Variation in the Proportion of Adults in Need of BP-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries: A Cross-Sectional Study of 1,037,215 Individuals from 50 Nationally Representative Surveys

Background: Current hypertension guidelines vary substantially in their definition of who should be offered blood-pressure-lowering medications. Understanding the impact of guideline choice on the proportion of adults who require treatment will be crucial for planning and scaling up hypertension care in low- and middle-income countries (LMICs). Methods: We extracted cross-sectional data on age, sex, blood pressure, hypertension treatment and diagnosis status, smoking, and body mass index for adults ages 30-70 from nationally representative surveys in 50 LMICs (N = 1,037,215). Our main objective was to determine the impact of hypertension guideline choice on the proportion of adults in need of blood-pressure-lowering medications. We considered four hypertension guidelines: the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline, the commonly used 140/90 mmHg threshold, the 2016 World Health Organization HEARTS guideline (WHO), and the 2019 United Kingdom National Institute for Health and Care Excellence (NICE) guideline. Results: The proportion of adults in need of blood-pressure-lowering medications was highest under the ACC/AHA followed by the 140/90, NICE, and WHO guidelines (ACC/AHA: women, 27.7% [95% CI: 27.2%, 28.2%], men, 35.0% [34.4%, 35.7%]; 140/90: women: 26.1% [25.5%, 26.6%], men, 31.2% [30.6%, 31.9%]; NICE: women, 11.8% [11.4%, 12.1%]; men, 15.7% [15.3%, 16.2%]; WHO: women, 9.2% [8.9%, 9.5%], men, 11.0% [10.6%,11.4%]). Individuals who were unaware that they have hypertension were the primary contributor to differences in the proportion needing treatment under different guideline criteria. Differences in the proportion needing blood-pressure-lowering medications were largest in the oldest, 65-69, age group (ACC/AHA: women, 60.2% [58.8%, 61.6%], men, 70.1% [68.8%, 71.3%]; WHO: women, 20.1% [18.8%, 21.3%], men, 24.1.0% [22.3%, 25.9%]). For both women and men and across all guidelines, countries in the European and Eastern Mediterranean regions had the highest proportion of adults in need of blood-pressure-lowering medicines while the South and Central Americas had the lowest. Conclusions: There was substantial variation in the proportion of adults in need of blood-pressure-lowering medications depending on which hypertension guideline was used. Given the great implications of this choice for health system capacity, policymakers will need to carefully consider which guideline they should adopt when scaling up hypertension care in their country.