Simplified hypertension screening methods across 60 countries: An observational study

Background
Simplified blood pressure (BP) screening approaches have been proposed. However, evidence is limited to a few countries and has not documented the cardiovascular risk amongst
missed hypertension cases, limiting the uptake of these simplified approaches. We quantified the proportion of missed, over-diagnosed, and consistently identified hypertension
cases and the 10-year cardiovascular risk in these groups.
Methods and findings
We used 60 WHO STEPS surveys (cross-sectional and nationally representative; n =
145,174) conducted in 60 countries in 6 world regions between 2004 and 2019. Nine simplified approaches were compared against the standard (average of the last 2 of 3 BP measurements). The 10-year cardiovascular risk was computed with the 2019 World Health
Organization Cardiovascular Risk Charts. We used t tests to compare the cardiovascular
risk between the missed and over-diagnosed cases and the consistent hypertension cases.
We used Poisson multilevel regressions to identify risk factors for missed cases (adjusted
for age, sex, body mass index, and 10-year cardiovascular risk). Across all countries, compared to the standard approach, the simplified approach that missed the fewest cases was
using the second BP reading if the first BP reading was 130–145/80–95 mm Hg (5.62%);
using only the second BP reading missed 5.82%. The simplified approach with the smallest
over-diagnosis proportion was using the second BP reading if the first BP measurement
was �140/90 mm Hg (3.03%). In many countries, cardiovascular risk was not significantly
different between the missed and consistent hypertension groups, yet the mean was slightly
lower amongst missed cases. Cardiovascular risk was positively associated with missed
hypertension depending on the simplified approach. The main limitation of the work is the
cross-sectional design