Elsevier

The Lancet

Volume 374, Issue 9703, 21–27 November 2009, Pages 1765-1772
The Lancet

Articles
Premature deaths attributable to blood pressure in China: a prospective cohort study

https://doi.org/10.1016/S0140-6736(09)61199-5Get rights and content

Summary

Background

Hypertension is a major global-health challenge because of its high prevalence and concomitant risks of cardiovascular disease. We estimated premature deaths attributable to increased blood pressure in China.

Methods

We did a prospective cohort study in a nationally representative sample of 169 871 Chinese adults aged 40 years and older. Blood pressure and other risk factors were measured at a baseline examination in 1991 and follow-up assessment was done in 1999–2000. Premature death was defined as mortality before age 72 years in men and 75 years in women, which were the average life expectancies in China in 2005. We calculated the numbers of total and premature deaths attributable to blood pressure using population-attributable risk, mortality, and the population size of China in 2005.

Findings

Hypertension and prehypertension were significantly associated with increased all-cause and cardiovascular mortality (p<0·0001). We estimated that in 2005, 2·33 million (95% CI 2·21–2·45) cardiovascular deaths were attributable to increased blood pressure in China: 2·11 million (2·03–2·20) in adults with hypertension and 0·22 million (0·19–0·25) in adults with prehypertension. Additionally, 1·27 million (1·18–1·36) premature cardiovascular deaths were attributable to raised blood pressure in China: 1·15 million (1·08–1·22) in adults with hypertension and 0·12 million (0·10–0·14) in adults with prehypertension. Most blood pressure-related deaths were caused by cerebrovascular diseases: 1·86 million (1·76–1·96) total deaths and 1·08 million (1·00–1·15) premature deaths.

Interpretation

Increased blood pressure is the leading preventable risk factor for premature mortality in the Chinese general population. Prevention and control of this condition should receive top public-health priority in China.

Funding

American Heart Association (USA); National Heart, Lung, and Blood Institute, National Institutes of Health (USA); Ministry of Health (China); and Ministry of Science and Technology (China).

Introduction

Hypertension is a major public-health challenge worldwide because of its high prevalence and concomitant risks of cardiovascular disease.1, 2 An estimated 972 million adults, or 26·4% of the world's adult population, had hypertension in 2000.1 The number of adults with hypertension in 2025 is predicted to increase by 60% to 1·56 billion.1 This number, however, does not include prehypertension, which is also associated with increased risk of cardiovascular disease.3, 4 Several national surveys report that more than 30% of the general adult population has prehypertension.5, 6, 7

Prospective cohort studies have established a strong, graded, and independent positive association between blood pressure and risk of cardiovascular disease and premature death.8, 9, 10 Clinical trials have documented that lowering of blood pressure reduces cardiovascular mortality in patients with hypertension.10, 11 The number of blood-pressure-attributable deaths, however, has not been rigorously estimated in the general population. We aim to estimate the population-attributable risk and number of blood-pressure-attributable deaths in China in 2005, using data from a large prospective cohort study in a nationally representative sample of Chinese adults. Accurate estimates of the contribution of major risk factors to premature mortality are essential for development of policy to improve population health. These estimates can elucidate the potential for prevention and provide an evidence base for rational planning of health services, especially in economically developing countries where health-care resources are scarce and the blood-pressure-related disease burden is substantial.2, 12

Section snippets

Study population

In the 1991 China National Hypertension Survey, a multistage random cluster sampling design was used to select a nationally representative sample of the general population aged 15 years or older from all 30 provinces, autonomous regions, and municipalities of mainland China.13 The overall response rate was 89·5%. In 1999–2000, investigators from each province were invited to participate in the China National Hypertension Survey Epidemiology Follow-up Study. Of the 30 provinces, 13 were not

Results

Baseline characteristics of study participants from the 17 provinces included in the follow-up study were similar to those in the 13 excluded provinces. Mean baseline ages were 55·8 and 55·2 years; 49·2% and 48·3% were men; 24·0% and 23·2% had a high-school education; 19·8% and 18·8% were alcohol drinkers; 36·7% and 36·1% were physically inactive; 37·9% and 36·7% had ever smoked cigarettes; and 27·7% and 26·5% had hypertension in participants included and excluded from the follow-up study,

Discussion

Our results show that raised blood pressure is the leading preventable risk factor for premature deaths in China. We estimated that roughly 2·11 million cardiovascular deaths were attributable to hypertension in Chinese adults aged 40 years or older in 2005. Additionally, 0·22 million cardiovascular deaths were attributable to prehypertension. Of all cardiovascular deaths, 1·15 million related to hypertension and 0·12 million related to prehypertension were premature, of which more than 80%

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