Abstract
Tendency for mortality in hypertension has not been well-characterized in European Union (EU). Mortality data from 1980 to 2011 in EU were used to calculate age-standardized mortality rate (ASMR, per 100,000), annual percentage change (APC) and average annual percentage change (AAPC). The Joinpoint Regression Program was used to compare the changes in tendency. Mortality rates in the most recent year studied vary between different countries, with the highest rates observed in Slovakia men and Estonia women. A downward trend in ASMR was demonstrated over all age groups. Robust decreases in ASMR were observed for both men (1991-1994, APC = -13.54) and women (1996-1999, APC = -14.80) aged 55-65 years. The tendency of systolic blood pressure (SBP) from 1980 to 2009 was consistent with ASMR, and the largest decrease was observed among Belgium men and France women. In conclusion, SBP associated ASMR decreased significantly on an annual basis from 1980 to 2009 while a slight increase was observed after 2009. Discrepancies in ASMR from one country to another in EU are significant during last three decades. With a better understanding of the tendency of the prevalence of hypertension and its mortality, efforts will be made to improve awareness and help strict control of hypertension.
Keywords: Hypertension, mortality, tendency
Introduction
Hypertension, or elevated blood pressure, is among the most serious risk factors for cardiovascular disease (CVD). In 2008, approximately 40% of adults aged over 25 had been diagnosed with hypertension worldwide [1], and the number of people with hypertension rose from 600 million in 1980 to 1 billion in 2008 [2]. The estimated global mortality associated with hypertension has been increased since 2000 [3]. Complications of hypertension also account for 9.4 million deaths per year [4]. Hypertension is responsible for nearly 45% of deaths due to ischemic heart disease and 51% of deaths due to stroke [5]. The health consequences of hypertension can also be compounded by other risk factors such as hyperglycemia and hypercholesterolemia, which increase the odds of mortality [6]. Hypertension has been defined as a major public health problem by World Health Organization [7].
However, the prevalence and associated mortality of hypertension vary between different regions. The prevalence of hypertension is highest in the African region at 46% of adults aged 25 and above, while the lowest prevalence at 35% is in the Americans [8]. Generally, high-income countries have a lower prevalence of hypertension compared to low-income countries [9]. Among developed countries, European countries have been reported to have a much higher prevalence of hypertension comparing to Canada and the United States [10]. These maybe caused by less medical treatment and management in developing countries [11], and unhealthy lifestyle including increased salt and fat intake and lack of exercise [12].
The prevalence of CVD has been well-studied as a major cause of morbidity and mortality in the world [13]. However, hypertension, one of the most important risk factors of CVD, is less well-characterized, especially in the European Union (EU). A comprehensive and detailed investigation of mortality rate in the EU could provide insight into primary and secondary prevention of hypertension.
In the present study, we compared tendency in age-specific mortality and systolic blood pressure (SBP) in different EU countries from 1980 to 2011. This study may provide insights into the management of hypertension and eventually help reduce hypertension-related end-organ damage.
Methods
Data were extracted on country- and sex-specific death rate and population size from World Health Organization (WHO) global mortality database from 1980 to 2011 (or the most recent available year). All available European countries were included to analyze the age- and sex-specific mortality rate of hypertension [6]. We excluded records with invalid dates, missing age, or missing sex from the analysis, such as Cyprus [14]. Death and population data for Germany prior to 1990 were obtained by combining the former Federal Republic of Germany and the former Democratic Republic of Germany [6]. After this, data were analyzed from 26 European countries.
In our study, hypertension was defined as a blood pressure of ≥ 140/90 mmHg among the population defined as having hypertension. Mean SBP, which in this study was presented as age-standardized SBP trends by sex and country - was analyzed using 25-year crude total percent change. This method resulted in more representative and stable rates and minimized the effect of year-to-year fluctuation in systolic blood pressure trends. The average change in the five most recent years was compared to the average change in the five years prior.
Age groups were defined as (i) < 45 years, (ii) 45-54 years, (iii) 55-64 years, (iv) 65 years and over. All participants under 45 years of age were combined due to low mortality.
Age-standardized mortality rate (ASMR) was standardized according to the European standard population by the direct method. Annual percentage change (APC) and average annual percentage change (AAPC) for hypertensive disease during different periods were computed by Joinpoint Regression Program version 4.0. Joinpoint regression was performed to identify periods with distinct log-linear trends in death rates. We calculated all analyses separately according to sex due to different trends in the key variables. The two-sided significance level was set at p less than 0.05 for all tests [15].
Results
Hypertension-related mortality
Table 1 shows an overview of available years of population and death data by country and sex for 2011 (or the most recent year). Data were extracted from 1980 to 2011, for a period of up to 32 years. Eleven of the 26 countries had complete data for all 32 study years, and an additional four had 31 years, and three had 30 years, and seven had 25 to 29 years of data available. The least amount of data was from Slovakia, whose data were only available from 1992 onwards. The number of deaths was lower in men compared to women in 25 of 26 countries in 2011, except for Slovakia (784 in men and 392 in women). The mortality rate resulting from hypertension was from 0.5% to 11.5% in male (Belgium to Slovakia) and from 0.28% to 17.2% in female (Latvia to Estonia).
Table 1.
Overview of available years of population and death numbers by country and sex for 2011 (or the most recent years)
| Males 2011a | |||||
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| |||||
| European Union | Data years | Total population | Total deaths | Hypertensive disease | Deaths (% total) |
|
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| Austria | 1980-2011 | 4105493 | 36539 | 1172 | 3.2075% |
| Belgium | 1980-1999, 2003-2009 | 5290436 | 51356 | 261 | 0.5082% |
| Bulgaria | 1980-2011 | 3577946 | 56634 | 3216 | 5.6786% |
| Czech Republic | 1986-2011 | 5153009 | 54141 | 899 | 1.6605% |
| Denmark | 1980-2011 | 2690179 | 25718 | 362 | 1.4076% |
| Estonia | 1981-1982, 1985-2011 | 617809 | 7456 | 662 | 8.8788% |
| Finland | 1980-2011 | 2645475 | 25152 | 364 | 1.4472% |
| France | 1980-2009 | 30334982 | 273461 | 3113 | 1.1384% |
| Germany | 1980-2011 | 40152977 | 407628 | 9975 | 2.4477% |
| Greece | 1980-2010 | 5598793 | 56480 | 1446 | 2.5602% |
| Hungary | 1980-2011 | 4737813 | 63883 | 2463 | 3.8555% |
| Ireland | 1980-2010 | 2217664 | 15044 | 121 | 0.8043% |
| Italy | 1980-2003, 2006-2010 | 29350339 | 285068 | 9796 | 3.4364% |
| Latvia | 1980-2010 | 1033421 | 14584 | 308 | 2.1119% |
| Lithuania | 1981-1982, 1985-2010 | 1527510 | 21536 | 244 | 1.1330% |
| Luxembourg | 1980-2011 | 252018 | 1810 | 14 | 0.2210% |
| Malta | 1980-2011 | 206909 | 1664 | 6 | 0.3606% |
| Netherlands | 1980-2011 | 8263177 | 65259 | 448 | 0.6865% |
| Poland | 1980-1996, 1999-2011 | 18650105 | 198178 | 2309 | 1.1651% |
| Portugal | 1980-2003, 2007-2011 | 5042781 | 52786 | 643 | 1.2181% |
| Romania | 1980-2011 | 10434143 | 137957 | 11173 | 8.0989% |
| Slovakia | 1992-2010 | 2639896 | 27645 | 3183 | 11.5138% |
| Slovenia | 1985-2010 | 1014716 | 9292 | 861 | 1.8618% |
| Spain | 1980-2011 | 22697679 | 198121 | 3193 | 1.6116% |
| Sweden | 1980-2010 | 4669629 | 43919 | 642 | 1.4618% |
| UK | 1980-1999, 2001-2010 | 30643254 | 270945 | 2150 | 0.7935% |
|
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| Females 2011a | |||||
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| European Union | Data years | Total population | Total deaths | Hypertensive disease | Deaths (% total) |
|
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| Austria | 1980-2011 | 4105493 | 36539 | 2543 | 6.9596% |
| Belgium | 1980-1999, 2003-2009 | 5290436 | 51356 | 617 | 1.1761% |
| Bulgaria | 1980-2011 | 3577946 | 56634 | 3873 | 6.8386% |
| Czech Republic | 1986-2011 | 5153009 | 54141 | 1203 | 2.2824% |
| Denmark | 1980-2011 | 2690179 | 25718 | 523 | 1.9746% |
| Estonia | 1981-1982, 1985-2011 | 617809 | 7456 | 1281 | 17.1808% |
| Finland | 1980-2011 | 2645475 | 25152 | 673 | 2.7190% |
| France | 1980-2009 | 30334982 | 273461 | 5839 | 2.2140% |
| Germany | 1980-2011 | 40152977 | 407628 | 23587 | 5.7864% |
| Greece | 1980-2010 | 5598793 | 56480 | 1684 | 3.2013% |
| Hungary | 1980-2011 | 4737813 | 63883 | 4505 | 6.9402% |
| Ireland | 1980-2010 | 2217664 | 15044 | 197 | 1.4220% |
| Italy | 1980-2003, 2006-2010 | 29350339 | 285068 | 18866 | 6.6180% |
| Latvia | 1980-2010 | 1033421 | 14584 | 507 | 0.2776% |
| Lithuania | 1981-1982, 1985-2010 | 1527510 | 21536 | 330 | 1.6032% |
| Luxembourg | 1980-2011 | 252018 | 1810 | 22 | 0.7178% |
| Malta | 1980-2011 | 206909 | 1664 | 15 | 0.9357% |
| Netherlands | 1980-2011 | 8263177 | 65259 | 704 | 1.0787% |
| Poland | 1980-1996, 1999-2011 | 18650105 | 198178 | 3159 | 1.7815% |
| Portugal | 1980-2003, 2007-2011 | 5042781 | 52786 | 1216 | 2.4120% |
| Romania | 1980-2011 | 10434143 | 137957 | 16098 | 13.2204% |
| Slovakia | 1992-2010 | 2639896 | 27645 | 784 | 1.5194% |
| Slovenia | 1985-2010 | 1014716 | 9292 | 392 | 3.8317% |
| Spain | 1980-2011 | 22697679 | 198121 | 6476 | 3.5210% |
| Sweden | 1980-2010 | 4669629 | 43919 | 1163 | 2.4957% |
| UK | 1980-1999, 2001-2010 | 30643254 | 270945 | 3051 | 1.0495% |
Data are for year 2011, or most recent years available.
Tendency in age- and sex-specific mortality rate
ASMR for hypertension increased steadily from the youngest to the oldest age groups as shown in Figures 1 and 2. This trend was generally similar in males and females. In all age groups, four joinpoints were identified. The proportion increased with age, from 0.2 in 100000 people in their 20 s and 30 s to 14 in 100000 people in their 60 s and over (men) and 0.1 in 100000 people to 20 in 100000 people (women). Overall, almost all the age groups showed a statistically significant annual decrease in hypertensive disease. The most robust decreases in ASMR observed for both men (1991-1994, APC = -13.54) and women (1996-1999, APC = -14.80) were in the 55-65 year age group, while the weakest decreases were observed in the 55-65 year age group in men (1980-1991, APC = -0.20) and in the < 45 year age group in women (1980-1991 APC = -1.71). All four age groups demonstrated a slight tendency toward increasing ASMR from 2009 to the most recent years, which was in accordance with recent hypertension prevalence [16].
Figure 1.
Age-specific mortality rates (per 100,000) for hypertension by age group in male in the EU, 1980-2011. A. < 45 years; B. 45-54 years; C. 55-64 years; D. 65 years and over.
Figure 2.
Age-specific mortality rates (per 100,000) for hypertension by age group in female in the EU, 1980-2011. A. < 45 years; B. 45-54 years; C. 55-64 years; D. 65 years and over.
Joinpoint analysis: APC in ASMR in the EU
Table 2 shows inflection points and evidence for variable changes in ASMR from 1980 to 2011, and four joinpoints have been identified by Joinpoint analysis. The difference in the mortality rate associated with hypertensive disease between males and females was minimal for almost all countries. ASMR varied extensively between different countries, and over half the countries demonstrated continuous increases in recent years, especially Latvia, which has experienced sustained growth during the last three decades. Overall, we noted four patterns in mortality rates in the EU: 1): Up-down. Rose during the first, second or third trend and declined in the last trend, which included four countries (Belgium, Bulgaria, Denmark and Luxembourg). The notable exception to this pattern was Germany. 2): Up-down-up. The first or second trend was similar to 1, whereas in recent years, mortality rate consistently increased. This pattern was observed in ten countries. 3): Down-up-down. This pattern was reflected in six countries (Austria, Finland, Italy, Portugal, Slovenia, UK) and was notably different from pattern 2. 4): Down-up-down-up. This pattern was seen with three countries (Ireland, Poland, Slovakia).
Table 2.
Annual percentage change (APC) in age-standardized mortality rates in the EU of homogeneous variation identified by joinpoint analysis from 1980 to 2011. The Average Annual Percentage Change (AAPC) is significantly different from zero at alpha = 0.05
| Country | Trend1 | Trend2 | Trend3 | Trend4 | ||||||||||||
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| Males | Period | APC | Lower CI | Uper CI | Period | APC | Lower CI | Uper CI | Period | APC | Lower CI | Uper CI | Period | APC | Lower CI | Uper CI |
|
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| Austria | 1980-2000 | -3.4^ | -3.9 | -2.9 | 2000-2003 | -18.5 | -38 | 7.2 | 2003-2006 | 23 | -2.4 | 55.2 | 2006-2011 | 6.8^ | 3 | 10.8 |
| Belgium | 1980-1982 | -4 | -33.9 | 39.5 | 1982-1985 | 28 | -11.1 | 84.2 | 1985-1992 | -12.8^ | -17.3 | -7.9 | 1992-2009 | -2.6^ | -4 | -1.2 |
| Bulgaria | 1980-1993 | 5.0^ | 3 | 7 | 1993-1996 | 14.9 | -11.1 | 48.4 | 1996-2003 | 1.4 | -2.1 | 5 | 2003-2011 | -4.0^ | -6.2 | -1.7 |
| Czech Republic | 1986-1993 | 4.6 | -2.3 | 12 | 1993-1996 | -36.1 | -70.1 | 36.7 | 1996-1999 | 41.8 | -20.8 | 154.1 | 1999-2011 | 5.2^ | 2.9 | 7.6 |
| Denmark | 1985-1993 | 2.1 | -0.7 | 4.9 | 1993-1996 | -6 | -25.8 | 19.2 | 1996-1999 | 18.7 | -5 | 48.3 | 1999-2006 | 1.8 | -0.6 | 4.3 |
| Estonia | 1981-1992 | 0.4 | -8.3 | 10 | 1992-1995 | 61.4 | -31.4 | 279.7 | 1995-1998 | -22.2 | -63.9 | 67.5 | 1998-2011 | 17.5^ | 14.8 | 20.3 |
| Finland | 1980-1984 | -5.5 | -22 | 14.3 | 1984-1990 | 13.5^ | 0.3 | 28.5 | 1990-2001 | -9.5^ | -12.8 | -6 | 2001-2011 | 12.5^ | 9.2 | 15.8 |
| France | 1980-1995 | 0 | -0.5 | 0.5 | 1995-1998 | 10 | -1.2 | 22.5 | 1998-2001 | -22.4^ | -31.1 | -12.6 | 2001-2009 | 0.6 | -0.8 | 2 |
| Germany | 1980-1989 | -4.0^ | -5.8 | -2.2 | 1989-1994 | -15.3^ | -21.2 | -8.9 | 1994-2000 | -1.3 | -7.9 | 5.6 | 2000-2011 | 4.2^ | 2.7 | 5.7 |
| Greece | 1980-1984 | 0 | -11.1 | 12.4 | 1984-1987 | -32.1 | -60.4 | 16.3 | 1987-1990 | 24.5 | -25.5 | 108.1 | 1990-2010 | 1.4^ | 0.4 | 2.3 |
| Hungary | 1980-1985 | 6.2^ | 0.1 | 12.5 | 1985-1994 | 0.6 | -2 | 3.3 | 1994-1997 | -27.0^ | -46.6 | -0.2 | 1997-2011 | 4.3^ | 2.9 | 5.7 |
| Ireland | 1980-1994 | -4.4^ | -5.6 | -3.3 | 1994-1999 | 5.9 | -2.8 | 15.3 | 1999-2006 | 1.4 | -2.5 | 5.5 | 2006-2009 | -36.0^ | -46.6 | -23.3 |
| Italy | 1980-1989 | -2.5^ | -3.1 | -1.8 | 1989-2001 | 3.1^ | 2.7 | 3.6 | 2001-2006 | -12.8^ | -17.7 | -7.6 | 2006-2010 | 5.3^ | 3.5 | 7.3 |
| Latvia | 1980-1991 | 9.8^ | 4.8 | 15.2 | 1991-1999 | -6.7 | -13.6 | 0.7 | 1999-2007 | 40.1^ | 34.2 | 46.3 | 2007-2010 | 2.3 | -5 | 10.1 |
| Lithuania | 1981-1990 | -22 | -43.5 | 7.7 | 1990-1993 | 524.3 | -39.8 | 6375.9 | 1993-2001 | -5.6 | -11.2 | 0.3 | 2001-2010 | 8.4^ | 4.6 | 12.3 |
| Luxembourg | 1980-1983 | 15.8 | -15.8 | 59.4 | 1983-1991 | -9.1^ | -17.3 | 0 | 1991-1994 | 18.6 | -43.6 | 149.3 | 1994-2010 | -8.1^ | -10.7 | -5.4 |
| Malta | 1980-1985 | -2.8 | -11.9 | 7.3 | 1985-1988 | -41.7 | -81.2 | 81.4 | 1988-2000 | -11.2^ | -18.5 | -3.3 | 2000-2011 | 3.6 | -4.9 | 13 |
| Netherlands | 1980-1985 | 2.1 | -3.3 | 7.8 | 1985-1994 | -1.1 | -3.4 | 1.4 | 1994-1997 | -20.3 | -38.4 | 3 | 1997-2011 | 1.6^ | 0.4 | 2.8 |
| Poland | 1980-1996 | -1.0^ | -1.9 | 0 | 1996-2001 | -16.3 | -39.5 | 15.8 | 2001-2006 | 9.8 | 0 | 20.5 | 2006-2011 | -0.9 | -6.2 | 4.7 |
| Portugal | 1980-1993 | -4.6^ | -5.9 | -3.3 | 1993-2000 | 5.3^ | 1.3 | 9.5 | 2000-2003 | -17.7 | -34.4 | 3.1 | 2003-2011 | 6.1^ | 1.6 | 10.8 |
| Romania | 1980-1988 | 3.2 | -0.6 | 7.1 | 1988-1997 | -4.8^ | -8.1 | -1.4 | 1997-2000 | -14.3 | -41.2 | 25 | 2000-2010 | 5.9^ | 3.3 | 8.6 |
| Slovakia | 1980-1996 | -23.3 | -43.9 | 5 | 1996-2000 | 36.4 | -15.1 | 119.3 | 2000-2005 | -1.2 | -20.2 | 22.4 | 2005-2010 | -30.4^ | -44.7 | -12.3 |
| Slovenia | 1980-1996 | -6.1^ | -9.4 | -2.7 | 1996-1999 | -17.6 | -59.2 | 66.6 | 1999-2006 | 6.6 | -3.5 | 17.8 | 2006-2010 | -6.8 | -19.8 | 8.3 |
| Spain | 1980-1992 | 2.6^ | 1.4 | 3.7 | 1992-1997 | 9.4^ | 4.9 | 14.1 | 1997-2000 | -23.3^ | -32.9 | -12.4 | 2997-2010 | 5.2^ | 4.1 | 6.2 |
| Sweden | 1980-1989 | 14.2^ | 9.1 | 19.4 | 1989-1995 | 7 | -0.8 | 15.4 | 1995-1998 | -27 | -49.8 | 6.1 | 1998-2010 | 7.6^ | 5.4 | 9.8 |
| UK | 1980-1990 | -6.2^ | -6.8 | -5.5 | 1990-1999 | -0.9 | -2 | 0.1 | 1999-2003 | -15.6^ | -26 | -3.7 | 2003-2011 | 4.8^ | 3.2 | 6.4 |
|
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| Country | Trend1 | Trend2 | Trend3 | Trend4 | ||||||||||||
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| Females | Period | APC | Lower CI | Uper CI | Period | APC | Lower CI | Uper CI | Period | APC | Lower CI | Uper CI | Period | APC | Lower CI | Uper CI |
|
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| Austria | 1980-1994 | -5.1^ | -5.8 | -4.5 | 1994-2000 | 2.7 | -0.9 | 6.4 | 2000-2003 | -16.7 | -31.2 | 0.9 | 2003-2011 | 11.7^ | 10 | 13.5 |
| Belgium | 1980-1982 | 8.4 | -23.2 | 53 | 1982-1985 | 25.9 | -8.2 | 72.6 | 1985-1989 | -16.8^ | -27.4 | -4.6 | 1989-2009 | -1.7^ | -2.5 | -0.9 |
| Bulgaria | 1980-1993 | 3.6^ | 1.5 | 5.8 | 1993-1996 | 14 | -13.5 | 50.3 | 1996-2003 | 1.4 | -2.3 | -4.6 | 2003-2011 | -2.9^ | -5.2 | -0.6 |
| Czech Republic | 1986-1992 | 7.4 | -0.9 | 16.3 | 1992-1995 | -30.7 | -58.6 | 15.8 | 1995-2007 | 12.2^ | 8.5 | -4.6 | 2007-2011 | -1 | -9.6 | 8.3 |
| Denmark | 1985-1996 | 0.3 | -2 | 2.6 | 1996-1999 | 12.4 | -17.8 | 53.7 | 1999-2004 | 6.3 | -2 | -4.6 | 2004-2006 | -6 | -26 | 19.5 |
| Estonia | 1981-1992 | 0.8 | -8.7 | 11.2 | 1992-1995 | 84.6 | -31.5 | 397.5 | 1995-1998 | -29.9 | -64.1 | -4.6 | 1998-2011 | 21.1^ | 18.8 | 23.5 |
| Finland | 1980-1994 | 4.4^ | 2.5 | 6.4 | 1994-1997 | -23.4 | -48.5 | 14 | 1997-2005 | 1.1 | -4.4 | -4.6 | 2005-2011 | 13.3^ | 7.6 | 19.4 |
| France | 1980-1995 | 0.4 | -0.1 | 0.8 | 1995-1998 | 10.3^ | 0.7 | 20.8 | 1998-2001 | -21.8^ | -29.2 | -4.6 | 2001-2009 | 0.7 | -0.4 | 1.9 |
| Germany | 1980-1989 | -3.5^ | -5.4 | -1.7 | 1989-1994 | -14.1^ | -20.2 | -7.6 | 1994-2000 | -0.7 | -7.7 | -4.6 | 2000-2011 | 4.8^ | 3 | 6.6 |
| Greece | 1980-1984 | 0.6 | -10.9 | 13.5 | 1984-1987 | -34.6 | -63.4 | 16.9 | 1987-1990 | 29.8 | -24.3 | -4.6 | 1990-2010 | 0.4 | -0.5 | 1.4 |
| Hungary | 1980-1986 | 5.1^ | 0.2 | 10.1 | 1986-1994 | -0.7 | -4.1 | 2.7 | 1994-1997 | -26.8 | -47.4 | -4.6 | 1997-2011 | 3.9^ | 2.4 | 5.3 |
| Ireland | 1980-1982 | -15.1 | -35 | 11 | 1982-1993 | -3.3^ | -5.6 | -0.9 | 1993-2006 | 3.2^ | 1.5 | -4.6 | 2006-2009 | -28.9^ | -40.6 | -14.9 |
| Italy | 1980-1989 | -1.3^ | -2.3 | -0.3 | 1989-2001 | 3.3^ | 2.7 | 3.9 | 2001-2006 | -12.4^ | -19.2 | -4.6 | 2006-2010 | 6.1^ | 3.5 | 8.8 |
| Latvia | 1980-1990 | 11.8^ | 4.8 | 19.4 | 1990-1999 | 0.3 | -5.7 | 6.8 | 1999-2007 | 40.6^ | 36.3 | -4.6 | 2007-2010 | 0.4 | -4.8 | 5.9 |
| Lithuania | 1981-1993 | 56.4^ | 30.5 | 87.5 | 1993-1996 | 18.2 | -10.4 | 55.8 | 1996-2000 | -18.0^ | -29.1 | -4.6 | 2000-2010 | 9.3^ | 7.1 | 11.4 |
| Luxembourg | 1980-1983 | 22.7 | -7.7 | 63.1 | 1983-1989 | -11.3 | -21.7 | 0.4 | 1989-1997 | 5.9 | -2.2 | -4.6 | 1997-2010 | -12.4^ | -15.8 | -8.7 |
| Malta | 1980-1984 | 0.9 | -10.2 | 13.4 | 1984-1987 | -39.6 | -66.1 | 7.5 | 1987-2000 | -11.3^ | -16 | -4.6 | 2000-2011 | 6.0^ | 0.5 | 11.8 |
| Netherlands | 1980-1988 | 2.2^ | 0.2 | 4.3 | 1988-1994 | -0.4 | -3.9 | 3.3 | 1994-1997 | -23.9^ | -37.2 | -4.6 | 1997-2011 | 2.5^ | 1.6 | 3.4 |
| Poland | 1980-1996 | -2.2^ | -3.1 | -1.4 | 1996-2001 | -16.3 | -38.1 | 13.3 | 2001-2006 | 7.7 | -1.3 | -4.6 | 2006-2011 | -0.5 | -5.7 | 5.1 |
| Portugal | 1980-1992 | -2.9^ | -3.9 | -1.8 | 1992-2000 | 4.3^ | 2.2 | 6.4 | 2000-2003 | -16.2^ | -27.7 | -4.6 | 2003-2011 | 6.2^ | 3.4 | 9.1 |
| Romania | 1980-1988 | 3.2 | -0.1 | 6.7 | 1988-1997 | -4.7^ | -7.5 | -1.8 | 1997-2000 | -15.5 | -38.8 | -4.6 | 2000-2010 | 5.5^ | 3.3 | 7.8 |
| Slovakia | 1980-1996 | -22.6 | -45.1 | 9.3 | 1996-2000 | 31 | -21.2 | 117.8 | 2000-2005 | -0.2 | -20.8 | -4.6 | 2005-2010 | -28.5^ | -43.5 | -9.6 |
| Slovenia | 1980-1990 | -10.4^ | -16.3 | -4.1 | 1990-1995 | 2.6 | -6.9 | 13 | 1995-1998 | -22 | -44.4 | -46 | 1998-2010 | 3.4^ | 1.5 | 5.3 |
| Spain | 1980-1989 | 3.5^ | 1.6 | 5.5 | 1989-1997 | 9.4^ | 7.5 | 11.4 | 1997-2000 | -21.0^ | -29.7 | -4.6 | 2997-2010 | 4.3^ | 3.3 | 5.2 |
| Sweden | 1980-1990 | 12.4^ | 8.9 | 16 | 1990-1995 | 6.9 | -1.6 | 16.1 | 1995-1998 | -22.3 | -41.5 | -4.6 | 1998-2010 | 8.7^ | 7 | 10.4 |
| UK | 1980-1994 | -5.0^ | -5.4 | -4.5 | 1994-1998 | 4.1 | -1.5 | 10.2 | 1998-2002 | -15.2^ | -20.6 | -4.6 | 2002-2010 | 4.1^ | 2.7 | 5.6 |
P less than 0.05.
5-year average SBP rates
Data for SBP were obtained from the Global Burden of Disease 2000 study and updated with the most recent, country-level data [3]. We analyzed mean systolic blood pressure trends (age-standardized estimate) in each country’s population over a span of 25 years (Table 3). Almost all countries in the EU demonstrated a significant decrease in mean SBP in the last three decades in both men and women (Table 3). Between 1980 and 2009, the largest decrease in 25-year crude total percent change among men was in Belgium (-8.9%), while the smallest decrease was in Romania (-1.6%). The exception to these decreases in 25-year crude total percent change was Denmark, which experienced nearly no change (0.58%). Among women, all the countries in the EU experienced a decrease, the largest being in France (-8.06%) while the smallest was in Spain (-3.1%).
Table 3.
Mean systolic blood trends (age-standardized estimate) by country in over 25-year population during 1980 to 2009
| Males | Mean systolic blood trends (age-standardized estimate) | ||||
|
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| European Union | 1980-1984 | 1990-1994 | 2000-2004 | 2005-2009 | 25-year crude total % change |
|
| |||||
| Austria | 137.5 | 134.6 | 132.4 | 131.5 | -4.4 |
| Belgium | 135.3 | 133.2 | 130.6 | 123.4 | -8.9 |
| Bulgaria | 135.4 | 135.4 | 133.6 | 133.7 | -1.28 |
| Czech Republic | 136.7 | 135.7 | 133.5 | 129.2 | -5.46 |
| Denmark | 135.4 | 132.6 | 128.8 | 136.2 | 0.58 |
| Estonia | 140.5 | 138.6 | 129.8 | 129.4 | -5.7 |
| Finland | 141.8 | 137.5 | 134.8 | 135.1 | -4.7 |
| France | 137.8 | 134.4 | 130.8 | 129.8 | -5.8 |
| Germany | 139.3 | 135.3 | 140.3 | 139.7 | 0.3 |
| Greece | 132.7 | 129.9 | 128,9 | 128.7 | -3.0 |
| Hungary | 138.4 | 138.2 | 135.9 | 135.4 | -2.1 |
| Ireland | 138.5 | 136.0 | 135.8 | 135.1 | -2.5 |
| Italy | 136.2 | 135.1 | 131.8 | 131.1 | -3.7 |
| Latvia | 138.6 | 136.8 | 135.4 | 136.2 | -1.7 |
| Lithuania | 139.8 | 137.8 | 135.8 | 136.8 | -2.2 |
| Luxembourg | 138.4 | 135.3 | 132.4 | 131.2 | -5.2 |
| Malta | 135.7 | 133.3 | 132.5 | 132.1 | -2.7 |
| Netherlands | 137.6 | 133.6 | 131.9 | 131.3 | -4.6 |
| Poland | 136.8 | 135.3 | 133.8 | 134.5 | -1.7 |
| Portugal | 137.5 | 135.5 | 135.1 | 134.7 | -2.1 |
| Romania | 135.2 | 134.9 | 132.8 | 133.0 | -1.6 |
| Slovakia | 137.4 | 137.1 | 135.1 | 135.0 | -1.7 |
| Slovenia | 138.5 | 137.7 | 136.0 | 135.8 | -2.0 |
| Spain | 135.3 | 131.1 | 130.2 | 130.3 | -3.7 |
| Sweden | 137.4 | 133.9 | 132.7 | 131.9 | -4.0 |
| UK | 136.1 | 136.7 | 133.9 | 131.6 | -3.3 |
|
| |||||
| Females | Mean systolic blood trends (age-standardized estimate) | ||||
|
|
|||||
| European Union | 1980-1984 | 1990-1994 | 2000-2004 | 2005-2009 | 25-year crude total % change |
|
| |||||
| Austria | 132.9 | 129.7 | 125.9 | 124.4 | -6.4 |
| Belgium | 130.5 | 128.4 | 124.9 | 122.2 | -6.4 |
| Bulgaria | 135.0 | 132.2 | 129.2 | 128.4 | -4.9 |
| Czech Republic | 135.4 | 131.4 | 127.1 | 125.8 | -7.07 |
| Denmark | 129.0 | 125.8 | 122.0 | 120.0 | -7.06 |
| Estonia | 137.2 | 132.7 | 129.8 | 129.4 | -5.7 |
| Finland | 137.4 | 133.3 | 128.8 | 127.0 | -7,6 |
| France | 131.1 | 127.4 | 122.9 | 120.5 | -8.06 |
| Germany | 134.5 | 132.1 | 128.0 | 125.4 | -6.8 |
| Greece | 130.9 | 127.6 | 124.5 | 123.2 | -5.9 |
| Hungary | 134.8 | 132.1 | 129.7 | 128.7 | -4.6 |
| Ireland | 129.9 | 128.4 | 126.2 | 124.9 | -3.9 |
| Italy | 134.4 | 129.9 | 126.7 | 124.1 | -7.6 |
| Latvia | 136.4 | 132.8 | 130.1 | 129.6 | -5.0 |
| Lithuania | 137.4 | 133.9 | 125.0 | 130.6 | -4.93 |
| Luxembourg | 132.7 | 129.2 | 125 | 122.8 | -7.5 |
| Malta | 134.4 | 130.8 | 126.7 | 124.7 | -7.2 |
| Netherlands | 131.0 | 127.5 | 123.8 | 122.1 | -6.8 |
| Poland | 136.7 | 132.2 | 130.0 | 129.7 | -5.1 |
| Portugal | 134.6 | 127.6 | 129.2 | 127.6 | -5.2 |
| Romania | 133.9 | 131.8 | 129.5 | 129.0 | -3.7 |
| Slovakia | 135.3 | 132.9 | 130.2 | 129.5 | -4.3 |
| Slovenia | 136.0 | 133.2 | 130.5 | 129.7 | -4.6 |
| Spain | 132.1 | 127.4 | 124.3 | 128.0 | -3.1 |
| Sweden | 132.0 | 128.8 | 125.1 | 123.2 | -6.7 |
| UK | 130.9 | 131.7 | 127.8 | 124.6 | -4.8 |
Age-standardized mean SBP decreased from 1980 to 2009 in 25 countries of the EU with the exception of Hungary, which experienced almost no change during this period (Figures S1-26). Overall, SBP was higher in men than in women. The most significant change in SBP among men occurred in Belgium, where SBP decreased from 136.3 mmHg (95% CI: 129.1-143.3 mmHg) to 128.5 mmHg (95% CI: 121.5-135.8 mmHg). Among women, the most significant change occurred in France, from 138.8 mmHg (95% CI: 132-146 mmHg) to 119.5 (95% CI: 114.2-124.5 mmHg).
Elevated blood pressure (SBP ≥ 140 or DBP ≥ 90) (age-standardized)
Data regarding elevated blood pressure (SBP ≥ 140 or DBP ≥ 90) (age-standardized) by country over a period of 25 years ending in 2008 were extracted from the WHO database. As expected, age-standardized elevated blood pressure was substantially higher in the treated than in the untreated groups of both sexes (Table 4).
Table 4.
Age-standardized mean and 95% confidence interval of SBP in adult population over 25 years of age, based on data from World Health Organization in 26 countries of EU, 1980-2009
| Country | Overall (males) | On medication (males) |
|
| ||
| Austria | 28.7 [17.7-41.2] | 33.4 [23.6-43.7] |
| Belgium | 24.6 [15.7-35.4] | 42.6 [32.9-52.9] |
| Bulgaria | 40.0 [28.3-52.0] | 39.3 [30.7-48.5] |
| Czech Republic | 39.3 [31.4-47.3] | 48.1 [39.4-56.8] |
| Denmark | 26.5 [18.0-36.3] | 47.6 [41.4-53.6] |
| Estonia | 47.3 [35.5-59.3] | 40.6 [32.4-48.8] |
| Finland | 34.9 [25.9-44.3] | 52.9 [44.3-61.7] |
| France | 29.1 [22.0-36.4] | 47.4 [39.6-55.7] |
| Germany | 31.1 [23.1-40.0] | 42.3 [35.6-49.2] |
| Greece | 25.1 [16.3-35.4] | 44.8 [37.3-52.8] |
| Hungary | 42.7 [31.7-53.2] | 43.8 [35.0-53.0] |
| Ireland | 34.9 [27.1-43.3] | 50 [42.0-57.6] |
| Italy | 28.6 [22.2-35.3] | 47 [39.8-54.5] |
| Latvia | 44.5 [29.7-59.3] | 42.2 [35.9-48.8] |
| Lithuania | 45.5 [33.2-58.3] | 51.2 [40.7-61.9] |
| Luxembourg | 28.5 [16.6-42.1] | 52.1 [43.5-61.2] |
| Malta | 29.9 [19.2-42.1] | 42.1 [31.6-52.7] |
| Netherlands | 28.9 [20.1-38.9] | 43.3 [34.0-53.2] |
| Poland | 41.3 [32.4-50.3] | 42.4 [34.5-50.8] |
| Portugal | 34.5 [25.7-44.6] | 49.3 [42.8-56.1] |
| Romania | 39.0 [26.6-52.0] | 46.5 [38.8-54.9] |
| Slovakia | 42.1 [27.9-56.9] | 47.1 [37.9-56.7] |
| Slovenia | 43.3 [28.9-57.9] | 50.4 [40.1-60.6] |
| Spain | 27.7 [20.7-35.5] | 41.5 [34.8-48.5] |
| Sweden | 29.7 [21.9-38.6] | 43.1 [35.9-50.9] |
| United Kingdom | 27.7 [21.9-34.0] | 42.2 [36.3-48.7] |
|
| ||
| Country | Overall (females) | On medication (males) |
|
| ||
| Austria | 19.8 [11.1-30.7] | 33.4 [23.6-43.7] |
| Belgium | 16.8 [9.8-26.4] | 30.4 [21.6-40.4] |
| Bulgaria | 31.2 [19.6-42.9] | 40.9 [30.7-50.6] |
| Czech Republic | 27.7 [21.1-34.3] | 37.6 [31.6-43.4] |
| Denmark | 15.6 [9.3-23.9] | 28.4 [20.6-37.2] |
| Estonia | 33.2 [22.3-44.0] | 42.2 [32.7-51.1] |
| Finland | 22.7 [16.1-29.8] | 36.3 [28.9-43.7] |
| France | 16.2 [11.4-21.3] | 29.3 [23.0-35.4] |
| Germany | 20.7 [14.1-27.4] | 34.3 [27.0-41.5] |
| Greece | 19.8 [12.6-28.3] | 32.7 [24.9-41.1] |
| Hungary | 31.3 [21.1-42.2] | 41 [31.9-50.2] |
| Ireland | 20.7 [15.2-26.7] | 34.2 [27.7-40.7] |
| Italy | 20.6 [15.2-26.2] | 33.6 [27.4-39.8] |
| Latvia | 32.7 [19.2-46.4] | 42.2 [30.6-53.5] |
| Lithuania | 34.3 [23.0-45.3] | 43.4 [33.7-52.7] |
| Luxembourg | 17.9 [9.0-29.2] | 31.3 [20.5-42.6] |
| Malta | 20.3 [11.0-30.6] | 33.8 [23.7-43.9] |
| Netherlands | 17.6 [11.4-25.3] | 30.8 [23.4-38.9] |
| Poland | 33.0 [25.4-41.0] | 42.4 [35.8-49.0] |
| Portugal | 24.3 [17.0-32.5] | 37.4 [29.9-45.4] |
| Romania | 32.9 [21.9-44.0] | 41.7 [32.3-51.0] |
| Slovakia | 32.5 [19.8-45.5] | 42.3 [30.6-53.6] |
| Slovenia | 32.8 [19.5-46.5] | 31.7 [25.8-38.2] |
| Spain | 18.6 [13.6-24.7] | 32.5 [25.8-39.5] |
| Sweden | 19.3 [13.6-26.3] | 32.8 [27.0-39.0] |
| United Kingdom | 19.1 [14.5-24.4] | 33.4 [23.6-43.7] |
Discussion
This study reports recent trends in mortality rates related to hypertension and mean SBP trends between 1980 and 2011 in the EU. The results show that mortality rates decline over a period of 27 years with a slight increase in recent years. We report that the magnitude of this decline differs by age group. The biggest reduction of ASMR occurred in the age group 55-65 years among both men and women, with an AAPC -6.02 in men and -8.02 in women. This may be a result of delayed mortality or an improvement in treatment and adoption of healthy lifestyle. The smallest reduction of ASMR occurs in age groups 55-65 years in men and < 45 years in women.
In our analysis, the SBP trend over 25 years from 1980 to 2009 is consistent with ASMR in the EU, suggesting a correlation between mortality and SBP. Several prospective cohort studies have similarly revealed that lower SBP at baseline is associated with reduced CVD mortality and incidence [17,18]. It has also been reported that a decline of 2 mmHg SBP is related to a 5% reduction in 16-year mortality from CVD [19]. During the past few decades, countries in the EU have conducted large-scale health surveys to decrease the prevalence and mortality of CVD [20]. According to the WHO Monitoring of Trends and Determinants in CVD (WHO MONICA) Project [21], widespread diagnosis and treatment with low-cost medications have also significantly reduced SBP across populations, and this has in turn contributed to a reduction in mortality due to hypertension [22].
Interestingly, from 2009 to the most recent years examined, there was a slight increase in ASMR across all age groups. It is possible that the increasing prevalence of cardiovascular risk factors, such as hyperlipidemia, diabetes, and obesity, may explain the upward trend observed in the most recent three years [23]. For instance, blood pressure levels could be lowered by approximately 0.06 mmHg by reducing saturated fat consumption by 1% or by increasing monounsaturated and polyunsaturated fat consumption by 0.5% [24]. However, mortality due to hypertension could not be established conclusively from the data available because of the diagnosis criteria and treatment time [25]. The trend toward an increase in ASMR will require more studies to draw any definitive conclusions.
The trend in mortality observed during the last three decades was variable between different countries. There may be two reasonable explanations for this observation: Firstly, as a consequence of discrepancies in economic development, population structure and health care systems, the number of people with uncontrolled or severe hypertension differs from one country to another in the EU. For example, this number rose from 600 million in 1980 to nearly 1 billion in 2008 in some of the EU countries [26]. Secondly, the initial time of diagnosis and treatment. Because high blood pressure may present free of the symptoms, it is usually asymptomatic for years, even when values are dangerously high [27]. Thus, hypertension often remains undiagnosed until symptoms of high blood pressure appear. The initial diagnosis and treatment of this condition in different countries could have a significant effect on the mortality associated with hypertension.
In conclusion, SBP associated ASMR decreased significantly on an annual basis from 1980 to 2009 while a slight increase was observed after 2009 in the EU. Discrepancies in ASMR from one country to another in the EU are significant during last three decades. With a better understanding of the tendency of the prevalence of hypertension and its mortality, efforts will be made to improve awareness and help strict control of hypertension, which eventually help improve survival of hypertension-related disease and facilitate the gradual movement towards a healthy lifestyle.
Acknowledgements
This work was supported by grants from the National Natural Science Foundation of China (81370332 and 81170201 to XL Li, 81200169 to JJ Xiao), the Priority Academic Program Development of Jiangsu Higher Education Institutions (PAPD2010-2013 to XL Li), the Innovation Program of Shanghai Municipal Education Commission (13YZ014 to JJ Xiao), the Foundation for University Young Teachers by Shanghai Municipal Education Commission (year 2012, to JJ Xiao), an Innovation fund from betShanghai University (sdcx2012038 to JJ Xiao), and the Program for the integration of production, teaching and research for University Teachers supported by the Shanghai Municipal Education Commission (year 2014, to JJ Xiao). Dr XL Li is an Associate Fellow at the Collaborative Innovation Center for Cardiovascular Disease Translational Medicine.
Disclosure of conflict of interest
None.
Supporting Information
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