Table 3.

Challenges for blood-pressure-lowering studies in LMICs

Category	Challenge
Risk stratification	well-characterized cohorts of individuals with hypertension and other vascular risk factors are needed across LMIC
Socio-demographics	differences in sociodemographic profiles between LMIC and HIC populations are likely to affect design and outcomes of clinical trials (Alladi et al., 2018)8
Life expectancy	life expectancy is lower in LMIC compared with HIC, changing the age profile of participants;, see World Bank data: https://data.worldbank.org/indicator/SP.DYN.LE00.IN
High comorbidity burden	the high burden of coexistent vascular risk factors, including untreated diabetes, metabolic syndrome, dietary factors, and cigarette smoking, must be considered in developing trial-specific cohorts
Cognitive assessment	trials that evaluate cognitive outcomes also require a uniform set of cognitive tests that are validated across diverse populations. Cognitive testing is challenging due to cultural, educational, and linguistic diversity. Harmonization efforts are underway to fill this gap, and validated neuropsychological batteries are now available in multiple languages and for different educational levels (Akinyemi et al.53; Iyer et al.)54
Biomarker standardization	imaging and plasma biomarkers of dementia and vascular disease also need to be standardized for diverse populations
Genetic studies	genetic factors, notably APOE genotype, may affect cognitive outcomes and should be systematically incorporated into study design
Infrastructure	infrastructure to implement trials is needed, including training of clinicians and researchers