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Original Investigation
January 10, 2017

Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015

Mohammad H. Forouzanfar, PhD1; Patrick Liu, BS1; Gregory A. Roth, MD1; et al Marie Ng, PhD1; Stan Biryukov, BS1; Laurie Marczak, PhD1; Lily Alexander, BA1; Kara Estep, MPA1; Kalkidan Hassen Abate, MS2; Tomi F. Akinyemiju, PhD3; Raghib Ali, FRCP4; Nelson Alvis-Guzman, PhD5; Peter Azzopardi, MEpi6,7; Amitava Banerjee, DPhil8; Till Bärnighausen, MD9,10; Arindam Basu, PhD11; Tolesa Bekele, MPH12; Derrick A. Bennett, PhD4; Sibhatu Biadgilign, MSc13; Ferrán Catalá-López, PhD14,15; Valery L. Feigin, PhD16; Joao C. Fernandes, PhD17; Florian Fischer, MPH18; Alemseged Aregay Gebru, MPH19; Philimon Gona, PhD20; Rajeev Gupta, PhD21; Graeme J. Hankey, MD22,23,24; Jost B. Jonas, MD25; Suzanne E. Judd, PhD26; Young-Ho Khang, MD27; Ardeshir Khosravi, PhD28; Yun Jin Kim, PhD29; Ruth W. Kimokoti, MD30; Yoshihiro Kokubo, PhD31; Dhaval Kolte, PhD32; Alan Lopez, PhD33; Paulo A. Lotufo, DrPH34; Reza Malekzadeh, MD35; Yohannes Adama Melaku, MPH36,37; George A. Mensah, MD38; Awoke Misganaw, PhD1; Ali H. Mokdad, PhD1; Andrew E. Moran, MD39; Haseeb Nawaz, MD40; Bruce Neal, PhD41,42,43,44; Frida Namnyak Ngalesoni, MSc45; Takayoshi Ohkubo, MD46; Farshad Pourmalek, PhD47; Anwar Rafay, MS48; Rajesh Kumar Rai, MPH49; David Rojas-Rueda, PhD50; Uchechukwu K. Sampson, MD51; Itamar S. Santos, PhD52; Monika Sawhney, PhD53; Aletta E. Schutte, PhD54; Sadaf G. Sepanlou, PhD35; Girma Temam Shifa, MPH55,56; Ivy Shiue, PhD57,58; Bemnet Amare Tedla, BS59; Amanda G. Thrift, PhD60; Marcello Tonelli, MD61; Thomas Truelsen, DMSc62; Nikolaos Tsilimparis, PhD63; Kingsley Nnanna Ukwaja, MD64; Olalekan A. Uthman, PhD65; Tommi Vasankari, PhD66; Narayanaswamy Venketasubramanian, FCRP67; Vasiliy Victorovich Vlassov, MD68; Theo Vos, PhD1; Ronny Westerman, PhD69,70; Lijing L. Yan, PhD71; Yuichiro Yano, MD72; Naohiro Yonemoto, MPH73; Maysaa El Sayed Zaki, PhD74; Christopher J. L. Murray, DPhil1
Author Affiliations
  • 1Institute for Health Metrics and Evaluation, University of Washington, Seattle
  • 2Jimma University, Jimma, Ethiopia
  • 3Department of Epidemiology, University of Alabama at Birmingham
  • 4University of Oxford, Oxford, United Kingdom
  • 5Universidad de Cartagena, Cartagena de Indias, Colombia
  • 6Centre for Adolescent Health, Parkville, Victoria, Australia
  • 7South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
  • 8University College London, Farr Institute of Health Informatics Research, London, United Kingdom
  • 9Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 10Wellcome Trust Africa Centre for Health and Population Studies, Somkhele, Mtubatuba, KwaZulu-Natal, South Africa
  • 11School of Health Sciences, University of Canterbury, Christchurch, New Zealand
  • 12Madawalabu University, Bale Goba, Ethiopia
  • 13Independent Public Health Consultants, Addis Ababa, Ethiopia
  • 14University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Department of Medicine, Valencia, Spain
  • 15Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 16Auckland University of Technology, National Institute for Stroke and Applied Neurosciences, Auckland, New Zealand
  • 17Pharmacology and Experimental Therapeutics, IBILI - Institute for Biomedical Imaging and Life Sciences, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
  • 18Bielefeld University, Bielefeld, Germany
  • 19Mekelle University, Mekelle, Ethiopia; Kilte Awlaelo-Health and Demographic Surveillance System
  • 20University of Massachusetts Boston
  • 21Eternal Heart Care Centre and Research Institute, Jaipur, India
  • 22School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia
  • 23Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia
  • 24Western Australian Neuroscience Research Institute, Nedlands, Western Australia, Australia
  • 25Ruprecht-Karls-University Heidelberg, Department of Ophthalmology, Medical Faculty Mannheim, Mannheim, Germany
  • 26University of Alabama at Birmingham
  • 27Seoul National University College of Medicine, Seoul, South Korea
  • 28Iranian Ministry of Health and Medical Education, Tehran, Iran
  • 29Southern University College, Johor, Malaysia
  • 30Simmons College, Boston, Massachusetts
  • 31National Cerebral and Cardiovascular Center, Department of Preventive Cardiology, Suita, Osaka, Japan
  • 32Brown University/Rhode Island Hospital, Providence, Rhode Island
  • 33University of Melbourne, Melbourne School of Population and Global Health, Melbourne, QLD, Australia
  • 34University of São Paulo, São Paulo, Brazil
  • 35Tehran Universities of Medical Sciences, Digestive Disease Research Institute, Tehran, Iran
  • 36Mekelle University, School of Public Health, Mekelle, Ethiopia
  • 37The University of Adelaide, School of Medicine, Adelaide, South Australia, Australia
  • 38National Institutes of Health, Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, Maryland
  • 39Columbia University, New York, New York
  • 40Southern Illinois University, Springfield
  • 41The George Institute for Global Health, Sydney, NSW, Australia
  • 42The University of Sydney, Sydney, New South Wales, Australia
  • 43Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
  • 44Imperial College London, London, United Kingdom
  • 45Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
  • 46Teikyo University School of Medicine, Tokyo, Japan
  • 47University of British Columbia, Vancouver, British Columbia, Canada
  • 48Contech School of Public Health, Lahore, Punjab, Pakistan
  • 49Society for Health and Demographic Surveillance, Suri, India
  • 50ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
  • 51National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Maryland
  • 52University of São Paulo, Internal Medicine Department, São Paulo, Brazil
  • 53Marshall University, Huntington, West Virginia
  • 54Hypertension in Africa Research Team (HART); South African Medical Research Council, North-West University, Potchefstroom, South Africa
  • 55Arba Minch University, Arba Minch, SNNPR, Ethiopia
  • 56Addis Ababa University, Addis Ababa, Ethiopia
  • 57Northumbria University, Faculty of Health and Life Sciences, Newcastle upon Tyne, United Kingdom
  • 58University of Edinburgh, Alzheimer Scotland Dementia Research Centre, Edinburgh, United Kingdom
  • 59University of Gondar, Gondar, Ethiopia; James Cook University, Cairns, Queensland, Australia
  • 60Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
  • 61University of Calgary, Calgary, Alberta, Canada
  • 62University of Copenhagen, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
  • 63University Heart Center of Hamburg, Hamburg, Germany
  • 64Federal Teaching Hospital, Department of Internal Medicine, Abakaliki, Nigeria
  • 65University of Warwick, Warwick Medical School, Coventry, United Kingdom
  • 66UKK Institute for Health Promotion Research, Tampere, Finland
  • 67Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore
  • 68National Research University Higher School of Economics, Moscow, Russia
  • 69Federal Institute for Population Research, Wiesbaden, Germany
  • 70German National Cohort Consortium, Heidelberg, Germany
  • 71Global Health Research Center, Duke Kunshan University, Kunshan, China
  • 72Department of Preventive Medicine, Northwestern University, Chicago, Illinois
  • 73National Center of Neurology and Psychiatry, Kodaira, Japan
  • 74Mansoura Faculty of Medicine, Mansoura, Egypt
JAMA. 2017;317(2):165-182. doi:10.1001/jama.2016.19043
Key Points

Question  What is the worldwide association between elevated blood pressure and the burden of disease?

Findings  In studies from 154 countries that included 8.69 million participants, it is estimated that between 1990 and 2015 the rate of systolic blood pressure (SBP) of at least 110 to 115 mm Hg increased from 73 119 to 81 373 per 100 000 persons, and SBP of 140 mm Hg or higher increased from 17 307 to 20 526 per 100 000 persons. The estimated rate of annual deaths associated with SBP of of at least 110 to 115 mm Hg increased from 135.6 to 145.2 per 100 000 persons, and for SBP of 140 mm Hg or higher increased from 97.9 to 106.3 per 100 000 persons.

Meaning  Over the past 25 years, the number of individuals with worldwide SBP levels of at least 110 to 115 mm Hg and of 140 mm Hg or higher and the estimated associated deaths have increased substantially.


Importance  Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions.

Objective  To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015.

Design  A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis.

Main Outcomes and Measures  Mean SBP level, cause-specific deaths, and health burden related to SBP (≥110-115 mm Hg and also ≥140 mm Hg) by age, sex, country, and year.

Results  Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73 119 (95% uncertainty interval [UI], 67 949-78 241) to 81 373 (95% UI, 76 814-85 770) per 100 000, and SBP of 140 mm Hg or higher increased from 17 307 (95% UI, 17 117-17 492) to 20 526 (95% UI, 20 283-20 746) per 100 000. The estimated annual death rate per 100 000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). Loss of disability-adjusted life-years (DALYs) associated with SBP of at least 110 to 115 mm Hg increased from 148 million (95% UI, 134-162 million) to 211 million (95% UI, 193-231 million), and for SBP of 140 mm Hg or higher, the loss increased from 95.9 million (95% UI, 87.0-104.9 million) to 143.0 million (95% UI, 130.2-157.0 million). The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0 million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg.

Conclusions and Relevance  In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (≥110-115 and ≥140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher.