Background Hypertension affects over one billion people worldwide, posing a significant global health burden. Clinical practice guidelines could play a key role in guiding healthcare providers in improving hypertension management. However, how the quality of hypertension CPGs differs across country income settings is not well understood. This study aims to explore variation in the quality of hypertension CPGs, comparing low-, middle-, and high-income countries, using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Methods A Medline and grey literature search was conducted to identify hypertension CPGs in English from every country from January 2012 to September 2022. Two reviewers independently assessed and scored each CPG against the AGREE II tool. Results were described and the Kruskal-Wallis test was used to test for statistically significant difference in the domain scores across country income groups. Results Forty-three CPGs were included for analysis from across income settings. Guidelines from HICs scored higher in four out of the six domains. The highest scoring domain was 4: “clarity and presentation” (median score 83%), the lowest scoring was domain 6 “editorial independence” (median score 0%). Statistically significant differences between income settings were observed for domain 3 “rigour of development” (p <0.001), domain 4 “clarity and presentation” (p = 0.03) and domain 6 “editorial independence” (p = 0.04). Conclusions Whilst some variation exists in guideline quality across country income levels, the greatest degree of variation exists across the domains of the AGREE II tool. Global efforts to improve the quality of hypertension guidelines should focus on the transparent statement of editorial independence of guideline committees and apply rigorous replicable methods in the authoring of guidelines. Establishing national and international communities of practice to collaborate across income settings may reduce duplication of resource, allow for shared learning and promote the development of high-quality hypertension CPGs.

Background Hypertension affects over one billion people worldwide, posing a significant global health burden. Clinical practice guidelines could play a key role in guiding healthcare providers in improving hypertension management. However, how the quality of hypertension CPGs differs across country income settings is not well understood. This study aims to explore variation in the quality of hypertension CPGs, comparing low-, middle-, and high-income countries, using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Methods A Medline and grey literature search was conducted to identify hypertension CPGs in English from every country from January 2012 to September 2022. Two reviewers independently assessed and scored each CPG against the AGREE II tool. Results were described and the Kruskal-Wallis test was used to test for statistically significant difference in the domain scores across country income groups. Results Forty-three CPGs were included for analysis from across income settings. Guidelines from HICs scored higher in four out of the six domains. The highest scoring domain was 4: “clarity and presentation” (median score 83%), the lowest scoring was domain 6 “editorial independence” (median score 0%). Statistically significant differences between income settings were observed for domain 3 “rigour of development” (p <0.001), domain 4 “clarity and presentation” (p = 0.03) and domain 6 “editorial independence” (p = 0.04). Conclusions Whilst some variation exists in guideline quality across country income levels, the greatest degree of variation exists across the domains of the AGREE II tool. Global efforts to improve the quality of hypertension guidelines should focus on the transparent statement of editorial independence of guideline committees and apply rigorous replicable methods in the authoring of guidelines. Establishing national and international communities of practice to collaborate across income settings may reduce duplication of resource, allow for shared learning and promote the development of high-quality hypertension CPGs.

Objective: Hypertension is a leading cause of global morbidity and mortality and is a principal risk factor for cardiometabolic multimorbidity. Evidence regarding the prevalence of hypertension, hypertension treatment and blood pressure (BP) control is scarce in people with cardiometabolic long-term conditions (LTCs). May Measurement Month is the largest annual, global BP screening campaign providing one of the largest datasets on BP and cardiometabolic status. This study explores the association between cardiometabolic LTCs and hypertension, hypertension treatment, BP control, and mean BP. Design and methods: A total of 3,397,746 participants (≧18 years) from the three MMM campaigns in 2017–2019 arising from 103 countries were included. Data on three LTCs were collected: diabetes, myocardial infarction and stroke. Participants were subdivided based on number of LTCs. Hypertension was defined as having a systolic BP≧140mmHg and/or diastolic BP≧90mmHg, using the average of the second and third of three readings and/or taking antihypertensive medication. Multiple imputation was used to estimate BP readings if any readings were missing. Controlled hypertension was defined as a BP< 140/90mmHg on treatment. Results: Amongst all participants, 316940 (9.3%), 62731 (1.8%), and 28491 (0.8%) reported having one, two or three LTCs, respectively. There was a graded effect of increasing number of LTCs on rates of hypertension: 29.6% in those with no LTCs, and 63.0%, 68.6% and 71.2% in those with one, two or three LTCs, respectively. A similar graded effect was seen for the percentage of hypertensive participants on antihypertensive medication: 44.0% in those with no LTCs, and 79.6%, 87.1% and 89.8% in those with one, two or three LTCs, respectively. Despite higher treatment rates, BP control rates (<140/90mmHg) were similar in those with no LTCs, one or two LTCs (57.6%, 56.4% and 56.0%, respectively) but higher in those with three LTCs (67.9%). This was reflected in the average BPs of participants on treatment, with similar average BPs in those with no LTCs, one, or two LTCs (134/82mmHg, 135/81mmHg and 135/81mmHg, respectively) compared with lower BP (129/78mmHg) in those with three LTCs. Conclusions: With an increasing number of cardiometabolic LTCs, there was a graded increase in the likelihood of having hypertension, and amongst hypertensives, of being treated. Control rates were similar in those with two or fewer LTCs but higher in those with three LTCs, although BP control was suboptimal in all groups. Focused efforts in the higher-risk population with cardiometabolic LTCs are needed to reduce the global burden of hypertension.

Background: The increasing prevalence of people living with multimorbidity is an increasing challenge for health systems. Mean arterial pressure (MAP) serves as the steady component in a patient's arteries during one cardiac cycle while pulse pressure (PP) is recognized as the pulsatile component. Along with systolic blood pressure (BP) and diastolic BP, both MAP and PP are established risk factors for the development of major adverse cardiovascular events. The knowledge of how PP and MAP vary among hypertensives according to the presence of one or more long-term conditions (LTCs) is limited. May Measurement Month (MMM) is the largest contemporary global BP screening campaign designed to raise awareness of high BP. Purpose: To identify the association between BP parameters and number of LTCs (diabetes, myocardial infarction and stroke) in participants with hypertension. Design and methods: MMM is an opportunistic cross-sectional survey with over 4.8 million volunteers aged over 18 years recruited between 2017–2019, and 2021 in 106 countries. Three sitting BP readings were taken for each participant on a single occasion, with data on demographics, lifestyle, hypertension and LTCs collected. Hypertension was defined as systolic BP greater than 140mmHg and/or diastolic BP greater than 90mmHg (average of the second and third readings) and/or taking antihypertensive medication(s). Mixed-effects linear regression models were applied to compare the BP parameters with different numbers of LTCs, assuming random intercepts for country to account for clustering. Multivariable models were adjusted for age and sex (with an interaction term), medication use, current smoking and alcohol consumption. Findings: We analysed data from 1,107,432 individuals with hypertension, recorded data on LTCs and with all three BP readings. Overall, 860,376 (77.7%) had no LTCs, 188,306 (17.0%) had one, 40,592 (3.7%) had two, and 18,158 (1.6%) had three LTCs. After adjustment for potential confounders, the average PP of hypertensives without LTCs was 52.9mmHg. Compared to those with no LTCs, the PPs were significantly higher at 54.4mmHg, 54.9mmHg, and 53.6mmHg, in hypertensives with one, two or three LTCs, respectively (all p < 0.001). A strong inverse relationship was seen between MAP and numbers of LTCs, with mean MAPs of 104.1mmHg, 103.8mmHg, and 101.5mmHg in those with one, two or three LTCs respectively, compared to participants without (104.4 mmHg) (all p < 0.001). Conclusion: Our study highlights that the presence of one or more LTCs is associated with higher PP and lower MAP. These differences in PP and particularly reduced MAP may have implications for optimal BP management in people with multimorbidity.