.4)
Age, y
 18–244.0 (3.3–5.0)23.0 (20.7–25.5)0.6 (0.3–1.3)0.0 (0.0–0.1)17.9 (3.4–57.3)9.3 (0.0–24.3)
 25–346.1 (5.4–6.9)28. 0(25.7–30.4)3.2 (1.9–5.2)0.2 (0.1–0.3)37.4 (28.4–47.3)12.5 (7.1–17.9)
 35–4415.0 (13.6–16.5)41.7 (39.4–43.9)9.9 (7.4–13.1)1.2 (0.8–1.6)40.3 (35.5–45.3)14.0 (12.2–15.8)
 45–5429.6 (27.7–31.6)56.1 (53.5–58.7)16.1 (13.9–18.7)2.9 (2.4–3.5)40.1 (37.4–42.8)14.2 (12.6–15.9)
 55–6444.6 (42.4–46.9)67.2 (64.7–69.7)18.6 (16.0–21.4)5.0 (4.0–6.0)38.6 (35.6–41.7)16.0 (13.9–18.1)
 65–7455.7 (53.5–57.9)74.7 (72.4–76.9)18.4 (16.3–20.8)5.9 (4.9–6.9)34.9 (32.2–37.6)15.2 (13.2–17.2)
 ≥7560.2 (57.7–62.7)78.7 (77.1–80.2)17.0 (14.8–19.5)5.4 (4.4–6.3)32.7 (29.9–35.7)13.6 (11.8–15.3)
P value<0.001<0.001<0.001<0.0010.0040.194
Ethnicity
 Others21.1 (16.7–26.1)43.2 (38.7–47.7)8.4 (6.4–10.9)1.6 (1.2–2.1)28.3 (22.1–35.4)11.2 (8.0–15.6)
 Han23.5 (22.3–24.6)46.9 (44.6–49.1)16.1 (13.9–18.5)3.1 (2.6–3.7)38.3 (35.9–40.7)15.2 (13.7–16.7)
P value0.3180.105<0.001<0.0010.0080.070
Sex
 Men24.5 (23.0–26.0)52.3 (50.0–54.5)13.2 (11.4–15.3)2.3 (1.9–2.7)37.0 (34.5–39.7)13.9 (12.5–15.4)
 Women21.9 (20.7–23.1)40.4 (38.0–42.9)17.7 (15.3–20.4)3.9 (3.2–4.7)38.0 (35.3–40.7)15.7 (14.0–17.6)
P value<0.001<0.001<0.001<0.0010.2670.007
Body mass index
 <18.511.3 (9.9–12.8)27.0 (24.2–29.9)12.7 (10.4–15.4)2.8 (2.2–3.6)39.9 (35.7–44.2)21.9 (18.0–26.4)
 18.5–23.915.4 (14.3–16.6)36.6 (34.3–39.0)14.4 (12.2–16.8)2.6 (2.1–3.1)40.8 (37.5–44.3)17.7 (15.5–20.1)
 24.0–27.929.5 (28.0–31.1)56.3 (54.3–58.2)15.8 (13.5–18.4)3.2 (2.7–3.9)37.4 (34.7–40.3)14.7 (13.1–16.4)
 ≥28.044.5 (42.7–46.4)70.2 (68.4–71.9)16.0 (13.8–18.4)3.4 (2.7–4.1)33.9 (31.5–36.3)11.5 (10.1–13.1)
P value<0.001<0.0010.0630.009<0.001<0.001
Education status
 Elementary school36.5 (34.2–38.9)59.2 (56.6–61.8)15.0 (12.7–17.7)3.6 (2.9–4.5)34.2 (31.2–37.3)13.7 (11.9–15.7)
 Middle school18.7 (17.0–20.4)42.8 (40.3–45.4)15.8 (13.6–18.2)2.6 (2.1–3.1)41.2 (38.9–43.6)16.0 (14.6–17.4)
 High school or above9.5 (8.5–10.8)30.5 (27.9–33.2)13.9 (10.7–17.8)1.8 (1.3–2.5)44.8 (39.7–50.0)19.5 (15.8–23.7)
P value<0.001<0.0010.476<0.001<0.0010.007
Smoking status
 Nonsmokers21.2 (20.1–22.4)43.6 (41.2–46.1)16.1 (14.0–18.5)3.1 (2.6–3.7)37.9 (35.3–40.6)15.2 (13.7–16.9)
 Past smokers46.0 (43.6–48.3)68.1 (65.4–70.7)19.4 (16.9–22.2)5.1 (4.2–6.2)36.9 (33.7–40.3)14.9 (13.0–17.1)
 Current smokers27.9 (26.2–29.6)54.4 (52.1–56.7)12.1 (10.0–14.5)2.3 (1.9–2.8)36.3 (33.3–39.4)13.6 (12.0–15.4)
P value<0.001<0.001<0.001<0.0010.2710.063
Consumption of alcohol
 No21.7 (20.5–23.0)44.2 (41.8–46.6)16.3 (14.2–18.6)3.1 (2.6–3.7)37.8 (35.4–40.3)15.2 (13.7–16.7)
 Yes30.9 (29.0–32.9)58.3 (56.0–60.7)11.6 (9.4–14.2)2.2 (1.7–2.9)36.2 (33.0–39.6)13.4 (11.5–15.5)
P value<0.001<0.001<0.001<0.0010.1310.025
Family history of hypertension
 No20.1 (18.9–21.5)44.0 (41.6–46.5)12.1 (10.3–14.1)2.1 (1.8–2.5)36.2 (33.6–38.8)14.0 (12.6–15.5)
 Yes33.0 (31.5–34.5)54.1 (51.9–56.4)21.6 (19.2–24.2)5.2 (4.5–6.1)39.2 (36.4–42.0)15.9 (14.2–17.6)
P value<0.001<0.001<0.001<0.0010.0190.006
Region
 Urban23.4 (21.3–25.6)46.3 (43.3–49.4)19.4 (16.4–22.8)3.8 (3.1–4.7)42.4 (39.2–45.6)16.8 (14.8–19.1)
 Rural23.1 (21.5–24.8)46.5 (43.4–49.6)13.1 (10.3–16.4)2.5 (1.9–3.3)34.4 (30.8–38.3)13.6 (11.6–15.8)
P value0.8190.9440.0060.0140.0020.032

ACC indicates American College of Cardiology; and AHA, American Heart Association. Data are represented as percentage (95% confidence interval). All values were weighted to represent the total Chinese population ≥18 years of age based on Chinese Census 2010.

*Calculated according to the criteria of 2010 Chinese high blood pressure guideline.

Calculated according to the criteria of 2017 ACC/AHA high blood pressure guideline.

Antihypertensive Medicine Use

Calcium channel blockers were the most commonly used antihypertensive medication monotherapy (46.5%; Table V in the online-only Data Supplement). Diuretics, angiotensin-converting enzyme inhibitors, centrally acting agents, and single-pill combinations were more commonly used in rural residents. As to ingredients of single-pill combinations, 92.5% were composed of centrally acting drugs, vasodilators, and diuretics, whereas 3.8% were composed of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and diuretics. Among treated patients, 31.7% were prescribed ≥2 medications, with a significantly different pattern between urban and rural areas (P < 0.001).

Multivariable Risk Assessment

Men, older age, overweight/obesity, family history of HTN, lower educational level, smokers, and alcoholic drinkers were all significantly associated with an increased risk of HTN (P<0.05); overweight/obesity were associated with higher awareness and treatment, whereas higher education level and urban residences were significantly associated with higher control of HTN (Figure 2, Table VI in the online-only Data Supplement).

Figure 2.

Figure 2. Multivariable adjusted odds ratios for hypertension. A, Hypertension. B, Awareness. C, Treatment. D, Control. E, Control among treated hypertensive.

Discussion

This large survey from a national representative sample of ≈500 000 participants provides comprehensive estimates of the status of HTN in China. It showed that 23.2% of Chinese people ≥18 years of age, or ≈244.5 million individuals, had HTN, whereas 41.3%, or e≈435.3 million, had pre-HTN. The prevalence of HTN was similar in rural and urban settings, and it was highest among 3 municipalities that contain both urban and rural populations (Beijing, Tianjin, and Shanghai). Almost half the hypertensive population was aware of their HTN, 40.7% were treated, and the HTN control rate, although still low, was ≈3 times of that in 2002.16 Under the 2017 American College of Cardiology/American Heart Association guideline, the prevalence of HTN would be double and the control rate would be substantially decreased.

Compared with the results of the 2002 survey,16 in which participants were recruited by the use of a stratified multistage cluster sampling design, the prevalence of HTN has increased from 18% to 23.2%. Recently, a large-scale population-based screening project showed the prevalence of HTN was 44.7%; however, the participants 35 to 75 years of age were recruited through extensive publicity campaigns on television and in newspapers using a convenience sampling strategy.17 In contrast, our survey used a stratified multistage random sampling method to obtain a nationally representative sample. Therefore, this study provides a more accurate estimate of the status of HTN. Meanwhile, the huge pre-HTN population also represents a considerable cardiocerebrovascular disease risk burden.18 These results emphasize that elevated BP remains a serious public health problem in China.

Aging is 1 of the most important contributors to the development of high BP.19 It is expected that the elderly will account for 30% of the total population of China by 2050.20 In our survey, HTN increased with age, and the prevalence of HTN was >55% among citizens ≥65 years of age. In the last decade, the rapid economic growth, which came along with an unhealthy lifestyle, especially with a higher dietary sodium intake,21 is another new and crucial factor related to the increased prevalence of HTN in China.8,9,22,23

Previous studies in China between the 1990s and 2010 have shown that, compared with urban areas, rural areas had a significantly lower prevalence of HTN.9,16,24 Remarkably, we found no significant difference of HTN prevalence between rural and urban areas. This finding reflects the fact that, since 1993, the prevalence of HTN in rural areas has gradually become close to that in urban areas.25 Traditionally, the prevalence of HTN was significantly higher in northern China than in southern China.16,24,26 This survey, however, showed that Beijing, Tianjin, and Shanghai, the most developed provinces in China, had the highest prevalence of HTN, which was even higher than in US adults (29.1%).27 Residents in developed areas suffer from occupational and relationship stress, together with an unhealthy lifestyle, which most likely contribute to the development of HTN.28 It is worth noting that all provinces in China are a mix of urban and rural areas and residents to some degree. Beijing, Tianjin, and Shanghai have more urban areas relatively.29 The prevalence of HTN for both urban and rural areas was the highest in Beijing, Tianjin, and Shanghai (Table III in the online-only Data Supplement). In contrast, the rapid increase of economic growth in recent years, coupled with a lack of knowledge in healthy behavior, may contribute to the higher prevalence of HTN in Yunnan, Shanxi, Tibet, and Guizhou, which are among the less developed provinces in China. These results suggest that increased attention should be paid in these specific geographical regions with different strategies in HTN management.

Our study showed that the awareness and control rates of HTN have improved markedly, nearly 2 and 3 times as that in 2002, respectively,16 and similar to other recent national surveys.8,9 This improvement may be partially attributed to healthcare reform and community-based standardized BP management programs launched by the government over the last decade,3032 resulting in significant increases in healthcare access and quality.33 However, the awareness and control rates remain lower than in North American, which are 80% and 55%, respectively.34,35 Thus, there remains a huge potential health burden for future cardiovascular events in China. New methods36 and information-communication technology37 can improve BP control, improving the status of HTN in China in the future.

Despite the increase in treatment and control of HTN since 2002,16 overall, 60% of adults who were taking prescription medication for HTN remained uncontrolled. Although previous studies provided evidence that most patients with HTN require >1 single antihypertensive agent, particularly if they have comorbid conditions,38 ≈70% of the patients with HTN with drug treatment in China were currently using monotherapy. Although low-cost generic antihypertensive medications were available, the current treatment approach was ineffective.31 Therefore, strategies leading to increased use of combination therapy may prove effective.39

This study has several limitations. First, dietary salt consumption was not collected, and blood lipid and blood glucose levels were not measured in the whole population, which could influence the accuracy of the risk factor assessment for HTN. Fortunately, a subgroup with a sample size of 35 000 participants would be used to address this issue. Second, it would be of interest to investigate the relationship between risk factors and HTN or HTN-related disease burden in a cohort study rather than a cross-sectional study. Indeed, we will follow the current population of this study for several years. Furthermore, the potential impact of the 2017 American College of Cardiology/American Heart Association guideline on the prevention and treatment of HTN in Chinese population needs to be evaluated.

Conclusions

Our results showed that, although the prevalence of HTN is still increasing, the awareness, treatment, and control rates of HTN had improved significantly. The increasing prevalence, reduced urban-rural disparities, and changing of geographical distribution pattern of the HTN epidemic reflect dynamic changes over time. National strategies will be needed to further improve care of patients with HTN across China.

Acknowledgments

The authors thank all of the colleagues involved in the survey. The authors gratefully acknowledge Tianming Zhao, Guohui Fan, Jingyu Nie, and Suning Li for help in maintaining the data; and Yan Xie for help in preparing the investigators list.

Footnotes

*The names of the the China Hypertension Survey Investigators are listed in the online-only Data Supplement.

Sources of Funding, see page 2355

The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.117.032380/-/DC1.

http://circ.ahajournals.org

Zengwu Wang, MD, PhD, Division of Prevention and Community Health, National Center for Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 15 (Lin), Fengcunxili, Mentougou District, Beijing 102308, China; or Runlin Gao, MD, Department of Cardiology, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishilu, Xicheng District, Beijing 100037, China. E-mail or

References

  • 1. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the global burden of disease study 2013.Lancet. 2015; 385:117–171. doi: 10.1016/S0140-6736(14)61682-2.CrossrefMedlineGoogle Scholar
  • 2. GBD Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the global burden of disease study 2016.Lancet. 2017; 390:1151–1210. doi: 10.1016/S0140-6736(17)32152-9.CrossrefMedlineGoogle Scholar
  • 3. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, Wan X, Yu S, Jiang Y, Naghavi M, Vos T, Wang H, Lopez AD, Murray CJ. Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010.Lancet. 2013; 381:1987–2015. doi: 10.1016/S0140-6736(13)61097-1.CrossrefMedlineGoogle Scholar
  • 4. GBD Mortality Collaborators. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970–2016: a systematic analysis for the global burden of disease study 2016.Lancet. 2017; 390:1084–1150.CrossrefMedlineGoogle Scholar
  • 5. Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, Bahonar A, Chifamba J, Dagenais G, Diaz R, Kazmi K, Lanas F, Wei L, Lopez-Jaramillo P, Fanghong L, Ismail NH, Puoane T, Rosengren A, Szuba A, Temizhan A, Wielgosz A, Yusuf R, Yusufali A, McKee M, Liu L, Mony P, Yusuf S; PURE (Prospective Urban Rural Epidemiology) Study investigators. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries.JAMA. 2013; 310:959–968. doi: 10.1001/jama.2013.184182.CrossrefMedlineGoogle Scholar
  • 6. Egan BM, Li J, Hutchison FN, Ferdinand KC. Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals.Circulation. 2014; 130:1692–1699. doi: 10.1161/CIRCULATIONAHA.114.010676.LinkGoogle Scholar
  • 7. 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 Scholar
  • 8. Wang J, Zhang L, Wang F, Liu L, Wang H; China National Survey of Chronic Kidney Disease Working Group. Prevalence, awareness, treatment, and control of hypertension in China: results from a national survey.Am J Hypertens. 2014; 27:1355–1361. doi: 10.1093/ajh/hpu053.CrossrefMedlineGoogle Scholar
  • 9. Gao Y, Chen G, Tian H, Lin L, Lu J, Weng J, Jia W, Ji L, Xiao J, Zhou Z, Ran X, Ren Y, Chen T, Yang W; China National Diabetes and Metabolic Disorders Study Group. Prevalence of hypertension in china: a cross-sectional study.PLoS One. 2013; 8:e65938. doi: 10.1371/journal.pone.0065938.CrossrefMedlineGoogle Scholar
  • 10. Wang Z, Zhang L, Chen Z, Wang X, Shao L, Guo M, Zhu M, Gao R; China Hypertension Survey Group. Survey on prevalence of hypertension in China: background, aim, method and design.Int J Cardiol. 2014; 174:721–723. doi: 10.1016/j.ijcard.2014.03.117.CrossrefMedlineGoogle Scholar
  • 11. Chen Z, Wang X, Wang Z, Zhang L, Hao G, Dong Y, Zhu M, Gao R; China Hypertension Survey Group. Assessing the validity of oscillometric device for blood pressure measurement in a large population-based epidemiologic study.J Am Soc Hypertens. 2017; 11:730.e4–736.e4. doi: 10.1016/j.jash.2017.09.004.CrossrefGoogle Scholar
  • 12. Liu LS; Writing Group of 2010 Chinese Guidelines for the Management of Hypertension. 2010 Chinese guidelines for the management of hypertension.Zhonghua Xin Xue Guan Bing Za Zhi. 2011; 39:579–615.MedlineGoogle Scholar
  • 13. 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/APCM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.Hypertension. 2018; 71:e13–e115. doi: 10.1161/HYP.0000000000000065.LinkGoogle Scholar
  • 14. Chen CM, Kong LZ; China Obesity Problem Working Group. Chinese adults guidelines for the prevention and control of overweight and obesity. Beijing, China: People’s Medical Publishing House; 2006.Google Scholar
  • 15. Census Office of the State Council of China, Division of Population and Employment Statistics, National Bureau of Statistics of China. Tabulation on the 2010 population census on the People’s Republic of China. Beijing, China: China Statistics Press; 2012. http://www.stats.gov.cn/tjsj/pcsj/rkpc/6rp/indexch.htm. Accessed May 20, 2012.Google Scholar
  • 16. Wu Y, Huxley R, Li L, Anna V, Xie G, Yao C, Woodward M, Li X, Chalmers J, Gao R, Kong L, Yang X; China NNHS Steering Committee; China NNHS Working Group. Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002.Circulation. 2008; 118:2679–2686. doi: 10.1161/CIRCULATIONAHA.108.788166.LinkGoogle Scholar
  • 17. Lu J, Lu Y, Wang X, Li X, Linderman GC, Wu C, Cheng X, Mu L, Zhang H, Liu J, Su M, Zhao H, Spatz ES, Spertus JA, Masoudi FA, Krumholz HM, Jiang L. Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project).Lancet. 2017; 390:2549–2558. doi: 10.1016/S0140-6736(17)32478-9.CrossrefMedlineGoogle Scholar
  • 18. Julius S, Nesbitt SD, Egan BM, Weber MA, Michelson EL, Kaciroti N, Black HR, Grimm RH, Messerli FH, Oparil S, Schork MA; Trial of Preventing Hypertension (TROPHY) Study Investigators. Feasibility of treating prehypertension with an angiotensin-receptor blocker.N Engl J Med. 2006; 354:1685–1697. doi: 10.1056/NEJMoa060838.CrossrefMedlineGoogle Scholar
  • 19. Pinto E. Blood pressure and ageing.Postgrad Med J. 2007; 83:109–114. doi: 10.1136/pgmj.2006.048371.CrossrefMedlineGoogle Scholar
  • 20. Chen Z, Yu J, Song Y, Chui D. Aging Beijing: challenges and strategies of health care for the elderly.Ageing Res Rev. 2010; 9(Suppl 1):S2–S5. doi: 10.1016/j.arr.2010.07.001.CrossrefMedlineGoogle Scholar
  • 21. Ministry of Health. Annual report on health statistics. Beijing, China: Peking Union Medical College Publishing House; 2010.Google Scholar
  • 22. Jiang H, Room R, Hao W. Alcohol and related health issues in China: action needed.Lancet Glob Health. 2015; 3:e190–e191. doi: 10.1016/S2214-109X(15)70017-3.CrossrefMedlineGoogle Scholar
  • 23. Huang C, Yu H, Koplan JP. Can China diminish its burden of non-communicable diseases and injuries by promoting health in its policies, practices, and incentives?Lancet. 2014; 384:783–792. doi: 10.1016/S0140-6736(14)61214-9.CrossrefMedlineGoogle Scholar
  • 24. Wu X, Duan X, Gu D, Hao J, Tao S, Fan D. Prevalence of hypertension and its trends in Chinese populations.Int J Cardiol. 1995; 52:39–44.CrossrefMedlineGoogle Scholar
  • 25. Li J, Shi L, Li S, Xu L, Qin W, Wang H. Urban-rural disparities in hypertension prevalence, detection, and medication use among Chinese adults from 1993 to 2011.Int J Equity Health. 2017; 16:50. doi: 10.1186/s12939-017-0545-7.CrossrefMedlineGoogle Scholar
  • 26. Reynolds K, Gu D, Muntner P, Wu X, Chen J, Huang G, Duan X, Whelton PK, He J; InterASIA Collaborative Group. Geographic variations in the prevalence, awareness, treatment and control of hypertension in China.J Hypertens. 2003; 21:1273–1281. doi: 10.1097/01.hjh.0000059043.65882.15.CrossrefMedlineGoogle Scholar
  • 27. Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the united states: national health and nutrition examination survey, 2011–2012.NCHS Data Brief. 2013 October; 133:1–8.Google Scholar
  • 28. Spruill TM. Chronic psychosocial stress and hypertension.Curr Hypertens Rep. 2010; 12:10–16. doi: 10.1007/s11906-009-0084-8.CrossrefMedlineGoogle Scholar
  • 29. National Bureau of Statistics of China. National data.2013. http://data.Stats.Gov.Cn/english/swf.Htm?M=turnto&id=3. Accessed June 20, 2017.Google Scholar
  • 30. Wang ZW, Wang X, Zhang LF, Wang W, Chen WW, Zhu ML, Hu SS, Lei ZL, Kong LZ, Liu LS. Hypertension Control in Communities (HCC): evaluation result of blood pressure management among hypertensive.Zhonghua Liu Xing Bing Xue Za Zhi. 2010; 31:1–4.MedlineGoogle Scholar
  • 31. Wang Z, Wang X, Chen Z, Wang W, Zhu H, Chen W, Zhu M, Hu S, Staessen JA, Liu L, Fodor JG; Hypertension Control in Community Health Center Project Group. Hypertension control in community health centers across China: analysis of antihypertensive drug treatment patterns.Am J Hypertens. 2014; 27:252–259. doi: 10.1093/ajh/hpt186.CrossrefMedlineGoogle Scholar
  • 32. Chen Z. Launch of the health-care reform plan in China.Lancet. 2009; 373:1322–1324. doi: 10.1016/S0140-6736(09)60753-4.CrossrefMedlineGoogle Scholar
  • 33. GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the global burden of disease study 2015.Lancet. 2017; 390:231–266.CrossrefMedlineGoogle Scholar
  • 34. Yoon SS, Gu Q, Nwankwo T, Wright JD, Hong Y, Burt V. Trends in blood pressure among adults with hypertension: United States, 2003 to 2012.Hypertension. 2015; 65:54–61. doi: 10.1161/HYPERTENSIONAHA.114.04012.LinkGoogle Scholar
  • 35. Joffres M, Falaschetti E, Gillespie C, Robitaille C, Loustalot F, Poulter N, McAlister FA, Johansen H, Baclic O, Campbell N. Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study.BMJ Open. 2013; 3:e003423. doi: 10.1136/bmjopen-2013-003423.CrossrefMedlineGoogle Scholar
  • 36. Milani RV, Lavie CJ, Wilt JK, Bober RM, Ventura HO. New concepts in hypertension management: a population-based perspective.Prog Cardiovasc Dis. 2016; 59:289–294. doi: 10.1016/j.pcad.2016.09.005.CrossrefMedlineGoogle Scholar
  • 37. Kario K. Evidence and perspectives on the 24-hour management of hypertension: hemodynamic biomarker-initiated “ anticipation medicine” for zero cardiovascular event.Prog Cardiovasc Dis. 2016; 59:262–281. doi: 10.1016/j.pcad.2016.04.001.CrossrefMedlineGoogle Scholar
  • 38. Frankel LK. The relation of life insurance to public hygiene. 1910.Am J Public Health. 2011; 101:1868–1869.CrossrefMedlineGoogle Scholar
  • 39. Hua K, Hao G, Li W. Cardiovascular outcomes of lifestyle intervention in hypertensive patients with antihypertensive agents.Int J Cardiol. 2017; 227:751–756. doi: 10.1016/j.ijcard.2016.10.062.CrossrefMedlineGoogle Scholar

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