The Lancet Commissions

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A call to action and a lifecourse strategy to address the global

burden of raised blood pressure on current and future
generations: the Lancet Commission on hypertension
Michael H Olsen*, Sonia Y Angell, Samira Asma, Pierre Boutouyrie, Dylan Burger, Julio A Chirinos, Albertino Damasceno, Christian Delles,
Anne-Paule Gimenez-Roqueplo, Dagmara Hering, Patricio López-Jaramillo, Fernando Martinez, Vlado Perkovic, Ernst R Rietzschel,
Giuseppe Schillaci, Aletta E Schutte, Angelo Scuteri, James E Sharman, Kristian Wachtell, Ji Guang Wang

Executive summary importance of other cardiovascular risk factors—eg, Lancet 2016; 388: 2665–712
Elevated blood pressure is the strongest modifiable risk smoking, obesity, dyslipidaemia, and diabetes mellitus— Published Online
factor for cardiovascular disease worldwide. Despite on antihypertensive treatment. However, as a September 23, 2016
http://dx.doi.org/10.1016/
extensive knowledge about ways to prevent as well as to Commission on hypertension, this report focuses mainly S0140-6736(16)31134-5
treat hypertension, the global incidence and prevalence on issues and actions related to elevated blood pressure.
*Chair
of hypertension and, more importantly, its cardiovascular Previous action plans for improving management of
Department of Internal
complications are not reduced—partly because of elevated blood pressure and hypertension have not yet Medicine, Holbæk Hospital and
inadequacies in prevention, diagnosis, and control of the provided adequate results. Therefore, the Commission Centre for Individualized
disorder in an ageing world. has identified ten essential and achievable goals and ten Medicine in Arterial Diseases
(CIMA), Odense University
The aim of the Lancet Commission on hypertension accompanying, mutually additive, and synergistic key
Hospital, University of
is to identify key actions to improve the management of actions that—if implemented effectively and broadly— Southern Denmark, Odense,
blood pressure both at the population and the individual will make substantial contributions to the management Denmark (M H Olsen DMSc);
level, and to generate a campaign to adopt the suggested of blood pressure globally. The Commission deliberately Hypertension in Africa Research
Team (HART), North-West
actions at national levels to reduce the impact of has not listed these complementary key actions by
University, Potchefstroom,
elevated blood pressure globally. The first task of the priority because the balance between strength of South Africa (M H Olsen);
Commission is this report, which briefly reviews the evidence, feasibility, and potential benefit could differ by Division of Prevention and
available evidence for prevention, identification, and country. Primary Care, New York City
Department of Health and
treatment of elevated blood pressure, hypertension,
Mental Hygiene, New York, NY,
and its cardiovascular complications. The report Introduction USA (S Y Angell MD); Global NCD
focuses on how as-yet unsolved issues might be tackled Background Branch, Division of Global
using approaches with population-wide impact and Elevated blood pressure is globally the strongest Health Protection, Center for
Global Health, Centers for
new methods for patient evaluation and education in modifiable risk factor for cardiovascular disease and Disease Control and Prevention,
the broadest sense (some of which are not always related disability. Its prevalence and downstream Atlanta, GA, USA (S Asma DDS);
strictly evidence based) to manage blood pressure detrimental impact on health are increasing because of Department of Pharmacology
worldwide. longer life expectancy and increased exposure to risk in and INSERM U 970, Georges
Pompidou Hospital, Paris
The report is built around the concept of lifetime risk the population. Despite extensive knowledge about ways Descartes University, Paris,
applicable to the entire population from conception. to both prevent and treat hypertension, its global France (Prof P Boutouyrie PhD);
Development of subclinical and sometimes clinical incidence, prevalence, and (more importantly) Kidney Research Centre, Ottawa
cardiovascular disease results from lifetime exposure to cardiovascular complications are not reduced, partly Hospital Research Institute,
Department of Cellular and
cardiovascular risk factors combined with the because of inadequacies in prevention, diagnosis, and Molecular Medicine, University
susceptibility of individuals to the harmful consequences control of the disorder in an ageing world. of Ottawa, ON, Canada
of these risk factors. The Commission recognises the (D Burger PhD); Department of

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 The Lancet Commissions
Prevention: lifestyle and environmental changes
Health-promoting environment
Healthy behaviours
Measurement access
Blood pressure diagnosis and evaluation
Measurement quality
Empowerment
Secondary hypertension
Pharmacological prevention and monitoring
Workforce expansion
Medication access
Standardised treatment
Blood pressure and health-care systems
Health-system strengthening
Figure 1: Key actions
Medicine at University Hospital
of Pennsylvania and Veteran’s
Administration, PA, USA
(J A Chirinos PhD); Faculty of
Medicine, Eduardo Mondlane
University, Maputo,
Mozambique
(A Damasceno PhD); Christian
Delles: Institute of
Cardiovascular and Medical
Sciences, University of Glasgow,
Glasgow, UK (Prof C Delles MD);
INSERM, UMR970,
2666
Creating a healthy environment through strategies that accelerate socioeconomic
improvements and implementation of accepted health-promoting policies
Universal understanding of unhealthy and healthy lifestyles and blood pressure
through endorsed, early, and sustained education using new technologies
Universal access to measurement of blood pressure through inexpensive blood
pressure monitors (linked to establishment of global blood pressure surveillance)
Better quality of blood pressure measurements through endorsed protocols and
certified and validated blood pressure monitors
Better identification of people at high risk to optimise treatment approaches
through endorsed education of patients and health-care professionals (linked to
stratified treatment approaches)
Better identification of people with secondary hypertension through endorsed and
simple flow charts (linked to stratified treatment approaches)
Expand the workforce engaged in the management of blood pressure through
task sharing and the use of endorsed education of community health workers
(linked to health-care system accountability)
Universal access to affordable, high-quality, and effective antihypertensive drugs
through collaboration between all major stakeholders
Treatment approaches stratified according to age, cardiovascular risk, social, cultural,
and ethnic differences through endorsed education of health-care professionals and
initiation of new research
Promote and ensure capacity and accountability of the health system to conduct
surveillance and monitoring, and respond appropriately to blood pressure levels
Aim
The Lancet Commission on hypertension aims to identify
key actions to improve management of blood pressure at
both the population and the individual level (figure 1), and
generate a campaign to adopt the suggested actions at
national levels to reduce the effect of elevated blood
pressure worldwide. The first step of the work of the Lancet
Commission on hypertension consists of this report,
which briefly reviews the current evidence for prevention,
diagnosis, evaluation, and treatment of elevated
blood pressure, hypertension, and its cardiovascular
complications. The report focuses on unsolved issues,
rethinking these in the context of approaches with
population-wide impact and new techniques for patient
evaluation and education in its broadest sense, thereby
suggesting new ways to manage blood pressure globally.
Because new techniques will be an important part of the
suggested solutions, our proposals will not always have a
strong evidence base, but will highlight where further
research might be most beneficial. Therefore, the aim of
the Lancet Commission will not be to conduct an extensive
review of hypertension or rewrite current guidelines on its
management, but to create the momentum for improved
management of elevated blood pressure.
Structure
The report is built around the concept of lifetime risk
starting with the entire population from conception.
Development of subclinical and sometimes clinical
cardiovascular disease (figure 2) corresponds with
lifetime exposure to cardiovascular risk factors combined
with the susceptibility of individuals to the harmful
consequences of these risk factors. During the course of
life, intervention is possible at different stages (figure 3),
with primordial (before any risk factor elevation),
primary, or secondary prevention strategies, on an
individual or population level, through environmental
changes, lifestyle changes, pharmacological treatment,
or a combination of these approaches. On the basis of
available evidence and future potential, we suggest new
strategies for programme-oriented, system-oriented, and
research-oriented actions. The Lancet Commission
recognises the importance of other cardiovascular risk
factors such as smoking, obesity, dyslipidaemia, and
diabetes mellitus on cardiovascular risk, which are very
important to take into account for initiation and goals of
antihypertensive treatment. However, as a Commission
on hypertension, this report focuses primarily on issues
and actions related to elevated blood pressure.
Nevertheless, many of the identified problems and
suggested actions are relevant for these other risk factors
as well.
Different types of research methodology are needed to
guide action. The use of randomised controlled trials is
feasible in high-risk populations in which studies of short
duration and relatively small cohort size allow for the
assessment of statistically relevant outcomes, but not in
relatively healthy populations in which long duration and
large sample sizes are needed to observe the outcomes of
interest.
We list ten mutually additive and synergistic key actions
directed towards ten identified essential goals, divided
into four categories bridging public health, health-care
systems, and clinical practice (figure 1). The Commission
deliberately has not ordered these key actions by priority,
because they are complementary and the balance between
strength of evidence and potential benefit is yet to be
determined and varies based on country context.
www.thelancet.com Vol 388 November 26, 2016
 The Lancet Commissions

Definition of hypertension Health–disease continuum

Because the relationship between blood pressure and Early vascular ageing Average lifecourse

More individualised strategies

organ damage Loss of QOL
cardiovascular risk is a continuum throughout the

Elevated BP Subclinical target- CV disease

(eg, absolute risk-based)

commonly observed range, there is no biological rationale
to define a threshold from which normal blood pressure Avoidable threshold 3:
turns into hypertension. The definition of hypertension as development of clinical disease

a disease entity is relevant mainly for the initiation or

change of treatment. However, the prognostic benefit of
blood pressure reduction is dependent on both the overall Avoidable threshold 2:
development of subclinical
cardiovascular risk of the patient and perhaps also how target-organ damage
the reduction is accomplished. Therefore, initiation of

Population-based strategies
treatment is dictated by an individual’s risk profile and set
of comorbidities (ie, assessed cardiovascular risk) and the Ideal lifecourse
Avoidable threshold 1:
development of elevated BP
level of blood pressure above which there is clear evidence
Healthy

that treatment will improve prognosis.

Therefore, the Commission defines individuals as having
hypertension when they persistently cross the blood Lifecourse
pressure threshold above which there is robust scientific Childhood Early adulthood Middle-age Advanced age Elderly (>80 years)
evidence that antihypertensive treatment will improve their
prognosis. Generally—particularly if the cardiovascular Figure 2: The lifecourse approach to management of elevated blood pressure
The figure shows three lifecourse trajectories of health and disease: the average lifecourse of individuals with early
risk of the individual is unknown—this threshold will be
vascular ageing, the average lifecourse in general, and the ideal lifecourse. Preventive efforts should be focused on
the traditional cutoff values of 140 mm Hg systolic, three avoidable thresholds, with the goal (small arrows) to improve lifecourse trajectory as much as possible.
90 mm Hg diastolic, or both. However, in some groups of CV=cardiovascular. QOL=quality of life. BP=blood pressure.
individuals, other values are possible. Specifically, growing
evidence from antihypertensive trials suggests that many approach is based on the need to consider early lifetime Paris-Cardiovascular
individuals at high risk or with particular comorbidities programming, long-term benefits, and changing ResearchCenter, F-75015, Paris,
France (Prof A-P Gimenez-
should have different hypertension thresholds, as in priorities with ageing.
Roqueplo PhD); Paris Descartes
patients with type 2 diabetes.1 However, among individuals A large body of evidence suggests that up to 80% of University, F-75006, Paris,
at low risk, the support for targets below 160 mm Hg cardiovascular disease can be prevented through a healthy France
systolic, 100 mm Hg diastolic, or both, are primarily based lifestyle (sufficient physical activity, avoidance of obesity, (Prof A-P Gimenez-Roqueplo);
Assistance Publique-Hôpitaux
on epidemiological data, which cannot directly be translated moderate alcohol intake, healthy diet, and no tobacco or de Paris, Hôpital Européen
into evidence for pharmacological treatment. Inherently, drug use).5 This finding has been consistently replicated Georges Pompidou,
the threshold used to define hypertension is very likely to even when the definition of a healthy lifestyle is narrowed Department of Genetics,
be a shifting point of reference driven by emerging or expanded to use different components such as F-75015, Paris, France
(Prof A-P Gimenez-Roqueplo);
evidence, whereas the thresholds for treatment initiation sufficient sleep duration.6 Importantly, this evidence is The University of Western
and goals are likely to shift even more due to differences in derived from epidemiological surveys that query an Australia—Royal Perth
resource availability and individual preferences. individual’s habitual behaviour (or attitude), and the Hospital, Perth, WA, Australia
Independent of how hypertension is defined, the observed benefits thus result from the cumulative effects (D Hering PhD); Direccion de
Investigaciones, FOSCAL and
prevalence of hypertension is strongly influenced by two of health behaviour over an individual’s lifetime, not a Instituto de Investigaciones
opposite directed factors. On the one hand, age-specific change in lifestyle. However, it is important to emphasise MASIRA, Facultad de Medicina,
blood pressure levels in high-income (and increasingly that lifestyle is heavily influenced by socioeconomic Universidad de Santander,
middle-income) countries are falling beyond what can be factors, and therefore healthy lifestyles are not always Bucaramanga, Colombia
(Prof P López-Jaramillo PhD);
explained by improved detection and treatment of available to all individuals, communities, or populations. Hypertension Clinic, Internal
hypertension, but might partly be accounted for by The Commission finds it likely that exposure to Medicine, Hospital Clinico,
improvements in early-life health and nutrition.2,3 On the cardiovascular risk factors in childhood or even during University of Valencia, Valencia,
other hand, this positive effect is partly counteracted by the fetal life promotes the development of vascular changes Spain (F Martinez PhD); The
George Institute for Global
ageing of the population worldwide, leading to an increase that launch the individual more towards the trajectory of Health, University of Sydney,
in the prevalence of hypertension among low-income and so-called early vascular ageing, in which an accumulation Sydney, NSW, Australia
middle-income countries.4 Because of the force of ageing, of (still subclinical) vascular damage occurs already in (Prof V Perkovic PhD);
Department of Cardiology,
even a marginal additional effect on blood pressure trends early adulthood. In the Young Finns Study, risk factor
Ghent University and
will have very large health benefits globally, especially in load (defined as extreme quintiles for LDL cholesterol, Biobanking & Cardiovascular
low-income and middle-income countries.2 HDL cholesterol, systolic blood pressure, body-mass Epidemiology, Ghent
index [BMI], and smoking) at age 3–18 years predicted University Hospital, Ghent,
Belgium (E R Rietzschel PhD);
Lifecourse approach intima-media thickening,7 increased arterial pulse wave
Department of Internal
Throughout this report, the Commission tackles velocity,8 elevated blood pressure,9 and loss of carotid Medicine, University of Perugia,
prevention and treatment of elevated blood pressure with distensibility10 on re-examination 21 years later in early Terni University Hospital, Terni,
a lifecourse approach. The evidence underpinning this adulthood (age 24–39 years). In this same cohort, more Italy (G Schillaci MD); Medical

www.thelancet.com Vol 388 November 26, 2016 2667

 The Lancet Commissions

Health–disease continuum
basis of epidemiological data, and by more than 45% on
Early vascular ageing Average lifecourse the basis of modelling with genetic data.5,14 The much-
organ damage Loss of QOL
Subclinical target- CV disease

lower benefit found in trials, probably related to off-target

Late preventive effort effects and poor adherence to therapy, underlines the
importance that this type of evidence demonstrates net
Health–disease
and epigenetic imprinting
Early lifecourse variability

clinical benefit. Furthermore, all these expectations are

(Influenced by maternal

continuum
influenced by genetics

Gain in disease progression

Early preventive effort based on the assumption that the relationship between
health)

Gain in time blood pressure and outcome is exponential, although

some data suggest a U-shaped association.15,16
Lifecourse Prevention of functional impairment at older ages is
Elevated BP

Birth
also important. In individuals older than 75 years, in
whom multiple diseases (primarily cardiovascular) co-
Ideal lifecourse exist, a lifecourse approach will be aimed at preservation
of functional reserve, slowing disease progression, and
mitigating complications to optimise quality of life, with
Healthy

the potential to decrease the demand on the health-

Lifecourse care system.17
Childhood Early adulthood Middle-age Advanced age Elderly (>80 years) Arterial ageing has a complex relationship with increased
blood pressure and cardiovascular risk, acting as a marker,
Figure 3: Early-life effects and impact of preventive efforts in the management of elevated blood pressure an outcome, and a driver (figures 2, 3). As shown in the
The insert shows the effects of genetic susceptibility and epigenetic imprinting during fetal life. Preventive efforts
result in downward shifts in the lifecourse curve, with earlier preventive efforts affecting lifecourse trajectory more
lifecourse approach in figure 2, there are three avoidable
than later preventive efforts. CV=cardiovascular. QOL=quality of life. BP=blood pressure. thresholds on which preventive efforts should be focused:
the development of elevated blood pressure, development
Research Council Unit on leisure-time physical activity in childhood was associated of subclinical cardiovascular damage, and, finally, the
Hypertension and with better carotid artery elasticity later in life,10 whereas development of overt cardiovascular disease leading to
Cardiovascular Disease,
an improvement in risk factor profile between youth and physical and cognitive disability, loss of autonomy, and loss
Hypertension in Africa Research
Team (HART), North-West adulthood slowed the progression of subclinical of quality of life. Some individuals with early vascular ageing
University, Potchefstroom, cardiovascular damage. Confirmatory findings were (red line) will cross these thresholds earlier in life. The
South Africa reported in the CARDIA and AGHALS cohorts.11,12 optimum or ideal lifecourse (green line) represents
(Prof A E Schutte PhD);
Hypertension Center,
In terms of genetic evidence, findings from several large- individuals who only develop elevated blood pressure or
Hypertension and Nephrology scale studies13 have clearly shown that the random subclinical cardiovascular damage, but too late in the
Unit, Department of Medicien, allocation of blood-pressure-related genetic variants (single lifecourse to substantially affect quality of life. The main
Policlinico Tor Vergata, Rome, nucleotide polymorphisms) is associated with a difference goal of preventive efforts (small grey arrows) is to shift an
Italy (A Scuteri PhD); Menzies
Institute for Medical Research,
in both blood pressure and cardiovascular outcome. individual’s lifecourse towards the ideal lifecourse. The
University of Tasmania, Hobart, Within the context of a lifecourse approach, the effect of a dashed endings of the lifecourse lines (specifically the ideal
TAS, Australia genetic variant on blood pressure seems to increase with lifecourse) are there to underscore that the goal of prevention
(J E Sharman PhD); Department ageing, suggesting a lifecourse effect of accelerated is not necessarily avoidance of ever developing cardio
of Cardiology, Division of
Cardiovascular and Pulmonary
ageing.14 Although lifestyle changes typically induce rather vascular disease, but avoidance of premature cardiovascular
Diseases Oslo University small reductions in blood pressure, they affect the large disease. Furthermore, there is always uncertainty at the end
Hospital, Oslo, Norway low-risk population and can act over decades, having the of life, and an individual on the ideal lifecourse can still
(K Wachtell DMSc); and potential to improve cardiovascular outcome on a suddenly develop cardiovascular disease. Depending upon
The Shanghai Institute of
Hypertension, RuiJin Hospital,
population level. By contrast, randomised controlled trials genetic disposition and/or epigenetic imprinting during
Shanghai Jiaotong University are typically designed to test large effects, in sick or high- fetal life, individuals can start their lifecourse higher or
School of Medicine, Shanghai, risk populations over a few years. In this sense, genetic lower on the health–disease continuum (the enlarged
China (Prof J Guang Wang PhD) studies are highly informative because they provide insert), reflecting the so-called cohort effect. The orange
Correspondence to: information about the effect of small variations in blood dashed lines show the impact of a preventive effort, with a
Mr Michael H Olsen,
Smedelundsgade 60,
pressure in the general population, in a fashion that is resultant downward shift in the lifecourse curve. Early
4300 Holbæk, Denmark randomly allocated and blinded to the individual preventive efforts are likely to result in a substantial gain in
mho@dadlnet.dk (who is usually unaware of their own genetic time (x-axis) or reduction in disease progression (y-axis)
predisposition), avoiding the risk of bias inherent in compared with later preventive efforts.
epidemiological studies about lifestyle changes. Thus,
natural genetic variation can hint at the effects that could Primordial, primary, and secondary prevention
be achievable with an intervention, provided it is both long The goal of primordial prevention is to maintain the state
term and free from off-target (ie, unwanted) effects. A of cardiovascular health and optimal blood pressure,
10 mm Hg decrease in systolic blood pressure is expected leading to an ideal lifecourse maintained within the
to reduce coronary heart disease risk by 17% on the basis of healthy range from birth to end of life. This goal
data from blood-pressure-lowering trials, by 25% on the necessitates a solid population-based strategy, combining

2668 www.thelancet.com Vol 388 November 26, 2016

 The Lancet Commissions

policy and environmental change, behavioural (ie, East Asia Laos STEPS 2013
lifestyle) incentives, education, and community-level and Pacific
Cambodia STEPS 2010
actions aimed at minimising the risk factor burden for the Mongolia STEPS 2013
population at large. Because these actions are not Europe and Albania DHS 2008–09
individualised (ie, individually tailored), the Commission central Asia Armenia DHS 2005
Moldova STEPS 2013
defines these actions as population based although they
Azerbaijan DHS 2006
reach individuals. Primary prevention (preventive actions Uzbekistan STEPS 2014
after hypertension is diagnosed) aims to avoid Ukraine DHS 2007
cardiovascular complications. Secondary prevention (after Kyrgyzstan DHS 2012
subclinical end-organ damage or overt cardiovascular Latin America and Caribbean Peru DHS 2012
Middle East and Egypt DHS 2008
disease develops) aims to avoid further cardiovascular north Africa Qater STEPS 2012
damage, cardiovascular events, and reduction in quality of South Asia Bhutan STEPS 2014
life. By contrast with primordial prevention, these Nepal STEPS 2013
Bangladesh DHS 2011
preventive actions are generally driven by an individual’s Sub-Saharan Malawi STEPS 2009
absolute risk. This approach necessitates a well Africa Tanzania STEPS 2012
functioning health system with the capacity to readily Togo STEPS 2010
Benin DHS 2011–12
detect individuals whose risk or blood pressure surpasses Namibia DHS 2013
a specific risk threshold for which a more individualised, Lesotho DHS 2009–10
clinical (often drug-based) approach is indicated, and to 0 20 40 60 80 100
Percentage of adults
deliver this strategy superimposed on ongoing lifestyle
interventions. Not aware Not on medication
On medication, blood pressure not controlled On medication, blood pressure controlled
Policy makers, health-care systems, the pharmaceutical
and food industries, and civil society are responsible for Figure 4: Adults with raised blood pressure or on medication for hypertension disaggregated by diagnosis
creating a healthy environment that removes barriers to and treatment status
STEPS=WHO STEPwise approach to surveillance. DHS=Demographic and Health Survey.
health and empowers populations to practise healthy
behaviours.
closely associated with different birth cohorts and mean
Summary of essential goals and key actions age of the population, it is a largely preventable condition
Previous action plans to improve prevention and caused by lifestyles increasingly characterised by
management of elevated blood pressure and hypertension reduced physical activity, unhealthy diet, overweight,
have not yet had global impact. We identified several and obesity,21–24 together with a poorly understood
achievable goals and accompanying actions that, if genetically influenced susceptibility to cardiovascular
implemented effectively and broadly, will make substantial risk factors. Social determinants of health such as
contributions to improve outcomes related to elevated socioeconomic disadvantage early in life drive related
blood pressure worldwide. Recognising the inequitable inequities in the burden of hypertension, morbidity, and
distribution of financial and other resources across and premature death in specific populations.4
within countries and regions, the Commission has further Despite blood pressure measurements in more than
classified the goals and actions appropriate at two different 150 national population-based surveys in 97 countries,
levels. We denote as essential those actions recommended no fully reliable global or regional estimates of
to be undertaken in all countries and regions, irrespective hypertension treatment coverage exist. Figure 4 shows
of income levels; the remaining actions are those that the distribution of diagnosis and control of raised blood
should be undertaken when additional resources permit. pressure in national surveys in selected countries that
are not part of the Organization for Economic Co-
The global perspective operation and Development. In most of these surveys,
Size of the problem at least half of adults with raised blood pressure had not
Because hypertension rarely causes symptoms in the been diagnosed with hypertension. Treatment coverage
early stages, it is a silent killer, causing accelerated is therefore low, ranging from 7% to 61% among people
atherosclerosis, damage to major organs, disability, and who had presented with raised blood pressure in the
death from cardiovascular disease.18 Approximately one household surveys (figure 5). Effective coverage is
in four adults have hypertension (when defined as blood considerably lower than total coverage, ranging from
pressure greater than 140 mm Hg systolic or 90 mm Hg 1% to 31%. Data from 11 national Demographics and
diastolic) and by 2025, hypertension is projected to affect Health Surveys disaggregated by wealth quintile
more than 1·5 billion people worldwide.19 In recent suggest that coverage of hypertension treatment differs
decades, there has been an epidemiological shift in the substantially across wealth quintiles in some but not all
main cause of global disease burden from communicable countries (figure 5).25 A consistent association between
to non-communicable disease, with hypertension being wealth and coverage is observed in Bangladesh, Benin,
the leading risk factor.20 Although blood pressure is Egypt, Namibia, and Peru. In nine of the 11 countries,

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 The Lancet Commissions
Europe and
Albania 2008–09
central Asia
Armenia 2005
Azerbaijan 2006
Kyrgyzstan 2012
Ukraine 2007
Latin America
and Caribbean Peru 2012
Middle East and
Egypt 2008
north Africa
South Asia Bangladesh 2011
Sub-Saharan Benin 2011–12
Africa
Lesotho 2009–10
Namibia 2013
0 10 20 30 40 50 60
Coverage (%)
Quintile 1 (poorest) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (richest)
Figure 5: Percentage of adults with raised blood pressure or on medications for hypertension, who are
currently taking medications for hypertension, by wealth quintile25
Raised blood pressure defined as systolic blood pressure greater than 140 mm Hg or diastolic blood pressure
greater than 90 mm Hg. Figure shows data for adults aged 35–59 years, except for Albania, Armenia, Kyrgyzstan,
and Ukraine (age 35–29 years), and Peru (age 40–59 years).
however, the poorest adults have lower treatment
coverage than adults in the richest quintile.25
Epidemiologically there is a strong dose–response
association between blood pressure and cardiovascular
mortality that persists to 115/75 mm Hg.26,27 Thus, a
substantial residual cardiovascular risk is present even
in individuals with controlled hypertension.28–30 Elevated
blood pressure and hypertension coexist with other risk
factors24 and are among the most common problems
managed by general practitioners,31 yet even among
people with treated hypertension, less than half—on
average—have blood pressure within well controlled
levels.32,33 Many factors affect these unfavourable
statistics including poor adoption of recommended
lifestyle changes and low adherence to recommended
pharmacological antihypertensive treatment, to name
but a few. There is a major need for change, and the goal
of this Commission is to generate a global campaign to
implement priority actions to prevent elevated blood
pressure and improve the management of hypertension.34
The Commission therefore examines why the detection
of blood pressure is low, why blood pressure control
remains suboptimal, and how both can be improved.
Effect of age on risk factors and treatment goals
The average age of the world population has increased in
recent decades, contributing to hypertension increasing in
importance relative to other risk factors.20,35 The number of
Europeans older than 65 years is predicted to double
during the next 50 years to about 150 million, and in
roughly the same period people older than 90 years are
expected to constitute roughly 12% of elderly people in
Europe (up from 0·5% of the US population in 200036),
increasing the prevalence of hypertension. Cardiovascular
diseases are projected to increase by a quarter in the next
2670
30 years, and the number of cases among those aged
75–84 years is estimated to double in the same period.37
Thus, age-related factors such as increased prevalence of
type 2 diabetes and other cardiovascular risk factors
should be considered within hypertension treatment
plans for the future. Furthermore, it is important to realise
that successful prevention does not necessarily avoid
events, but usually delays them until a later time.
For the same elevation in blood pressure, risk of
cardiovascular events increases with age, and treatment of
hypertension in elderly people is therefore of particular
importance.38 Most of the earlier trials showing prognostic
benefits of antihypertensive treatment in elderly people
were done in those with systolic blood pressure of
70
160 mm Hg or higher (a threshold greater than that
proposed in most current guidelines). The Systolic Blood
Pressure Intervention Trial (SPRINT)39 oversampled
individuals aged 75 years or older without diabetes or a
history of stroke, living outside of nursing homes and
assisted living facilities, and showed benefits when
treatment was targeted to a systolic blood pressure less than
120 mm Hg compared with a target of 135–139 mm Hg.
These data should be interpreted against the background of
the specific blood pressure measurement in SPRINT—
which is known to result in values approximately 10 mm Hg
lower than with standard office measurements—but
nevertheless indicate benefits of tight blood pressure control
in elderly people.1,39,40 However, attainment of low blood
pressure targets might be associated with increased adverse
drug reactions such as dizziness, electrolyte disturbances,
and alteration of kidney function.39,41 This finding suggests
that blood pressure targets might need to be individualised,
particularly for elderly people, although it is also these
individuals in whom antihypertensive treatment improves
prognosis the most.39,42
Early vascular ageing and subclinical cardiovascular
damage
Hypertension is a systemic condition affecting the whole
vasculature. In rat models of hypertension, capillary
rarefaction has been found to precede the development
of hypertension43,44 and microvascular changes such as
capillary thinning are also characteristic of human
hypertension.45 On a functional level, the ability of the
endothelium to regulate vascular tone is altered during
the development of hypertension, partly due to increased
release of reactive oxygen species and reduced availability
of endothelium-derived nitric oxide.46 In human beings,
arterial stiffening precedes hypertension.47 At the same
time, high blood pressure causes damage to large and
small arteries, leading to further endothelial dysfunction,
reduced vascular compliance, increased vascular
stiffness, reduced lumen diameter, and formation of
atherosclerotic plaques.48 From a clinical perspective
(and, in part, irrespective of whether they are cause or
consequence), hypertension is clearly associated with
changes in vascular function and structure that are more
www.thelancet.com Vol 388 November 26, 2016

pronounced than the changes that would be expected as
part of a normal ageing process. This process is referred
to as early vascular ageing.49
Findings from clinical studies have shown that
subclinical vascular damage is associated with adverse
outcome. For example, increased vascular stiffness is a
predictor of cardiovascular events and all-cause mortality
independent of traditional cardiovascular risk factors.50,51
The availability of devices and techniques to non-
invasively assess subclinical changes in vascular
structure and function has fuelled interest in vasculature
properties as a surrogate marker of cardiovascular risk.
This approach is attractive because it would shift clinical
practice from the current concept of disease based on
risk factors towards a more precise assessment of an
individual’s position on the cardiovascular continuum.52
An individual’s vascular phenotype would be the result of
the combined action of all known and unknown risk
factors and provide a personalised assessment of vascular
(and cardiac) risk.
However, although guidelines agree that some
assessment of target-organ damage is required as part of
the clinical assessment of patients with hypertension, the
current evidence only supports rather crude and late
measures such as albuminuria or assessment of left
ventricular hypertrophy.1,53,54 When more detailed assess-
ment of vascular function and structure is mentioned in
guidelines, the recommendations remain vague and not
binding.1 This lack of detail is related to the fact that the
usefulness of assessments of subclinical vascular damage
to guide therapy, even if it were affordable, remains
unproven.55 The potential of vascular phenotyping has not
yet been sufficiently exploited and definitive clinical
studies to define the role of subclinical organ damage in
the definition of individual patients’ risk and subsequent
treatment are needed.
Different situations around the world
About 80% of all cardiovascular mortality occurs in
low-income and middle-income countries, where the
greatest burden of hypertension is observed.35 Although
there has been a trend towards reduction in mean systolic
blood pressure among adults in Europe, Australia, and
North America between 1980 and 2008, systolic blood
pressure increases have been observed in low-income and
middle-income countries.20 WHO estimates that the
prevalence of hypertension is highest in Africa (46% of
adults older than 25 years), 35% in North and South
America together, and 40% in the rest of the world,18 with
extremely low levels of awareness and control.56 However,
reliable data about frequency, rate of control, and efficacy
of interventions are not known, especially in low-income
and middle-income countries.
In addition to geographical differences, stark disparities
exist within countries between specific populations and
local areas, with marked socioeconomic differences.
These differences have evolved or persisted even within
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The Lancet Commissions
the context of improved national indicators, and have
been observed in countries of all income levels. For
example, in the USA, although hypertension control
improved for the population overall between
1999 and 2012,57,58 substantial differences between black
populations and white populations in control of blood
pressure have been reported.59,60 Within New York City,
geocoded population surveys shows that lower-income
neighbourhoods have higher prevalence of hypertension
than wealthier neighbourhoods.61 Although proximate
and modifiable causes of hypertension include exposure
to factors such as poor diet, excessive alcohol intake, and
physical inactivity, social factors such as education,
income, social norms, and attitudes (eg, racism and
discrimination) are associated with health inequities
including in hypertension.62,63
During the past two decades, age-standardised
mortality from cardiovascular disease has improved
within urban environments in high-income countries,
which might have resulted from improved access
to medical care64 and the availability of healthier
food options, smoke-free spaces, and access to
opportunities for other healthier lifestyle options. In low-
income and middle-income countries, however, rapid
urbanisation is increasing population exposure to
environments that are associated with a higher
prevalence of hypertension than rural environments.33,56
Factors that contribute to increased blood pressure in
cities include more sedentary work life, increased use of
inactive transportation modes (such as driving or use of
escalators), and intake of more calorie-dense and
nutrient-poor processed foods compared with rural
environments.64 Furthermore, inadequate financing and
development of the primary health-care system in low-
income and middle-income countries often leaves
disease and risk factors undetected and poorly managed.
Primary health-care centres in low-income and middle-
income countries are often inadequately equipped with
basic diagnostic tools, and health-care providers cannot
match the demands for improved identification of
patients with hypertension and for more aggressive
treatment of the condition.
A common theme associated with prevention of disease
and promotion of health is to create environments that
make physical activity and healthy diets easily accessible,
for example by building segregated bicycle infrastructure
and implementing systems to ensure a range of affordable
fresh fruit and vegetables in urban areas. Universal access
to health-care services and low-cost, high-quality
medications makes diagnosis, treatment, and control
more likely. By contrast, in environments that deter these
activities (for example, communities where roads are
unsafe for pedestrian traffic, where healthy foods are
unavailable to purchase, or where health-care facilities or
health insurance are inadequate), individuals become
disempowered to make healthy choices, resulting in less
healthy behaviours and populations.
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Hypertension in the years to come and technological
developments
The steady increase in the prevalence of hypertension
during recent decades seems likely to continue, especially
in low-income countries. This growth has also led to
substantial increases in mortality and morbidity due to
suboptimal blood pressure, which is also likely to
continue. The estimated number of blood-pressure-
related deaths yearly has increased by 49% to 10·4 million
in 2013, and the number of disability-adjusted life-years
has increased by 45%.65 Most of this increase has probably
occurred in low-income and middle-income countries.
As a result of increases in population, ageing, urban-
isation, and obesity, the number of people with
hypertension can be expected to increase in low-income
countries and some middle-income countries if not
counteracted by concerted action. However, in high-
income countries, age-adjusted blood pressure is
decreasing, thereby mitigating the effect of the ageing
population on the prevalence of hypertension. It is,
therefore, clear that not only prevention and detection
but also treatment and control of hypertension should be
top priorities that are currently not well addressed.
The impact of hypertension can be reduced
through existing strategies.66,67 Cost-effective models of
interventions appropriate to use in countries with few
resources have been suggested,68 and would be expected
to reduce the global burden of non-communicable disease
(such as cardiovascular disease induced by high blood
pressure) if implemented in countries of any income
level.69 The emergence and rapidly growing uptake of
technological innovations offer further opportunities to
use these tools to improve outcomes. This Commission
proposes several strategies to lower the global burden
of blood-pressure-related disease in the future
through the better use of advanced technologies and
systems to improve individual characterisation, enhance
population-level empowerment, and strongly address
prevention across the lifecourse.
Prevention: lifestyle and environmental changes
Current evidence, problems, and perspectives
It is striking that all blood pressure guidelines1,53,70 agree
that individual lifestyle modification is the cornerstone of
prevention and is the first line of treatment. However,
two important challenges emerge in terms of clinical
hypertension guidelines. First, the guidelines are written
mostly by clinicians, such as cardiologists and
nephrologists with training and experience in the clinical
management of hypertension and cardiovascular disease,
who therefore focus on individual patient recom-
mendations. Second, hypertension treatment guidelines
are designed for patients already diagnosed with
hypertension, although individual lifestyle modifications
are often not achieved despite robust evidence for the
effectiveness of a healthy lifestyle to lower blood
pressure.71 Substantial community-wide benefits can be
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obtained in individuals who have not yet entered clinical
care and have no immediately detectable risk but might
be on a trajectory for high blood pressure on the basis of
existing epidemiological trends, as well as those at high
risk or with existing disease.
Improvements in the prevention of blood-pressure-
related disease will be achieved not only by better clinical
treatment strategies for people already receiving
blood-pressure-lowering therapy, but also through system-
based strategies that ensure low blood pressure levels
across populations; up to half of blood-pressure-related
morbidity occurs in people with a systolic blood pressure
less than 140 mm Hg.67,72 Furthermore, the strongest risk
factor for development of hypertension is a blood pressure
just below the cutoff value for hypertension—also referred
to as prehypertension. Successful population-based
strategies will therefore reduce the risk for people at all
blood pressure levels, preventing incident hypertension,
delaying disease onset, and reducing risk in patients with
existing disease. Tackling this large group should be at the
forefront of preventive efforts, because a substantial part
of blood-pressure-related disease burden originates from
this nominally normotensive group.67
Despite this knowledge, the largest proportion of
funding and research activities is still projected towards
individual pharmacological and device-based treatment,
such as the best combinations of antihypertensive therapy
or new strategies to treat resistant hypertension. But within
the global context, most individuals with hypertension are
still unaware of their blood pressure. This discrepancy was
evident in the Prospective Urban Rural Epidemiology
study,33 which examined hypertension prevalence,
awareness, treatment, and control figures among
142 042 individuals from low-income, middle-income, and
high-income countries. The largest proportion of
hypertensive individuals (53·5%) were unaware of their
hypertension status, and of those with hypertension, only
13% were controlled (figure 6)—findings consistent with
other global, regional, and national studies. The questions
to be answered are why is detection so low, why is control
suboptimal, and how can these factors be improved?
The answers must be found through focused research.
How could we target the global population with
hypertension (including those who are still unaware of their
cardiovascular risk), those who are prehypertensive
(and, therefore, have increased risk but are not targeted
for pharmacology intervention), and those who
are normotensive? Individual-based pharmacological
approaches in patients with hypertension are evidence
based and should be enforced. However, considering that
the cardiovascular risk attributable to blood pressure is a
continuum, the most effective solution is probably to reduce
blood pressure in the population as a whole, although
neither the beneficial effect of this strategy or the suggested
ways to accomplish it are strictly evidence based. These two
very different approaches are complementary and might—
if used together—increase the chance of success.
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Effective incorporation of population-based approaches
is embedded in the Open Working Group on Sustainable
Development Goals endorsed by the UN General
Assembly.73 One of the 17 Sustainable Development Goals
is to “ensure healthy lives and promote well-being for all at
all ages”. Included in this goal is a target to reduce
premature mortality from non-communicable diseases by
33% by 2030, through prevention, treatment, and
promotion of mental health and wellbeing, thereby
extending the previous target of 25% reduction in
premature mortality from non-communicable diseases by
2025. Several of the non-communicable disease global
targets fit precisely within the sphere of primordial and
primary prevention, referring to specific targets for alcohol
use, physical activity, salt intake, tobacco use, and obesity.74
Many of these factors can be addressed on a population
level by governments taking action to develop the
appropriate social and economic environments that
would support the creation of communities where
healthy choices are easy and readily available (such as
tobacco legislation75,76). Such environments will inherently
shape the health behaviours of larger populations by
encouraging individuals within those communities to
take up healthy behaviour, actively participate in physical
activity, or choose to cook healthy meals at home, with
much greater chance of success than stand-alone
interventions targeted at individual patients.
The global prevalence of obesity and diabetes
underscores the need for effective prevention in
high-income countries77–79 as well as in the many middle-
income countries that now have high obesity levels.80 It
is important to introduce such interventions in low-
income and middle-income countries,81 where tobacco
and alcohol use, poor nutrition,82 and subsequent
obesity are increasing.83 However, low-income countries
are often challenged with the dual epidemics of non-
communicable and communicable diseases, which
continue placing excessive financial burden on their
health systems. Wide promotion and availability of
unhealthy diets, including processed foods and sugar-
sweetened beverages that are affordable and easily
available, can hardly be counteracted by individual
promotion of healthy lifestyle by health-care
practitioners alone. Policy interventions to make healthy
choices easier will enable and drive these broader—and
more sustainable—population-wide changes. They will
require governments to carefully consider the long-term
and short-term effects of decisions related to the
social, economic, food, and physical environments, and
support evidence-informed approaches to creating
health-promoting environments—for example, by en-
couraging the production and promotion of healthy
foods, differential taxation approaches, and enforced
clearer labelling, in a similar way to that achieved with
tobacco. Translating successes and embracing new
and stronger actions to change current directions
is necessary.
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The Lancet Commissions
Normotensive Hypertensive Unaware Aware No Treated, blood Treated, blood
and treatment pressure pressure
prehypertensive uncontrolled controlled
Figure 6: Awareness of hypertension status
In the PURE study,33 most (53·5%) individuals with hypertension were unaware of their hypertensive status,
and only 13% had well controlled blood pressure.
Evidence-based health behaviours
Substantial evidence supports the effectiveness of
specific health behaviours to improve blood pressure,
cardiovascular morbidity, and mortality. In terms of
dietary intake, extensive evidence supports the beneficial
effects of the Mediterranean diet (with extra virgin olive
oil or nuts)84–86 and Dietary Approaches to Stop
Hypertension (DASH) diet,87,88 as well as a reduction in
salt intake16,89,90 and increased potassium intake.91
Significant blood-pressure-lowering effects have been
shown for dietary nitrate (found in beetroot juice and
green leafy vegetables).92–94 Convincing evidence also
supports cardiovascular protection by physical activity
and improved fitness,95–99 weight loss,100–102 tobacco
cessation,103,104 moderate105 to limited alcohol intake,106,107
and management of psychosocial stress.108,109 Importantly,
not only do these preventive measures improve blood
pressure and cardiovascular outcome, but also most have
multiple cross-cutting benefits, resulting in prevention
of non-communicable diseases in general. For example,
lifestyle modification can be more effective than
metformin to prevent type 2 diabetes.110
The effects of some interventions on hard cardiovascular
endpoints have not yet been formally tested to date in
adequately powered randomised trials. However, a large
trial assessing the effects of reducing sodium intake on
stroke is underway in China (the China Salt Substitute
and Stroke Study; NCT02092090). Similar cluster-based
methods could allow evidence to be generated for other
lifestyle interventions.110 Although debate continues in the
absence of these types of outcome data, overall the blood
pressure benefits achieved by lifestyle modification are
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expected to translate into long-term cardiovascular
benefits that will outweigh any putative associated risks.
The major challenge is to achieve sustainable changes
in lifestyle and behaviour, especially when making use of
individual-based approaches. Sustainability has proven
difficult with clinical approaches, which require
substantial resources over a long period of time, and
therefore are only applicable to very high-risk individuals.
Additionally, the effects of clinical lifestyle interventions
do not persist.111 Finally, engagement and motivation of
individuals across populations is not feasible with high-
resource approaches. These problems might partly
explain why these preventive measures have not been
successfully scaled at a global level.
Hence, the conclusion of this report is to focus on
population-based strategies that involve broad public-
health and systems approaches. However, among
individual-based approaches, some strategies could be
worth undertaking. An important first step to mobilising
population-wide action is probably awareness, as shown
by findings from the PURE study.33 A global initiative will
be required to achieve this goal. Emerging technologies
using novel approaches include mobile technology,
where the findings from the Tobacco, Exercise and Diet
Messages trial112 demonstrated that advice, reminders,
and support through text messaging effectively reduced
systolic blood pressure, LDL cholesterol, BMI, and
smoking, and increased physical activity. A systematic
review113 further indicated that text messaging approaches
more than doubled the odds of medication adherence,
but long-standing effects have not yet been tested. In
terms of health literacy, the medical community has the
responsibility of training the trainers—ensuring quality
and consistency of the health education curriculum in
schools—but cannot be the primary vector to deliver the
message on a sufficiently large scale. Patient empower-
ment could be one strategy that substantially improves
adherence and thereby probably improves outcomes.
Alternative and promising approaches include peer-
group interventions based on elements of social cognitive
theory,114 and disclosure of a genetic risk score, where
preliminary results suggest that this knowledge can be a
positive driver to act on other modifiable risk factors.115
Unfortunately, the limitations of individual-based
approaches in achieving behavioural change at a
population level are highlighted by the worldwide obesity
crisis,116 reflecting difficulties in achieving and sustaining
lifestyle changes in individuals. This situation is mirrored
by alarming hypertension prevalence, especially in low-
income and middle-income countries.3,117,118 It is therefore
clear that different approaches are required.
Population-based approaches to improve
cardiovascular health
Individual approaches to long-term adherence to new
health behaviours are far from optimal.119 Findings from
a Swedish study120 showed that if all individuals followed
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a low-risk lifestyle, the risk of observed stroke would be
reduced by 62% and the risk of observed myocardial
infarction would be reduced by 79%. Evidence shows
that specific health behaviours such as tobacco
cessation,103 increased physical activity,95,96,98,99 reduction of
overweight,100–102 and a healthy diet121,122 can reduce blood
pressure and cardiovascular events. However, only 1% of
the Swedish population was leading a low-risk lifestyle.120
Therefore, a different strategy which does not focus on
the individual is necessary.
To improve population cardiovascular health,
several approaches are suggested: (1) health-promoting
environments are essential, and require strong
leadership of an organisation with global reach—such as
the UN—and intense involvement from multiple
stakeholders;123 (2) according to WHO, an effective
school health programme can be one of the most cost-
effective investments a nation can make to simul-
taneously improve education and health.124 Health
education—continuing through the lifecourse as
cardiovascular risk increases and hypertension begins to
develop—would improve health literacy at all ages
(figure 2) and increase awareness and detection of
hypertension. It will require the combined efforts of
governments, teachers, and communities; (3) technology
can indirectly improve population blood pressure by
ensuring the availability of healthy foods such as fruit
and vegetables throughout the year to wider communities
and by increasing physical activity. Refrigerators can
increase the availability of fresh foods and simultaneously
reduce the use of potentially harmful additives, such as
sodium nitrate. The videogaming industry,125 wearable
technology (eg, fitness bands), and social media can
increase physical activity and general knowledge about
healthy behaviours; (4) wider implementation of
successful governmental actions including smoke-free
policies,75,76 marketing of foods and alcohol (eg, the
banning of adverts for alcohol126 or unhealthy foods127,128),
sin taxes (eg, sugar taxes),129,130 and regulation of the
sodium content of processed foods; (5) owing to
population diversity (cultural and social environments),
unique approaches might be necessary to ensure
successful acceptable population activities.131,132 Further-
more, the global health environment is constantly
changing, and traditional cardiovascular risk assessment
based on large cohorts from the early 1990s might
become less effective as smoking habits decrease and
obesity increases. The additive value of new risk markers
(eg, arterial stiffness)133 is unclear, especially regarding
functional outcomes like cognitive impairment.134
Therefore, continued research is needed to develop
more effective population-based cardiovascular pre-
vention strategies; and (6) to empower the general
population and medical community, professional
societies and health-care experts should contribute to
clear, evidence-based recommendations that are easily
available on websites and apps.
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Salt reduction in the population
Globally, average estimated salt intake is 7·5 g/day
(sodium intake 3·0 g/day), ranging from 5·5 to 13·7 g/day
(sodium intake 2·2 to 5·5 g/day).135 More than 75 countries
have national strategies for salt reduction in place.136
Findings from randomised trials have demonstrated that
salt restriction from high levels leads to clear reductions in
blood pressure.137,138 In the absence of randomised studies
on cardiovascular events, findings from observational
studies89,135,139 and a long-term observational follow-up of
the TOPH I and II trials140 have suggested that sodium
reduction, including to less than 2300 mg per day,89 is
likely to translate to cardiovascular benefits, while other
observational studies16,141–143 have suggested that the
relationship between sodium excretion and cardiovascular
events might be U-shaped, because an increased risk was
observed in people with a sodium excretion less than
approximately 3 g/day when estimated from a morning
fasting urine sample. However, observational studies are
limited by their inability to determine causality. A trial
assessing the effect of reducing salt intake on stroke is
underway (the China Salt Substitute and Stroke Study,
NCT02092090) and could provide further evidence.
Additionally, data from large populations undergoing
initiatives for salt reduction (such as the UK144 and more
recently South Africa, the first country to legislate
mandatory industry salt reduction in various processed
foods)127 will also provide longitudinal information. The
Commission finds that further research should be
prioritised, including randomised controlled trials—
when feasible—and trials that help to determine the most
effective population-level sodium-reduction strategies.
Maternal health and fetal programming
Fetal programming refers to the concept that environ-
mental conditions during pregnancy can predispose to
disease during adulthood.
A substantial body of evidence links maternal health
and the fetal environment to future health of offspring.
In particular, epidemiological evidence indicates that low
birthweight (defined by WHO as <2500 g) increases risk
of developing hypertension and cardiovascular disease in
later life.145–147 A reduced number of nephrons148,149 and
abnormal vascular development150 have been proposed as
possible explanations for this relationship, although
the underlying mechanisms responsible for fetal
programming towards hypertension are incompletely
understood. Epidemiologically, blood pressure has been
falling in high-income countries for decades well before
major lifestyle interventions such as taxation on tobacco,
promotion of physical activity, and restriction of salt
intake,2,151 and the same blood pressure decline has also
begun in some middle-income countries.3 The blood
pressure declines have both cohort and period effects,
suggesting that the changing determinants are a
combination of social changes (affecting specific cohorts)
and technological or structural changes.152 A large part of
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The Lancet Commissions
the cohort effect can be explained by improvements in
maternal health influencing fetal programming and
changes in early-life diet.153 The precise mechanisms are
unknown but epigenetic changes might be one of several
possible mechanisms.154
Irrespective of the mechanism, the fetal environment is a
crucial determinant of hypertension and efforts should be
made to improve maternal and fetal health globally. Indeed,
in low-income and middle-income countries an estimated
27% of all livebirths were small for gestational age with
approximately 15% of all births being classified as low
birthweight.155 Maternal malnutrition, smoking, alcohol
abuse, pre-eclampsia, and diabetes all represent possible
targets to stop fetal programming of hypertension.156
Summary of possible actions
Primordial and primary prevention of hypertension
should be applied full circle throughout the lifecourse of
populations by creating and enabling sound economic
and social environments that would directly result in
health-promoting environments (table 1). The cross-
cutting benefits to all non-communicable diseases are
immense, and can only be achieved by strong leadership
and intense cooperation between multiple stakeholders
(including governmental and non-governmental
organisations, food and fitness industries, educational
systems, media outlets, mobile technology companies,
and employers), with full engagement of a global body
such as the UN; the European Union pledge for
responsible marketing of food and beverages157 to children
is an example of such international leadership. We should
further improve applications of technology to strengthen
health and food monitoring systems, as well as food
delivery and storage, but also use novel technology and
the mobile industry that might aid in achieving this goal.
Awareness should be emphasised throughout, including
equal basic access to validated blood pressure monitors in
low-income and middle-income countries. Task sharing
by community health workers in these countries to
increase awareness of hypertension is also proven to be
effective.158 Furthermore, celebrities might be encouraged
to become champions in promoting healthy lifestyles and
creating awareness of hypertension. These approaches
can be effective, as demonstrated by the Feed Me Better
campaign introduced by celebrity chef Jamie Oliver at
schools in the UK, which achieved multiple benefits
including improved bodyweight, micronutrient intake,
and better educational performance.159,160
Diagnosis and evaluation
Introduction to diagnosis and evaluation
Improved characterisation of patients, including accurate
diagnosis, is the primary requisite to guide therapy,
management, and follow-up in hypertension. A (more)
specific diagnosis of hypertension is fundamental to tailor
therapy (eg, non-pharmacological, drug class or classes,
and dose). Failures or weaknesses in this diagnostic
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Goals Actions Keywords

Low awareness of hypertension
Exposure to an unhealthy
environment
Lack of understanding regarding
the impact of unhealthy lifestyles
on hypertension
Knowledge gaps in the
effectiveness of prevention
programmes, policies, and use of
new technologies
Every adult should know their
blood pressure*
Maximise multisectoral
collaboration to create
health-promoting
environments*
Universal education about
healthy lifestyles over the life
course*
Resource allocation for
research into action-oriented
prevention
Ensure universal access to blood pressure measurement Measurement access
Tailored education about hypertension throughout the life course
Implement concerted, unified strategies and policies to accelerate socioeconomic improvements Health-promoting
and development of health-promoting environments environment
Make healthy food choices (fruit and vegetables) easier and discourage unhealthy foods
(excess calories, heavily processed foods)
Promote physical activity in daily living (active living by design) throughout the life course
Disincentivise and further regulate tobacco and alcohol
Early and sustained education about new technologies that leverage healthy lifestyles Healthy behaviours
(eg, gamification)
Educate and empower health workers and teachers to instil healthy lifestyles
Align and simplify educational material
Prioritise and produce cross-disciplinary and culturally relevant evidence to promote healthy ··
lifestyles†

*Essential goals. †Related to research.

Table 1: Identified problems and corresponding goals and actions relating to prevention

process can result in inappropriate treatment, potentially
leading to increased adverse drug reactions (particularly
in older individuals), inappropriate discontinuation of
therapy, greater cardiovascular risk due to poor blood
pressure control, or failure to treat the right patient.
Increased availability of new technologies has led to
opportunities on the one hand, but to substantial
challenges on the other. Measurement devices for blood
pressure have never been so available and affordable, but
many might not be validated according to scientific
standards. Many devices to investigate novel parameters
of potential pathophysiological relevance and risk
stratification are now available. Similarly, techniques to
measure different omics (circulating biomarkers) are
now available for individuals, but the huge amount of
data generated has little relevance for clinical practice at
this stage. One of the main hurdles in the implementation
of novel diagnostic tools is that alone they do not improve
outcomes and thus often lack evidence for clinical
benefit; improved outcomes (and thus evidence for use)
can only be achieved for any type of testing if combined
with treatment in a diagnostic-therapeutic strategy.
Diagnostic difficulties
A key objective of this Commission is that every person
should have their blood pressure measured. Although
blood pressure monitors are becoming cheaper, there is a
major need for wider access to very-low-cost, automated
devices that are valid and amenable for use in resource-
restricted communities. The devices should be operable
by unskilled individuals or the patient themselves, with a
preference for data to be automatically transmitted to
health-care providers.
The time-honoured technique of auscultatory mercury
sphygmomanography formed the basis for most of the
current knowledge about the clinical significance of
blood pressure and the benefits of treatment. However,
mercury sphygmomanometers have been phased out of
clinical use owing to safety concerns. New measurement
techniques are being developed161 and mercury-free blood
pressure monitors now available include oscillatory,
aneroid, and hybrid (with a mercury-like column)
devices. Each has specific problems in terms of
maintenance and calibration, and their accuracy can be
questioned in particular settings (including among
patients with arrhythmia or stiff arteries). Ideally, devices
should comply with the validity guidelines of scientific
societies, rather than just internal testing by the
manufacturer,162 and this information should be clearly
available for the customer. Correct cuff size is important
for device accuracy. Appropriately sized cuffs for children,
thin individuals, and (more importantly) obese
individuals are underused in medical practice,163 although
about 40% of people with hypertension require a blood
pressure cuff bigger than the standard adult size.164,165
Moreover, traditional cylindrical cuffs substantially
overestimate blood pressure compared with trunco-
conical cuffs in those with a pronounced trunco-conical
shape of the upper arm.166
Major difficulties exist in accurate determination of an
individual’s true blood pressure. The small number of
blood pressure measurements taken in the physician’s
office, commonly used to establish the diagnosis and
initiate treatment of hypertension, cannot account for
marked spontaneous variability in blood pressure. The
existence of white-coat and masked hypertension justify
the use of out-of-office and automated, unobserved
measurements, but office blood-pressure measures can
still be used as a crude indication of blood pressure
control and are preferable to no measure at all. Ideally,
diagnosis, initiation, and titration of treatment should be
guided by ambulatory, home, or automated, unobserved
blood pressure, the latter potentially being applicable in
resource-restricted environments.

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White-coat and masked hypertension are phenotypes
not identified by clinic blood-pressure measurement.
White-coat hypertension is defined as a persistently
elevated office measurement of blood pressure
concomitant with normal blood pressure outside the
office. It represents about 30% of all patients diagnosed
with hypertension and is associated with lower
cardiovascular risk than sustained hypertension.167
The condition might not require treatment with anti-
hypertensive drugs in the absence of associated risk
factors and organ damage, but this strategy remains to
be definitively tested.168 Home or ambulatory blood
pressure monitoring helps to confirm or exclude white-
coat hypertension, at least in people with mild hyper-
tension at low or moderate total cardiovascular risk.
Masked hypertension is the opposite of white-coat
hypertension (normal office blood pressure and elevated
out-of-office blood pressure), affecting about 5–10% of
the general population169,170 but higher among people
with untreated diabetes (29%)171 and is associated
with higher cardiovascular risk than white-coat
hypertension.168,172 People with normal or high-normal
office blood pressure together with organ damage or at
high cardiovascular risk should be offered home or
ambulatory blood-pressure monitoring, to exclude
masked hypertension. Both home and ambulatory blood
pressure are complementary methods173 and, when
measured and recorded according to protocol, might
offer substantial advantage beyond physician-measured
blood pressure in the office environment.174,175 Several
international guidelines recommend the use of home
blood-pressure monitoring as a method that has good
reproducibility, is well tolerated by patients, is more
widely accessible than ambulatory blood-pressure
monitoring, and is a relatively inexpensive option for
improved management of hypertension.1,176–179 Some
limitations of home monitoring can be overcome
through the use of memory-equipped devices, as well as
by taking advantage of telemonitoring (transmission of
blood pressure measurements directly to the doctor)
and smartphone applications. Further, ambulatory
monitoring might provide more information on key
issues such as blood pressure values during sleep and
routine daily activities. However, studies are still needed
to clarify whether antihypertensive treatment tailored on
the basis of out-of-office blood pressure, as compared
with conventional office measurements, will result in
stronger prevention of cardiovascular complications.
A practical and time-efficient method of blood pressure
measurement could be achieved with automated,
unobserved, in-clinic measurement, which provides
blood pressure values close to out-of-office values and
also limits white-coat effects.180,181 This method was used
in the SPRINT study39 in which repeated blood pressure
measures were recorded with an automated device after
5 min of rest while the participant was seated and alone.181
By using this refined blood-pressure-measurement
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The Lancet Commissions
method, SPRINT showed that lower blood-pressure
targets were more attainable than those generally
achievable using traditional office measurements, and
these lower blood-pressure levels were associated with
better outcomes in people with high cardiovascular
risk. Nonetheless, for all out-of-office methods,
some adaptation of the threshold values might be
necessary because they provide lower values than
physician-measured blood pressure.182
An additional challenge in refining the risk associated
with elevated blood pressure is that blood pressure values
can vary substantially with time: beat to beat, minute to
minute, hour to hour, day to night, over different days, or
between clinic visits over weeks, months, and even years.
Day-to-night variability provides important clinical
information; a reduced (non-dipping pattern) or inverted
(reverse dipping pattern) fall in blood pressure from day
to night is an established marker of adverse prognosis.183,184
Such patterns are associated with increased activity of the
sympathetic nervous system, secondary hypertension, or
orthostatic hypertension. Ambulatory blood-pressure
monitoring is best suited to explore day-to-night changes
in blood pressure, although nocturnal self-measurement
of blood pressure is also feasible.185 Long-term, visit-to-
visit variability in blood pressure is gaining interest as a
potential prognostic marker for stroke, cardiovascular
disease, and all-cause mortality, although evidence is
conflicting.186,187
Haemodynamic characterisation
Haemodynamic characterisation of hypertension (par-
ticularly as it pertains to pulsatile haemodynamics) is a
field of growing interest. Blood pressure is the result of
the flow generated by the left ventricle and the complex
impedance to that flow imposed by the arterial tree.188
One approach to haemodynamic characterisation of
patients with hypertension involves the assessment of
central systolic blood pressure, which variably differs
from the conventionally measured brachial systolic blood
pressure.189 There are conflicting observations regarding
the incremental prognostic value of central compared
with brachial blood pressure. However, it should be
emphasised that considerable differences in central
systolic blood pressure can occur among people with
similar brachial systolic blood pressure, and that
antihypertensive therapy can affect central and brachial
systolic blood pressures differently.190–193 Because central
blood pressure (and how it changes in response to drug
therapy) seems to relate more strongly to end-organ
damage than brachial blood pressure,194 precise
estimation of central blood pressure is expected to
improve management decisions in hypertension, as
suggested by findings from a randomised trial.195
Methods to measure central blood pressure might be
particularly useful in elderly people with high prevalence
of white-coat hypertension, and among young individuals
with isolated systolic hypertension.196,197
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It should be emphasised that the study of central
haemodynamics can yield much more information than
brachial or central (peak) systolic blood pressure. For any
given peak left ventricular pressure, late systolic load
(as opposed to early systolic load) promotes more left
ventricular hypertrophy, fibrosis, dysfunction, and
failure.198–205 Dimensionless measures of wave reflections
and late systolic load derived from the pressure waveform
are much stronger predictors of outcomes (particularly
heart failure) than central or peripheral pressures,
with statistically significant incremental prognostic
value.200–203,205–209 The quantitative assessment of pulsatile
haemodynamics continues to evolve, and will probably
yield improved understanding of the underlying
abnormalities leading to target-organ damage in hyper-
tension. Similarly, as technology evolves, assessments of
central haemodynamics are becoming increasingly
feasible in ambulatory settings, enhancing the ability to
characterise patients during daily activities.
Finally, characterisation of traditional haemodynamic
parameters—including peripheral resistance and volume
status—using non-invasive techniques (such as
impedance cardiography210) could provide useful
information for tailored management of hypertension.
The growth in the development of wearable devices
offers promise as potentially widely used tools that could
facilitate detailed information along these lines as the
associated technology develops. However, these devices
will only be relevant in selected groups because of
practical reasons.
Markers of subclinical cardiovascular damage
Markers of subclinical cardiovascular damage or of
vascular health integrate the effects of long-term exposure
to a highly variable risk factor such as blood pressure with
other cardiovascular risk factors, superimposed on an
individual’s genetic background. This time-integrative
characteristic combined with the ability to reflect both
known and unknown risk burden make these markers
highly attractive. Elevated urine albumin–creatinine
ratio,211 suggesting microvascular damage, and left
ventricular hypertrophy on electrocardiography (ECG212),
suggesting cardiac damage, predict cardiovascular events
independently of traditional risk factors.213 They are
relatively inexpensive methods, and easy to measure and
implement, making them feasible globally.
In hypertension, the target organs include the brain,
heart, kidneys, and arteries. Because arteries are implied
in the pathogenesis of target-organ lesions, they are
logical candidates as useful markers of subclinical
damage. Arteries adapt themselves to high blood
pressure by the walls becoming stiffer and thicker. Aortic
stiffness, measured as carotid-to-femoral pulse wave
velocity,214 has been associated with cardiovascular risk
even after adjustment for blood pressure and other
classic risk scores in more than 24 longitudinal
studies,215,216 as confirmed in meta-analyses51 of individual
2678
participant data. Because a wide range of baseline
reference values exists,217 and the measurements are non-
invasive and well standardised,218,219 routine clinical
measurements of aortic stiffness could be helpful in
deciding which patients are at increased risk despite only
mildly elevated blood pressure, potentially aiding
treatment decisions. However, simplification of the
technology will help to minimise operator variability and
maximise utility. Importantly, reference values for aortic
stiffness only exist at present for white populations,
emphasising the need for networks for research
collaboration to generate multiethnic reference values.
More research into new inexpensive methods to measure
or estimate aortic stiffness is also needed.220
The use of markers of subclinical cardiovascular
damage for population-level screening cardiovascular
risk is not recommended because these markers usually
lack specificity for future cardiovascular events, at least
in the short term. Thus, a high number of false-positive
diagnoses might be expected (ie, patients falsely
classified at high risk). Whether these are true false
positives or whether these individuals could benefit
from intervention has yet to be proven, and the cost-
effectiveness of such an approach is also unknown.
However, increased aortic stiffness is predictive of the
future occurrence of hypertension in the general
population.47,221 Thus, if it were easier and less time
consuming to measure, aortic stiffness might be useful
as first-line screening in certain populations.
People at moderate risk or patients with established
cardiovascular risk factors are typically the target
population for the use of markers of subclinical
cardiovascular damage; the markers can be used to
reclassify individuals from moderate to high risk, and
thereby inform primary prevention,222 or help to decide
treatment choice and intensity.213 However, whether this
use of markers leads to improved outcomes for patients is
still unclear. In any case, subgroup analyses from the
Heart Outcomes Prevention Evaluation (HOPE-3) study15
provide new perspective on the possible value of blood-
pressure-lowering therapy even among adults with
borderline elevated blood pressure and average risk,
irrespective of detailed measures of subclinical
cardiovascular damage.
For patients with advanced target-organ damage or
overt cardiovascular disease and already at high risk,
other biomarkers could help to diagnose and stratify
disease severity, or to guide treatment. For instance,
N-terminal prohormone of brain natriuretic peptide has
proven high value for the diagnosis of heart failure in
patients with acute dyspnoea, and N-terminal
prohormone of brain natriuretic peptide response to
treatment is indicative of outcome.223
Risk factor interactions
Risk factors cluster together, and since 1994 the
prevention of cardiovascular disease has become more
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focused on the assessment of (and the adoption of
accurate tools to quantify) total cardiovascular risk.224
Very few patients with hypertension have isolated high
blood pressure independent of other risk factors, and a
synergistic effect of multiple cardiovascular risk factors
(eg, lipid, glucose, etc) contributes to a total cardiovascular
risk that is greater than the sum of the risk carried by
each risk factor alone. Control of hypertension in patients
with multiple cardiovascular risk factors is more difficult
in high-risk than in lower-risk patients.1
The relatively poor control of hypertension in patients
with multiple risk factors despite effective anti
hypertensive and cardioprotective drugs225 demonstrates
that risk-factor clustering affects not only the
cardiovascular risk but also the efficacy of the
antihypertensive treatment. In this context, even though
the metabolic syndrome is not a unique entity,132 it has
been associated with masked hypertension, arterial
remodelling, inflammation, and increased odds of
cardiovascular events in middle-aged and older
individuals,131,226–228 with neurogenic abnormalities playing
a crucial role.229 Therefore, detailed characterisation of
the so-called phenotype of the individual patient with
hypertension might be essential, not only for risk
stratification and type of antihypertensive drug, but also
for the intensity of the antihypertensive treatment.230 The
different clusters of metabolic syndrome components
have varying effects on arterial ageing and risk for
cardiovascular disease, with differing prevalence across
Europe and the USA132 consistently shown in cohorts
participating in the Metabolic Syndrome and Arteries
Research Consortium (eg, in populations with differing
genetic factors, lifestyle, or influence of medical
treatment).231 Notably, differences in blood pressure levels
among the clusters of components did not account for
differences in the likelihood of having extremely stiff
arteries. Thus, the burden of elevated blood pressure
differs according to the specific associated cardiovascular
risk factors and not just by the number of associated
cardiovascular risk factors.
The best way to integrate multiple risk factors for treating
hypertension is still a matter of discussion. The 2013
European Society of Hypertension guidelines1 grade
interventions according only to the number of risk factors,
not to specific clusters. These scores to identify high
cardiovascular risk lose accuracy in different ethnic groups.
Additionally, the risk scores were constructed largely from
cohort studies done two or three decades ago, thus
reflecting different levels of cardiovascular risk factors in
the population. Last, but not least, whether the scores
correctly estimate the total cardiovascular risk associated
with multiple risk factors in the increasing population of
elderly individuals with comorbidities232 is uncertain.
Obstructive sleep apnoea and inadequate sleep hygiene
Impaired sleep quality unfavourably alters circadian
blood-pressure profile and autonomic cardiovascular
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The Lancet Commissions
regulation. Available evidence indicates that habitual
short sleep duration (less than 6 h per night) induces a
sustained increase in blood pressure in normotensive
and prehypertensive adolescents and adults, increasing
the risk of developing hypertension.233 Although the direct
association between sleep changes (eg, sleep deprivation,
short sleep duration, insomnia) and elevated blood
pressure is not entirely understood, and involves
numerous factors (eg, stress exposure, activation of the
sympathetic nervous system and the hypothalamic–
pituitary–adrenal axis, inflammation), the incidence and
prevalence of hypertension related to inadequate sleep
seems to be most important in adults younger than
60 years, especially women.234 Moreover, insufficient
sleep has been linked to weight gain and metabolic
abnormalities,235 which are implicated in the development
of hypertension.
In addition to sleep disruption and abnormal breathing
pattern during sleep, patients with obstructive sleep
apnoea commonly present with a non-dipping blood
pressure profile. The prevalence of obstructive sleep
apnoea is increasing, and its presence and severity are
strongly associated with obesity.236 The alarmingly high
prevalence of excess bodyweight among children
and adolescents suggests that obesity-related health
conditions will probably increase in younger popu
lations,237 leaving them at high risk for adverse health
problems throughout their lifecourse. Arterial
hypertension, particularly resistant hypertension, often
occurs in patients with obstructive sleep apnoea, and they
share multiple pathophysiological mechanisms resulting
in adverse consequences on various organs.234,238 Elevated
sympathetic activity is evident in patients with obstructive
sleep apnoea, and further augmentation of sympathetic
drive elicited by recurrent episodes of apnoea during
sleep could contribute to hypertension and cardiovascular
events.236,239 Despite the epidemiological association
between obstructive sleep apnoea and hypertension,240 the
reductions in blood pressure noted in clinical studies of
continuous positive airway pressure have been
remarkably small (roughly 1·3–3·0 mm Hg in systolic or
diastolic blood pressure).241–243 The small size of this effect
might be explained by similar overlapping patho-
physiological pathways linking obesity and obstructive
sleep apnoea to hypertension, or because diagnosis of
obstructive sleep apnoea and treatment with continuous
positive airway pressure is often started late after lengthy
exposure to high blood pressure that has already
remodelled the arterial tree.244–246 Findings from a
randomised trial247 showed that a weight loss intervention
combined with continuous positive airway pressure
therapy resulted in greater reduction in systolic blood
pressure (14·1 mm Hg) than did weight loss (6·8 mm Hg)
or continuous positive airway pressure (3·0 mm Hg)
alone at 24 week follow-up among individuals who
adhered to treatment. Findings from another trial
indicated that treatment with continuous positive airway
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pressure, but not nocturnal supplemental oxygen,
reduced 24 h mean blood pressure in patients with
obstructive sleep apnoea and controlled hypertension.248
With available evidence suggesting that continuous
positive airway pressure is useful for the treatment of
obstructive sleep apnoea, targeting of obesity is essential
to properly address cardiovascular risk in this population.
Weight loss is clearly effective in reducing the adverse
metabolic consequences of obesity, sympathetic activity,
hypertension, and obstructive sleep apnoea. Low-cost,
effective weight loss interventions in this population are
needed. Additionally, immediate global action and
policies to reduce physical inactivity, promote outdoor
activities, and institute prevention programmes to
control obesity are clearly warranted to reduce the global
burden attributable to hypertension.
Secondary hypertension
A key objective of the Commission is to increase the
diagnosis rate of secondary hypertension, which remains
underdiagnosed.1,249 Secondary hypertension (caused by
endocrine, renal, or vascular disorders, rare monogenic
diseases, or a drug or toxic agents) represents a rare
opportunity for curative antihypertensive therapy,
accounts for up to 5–10% of patients with hypertension,
and affects millions of people worldwide.250,251
To reduce the delay of diagnosis, decisional algorithms
should be simplified. General practitioners should be
educated to suspect secondary hypertension in every
patient with juvenile, resistant, or severe hypertension.1,249
Initially, medical history, physical examination (eg, an
abdominal bruit might reveal renal artery stenosis), and
simple laboratory tests—including estimated glomerular
filtration rate (for detection of chronic kidney disease)
and electrolytes (hypokalaemia might indicate an
endocrine hypertension)—should be examined. If
abnormalities are detected, physicians should be able to
request appropriate additional investigations. Endocrine
hypertension is mainly due to adrenal disorders causing
an excess of hormones which affect blood pressure
regulation. Primary aldosteronism (Conn’s syndrome or
bilateral adrenal hyperplasia) is the most common form
of secondary hypertension. The diagnostic algorithm is
sequentially based on biochemical tests (serum
potassium, aldosterone–renin ratio, urine aldosterone
secretion, and confirmatory tests in the absence of intake
of products derived from liquorice and other agents
that affect aldosterone–renin ratio) followed by
adrenal CT scan or MRI and adrenal venous
sampling to discriminate unilateral or bilateral
disease.252 Catecholamine-producing tumours (phaeo-
chromocytoma or extra-adrenal paraganglioma) are
severe disorders, sometimes revealed by life-threatening
emergencies or in the context of a hereditary
predisposition (up to 40% of affected patients carry a
mutation in a susceptibility gene). Evidence-based
guidelines recommend measurement of metanephrines,
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genetic testing, and imaging studies253 as well as
long-term follow-up after surgery.254 Renovascular
hypertension, due to fibromuscular dysplasia (typically
in young women) or atherosclerotic stenosis of renal
arteries (typically in elderly people with cardiovascular
risk factors) can be diagnosed by CT or MRI.255
Although education of general practitioners is essential,
evaluation of patients by a multidisciplinary team in
centres experienced in dealing with secondary
hypertension should be favoured. Creation of dedicated
registries at the international level should be promoted to
produce and validate robust and cost-effective diagnostic
algorithms. Development of next-generation sequencing
methods in the routine diagnostic setting would improve
diagnosis for monogenic forms of hypertension and
catecholamine-secreting tumours. Development of non-
invasive imaging techniques able to differentiate
fibromuscular dysplasia from atherosclerotic stenosis, to
quantify the degree of stenosis and to appreciate its effect
on renal function should be encouraged. Given the
substantial efforts often required to accurately identify
secondary hypertension, diagnosis of secondary
hypertension cannot be the highest-priority goal in low-
income and middle-income countries. However, an action
for the future should be to increase the availability of
relevant investigations in communities with few resources.
New cardiovascular biomarkers and omics
A biomarker is a characteristic that can be objectively
measured and evaluated, and acts as an indicator of
normal biological processes, pathogenic processes, or
pharmacological responses to therapeutic interventions.256
In hypertension, blood pressure is an almost ideal
biomarker. Blood pressure is causally related to the
development of the condition, defines the condition,
predicts the outcome, is the target of therapeutic
interventions, and serves as a surrogate marker to assess
the benefit of therapies. Therefore, the role that other
biomarkers could have in hypertension requires careful
thought. We discuss three relevant scenarios briefly.
First, and bearing in mind the Commission’s definition
of the condition, hypertension is not merely persistently
elevated blood pressure; we see the potential for a new
definition of hypertension based on a molecular pheno-
type characterised by complex biomarkers. Genetic
polymorphisms have been identified with highly
significant associations with blood pressure, but the
proportion of variance explained by these genetic
markers is only about 3–5%.257 The specific composition
of proteins in hypertension assessed by proteomic
techniques258 and the description of the metabolome
associated with hypertension259 could potentially redefine
hypertension at a molecular level. At present, little
research in this area has been done, but the potential of
proteomics260 and other comprehensive molecular
techniques should be fully exploited to better characterise
the condition termed hypertension.
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 The Lancet Commissions

Second, biomarkers could help in the prediction of the
risk of developing hypertension. In this scenario, raised
blood pressure would again be a symptom that points
towards the underlying pathology, most likely changes in
the resistance of small and large arteries. Blood pressure
therefore only rises after functional and structural
changes in the vasculature have already occurred, before
diagnosis of hypertension. There are good reasons to
believe that prediction and preventive treatment before
the onset of hypertension have the potential to further
reduce hypertension-associated morbidity and mortality.
Third, in patients with hypertension, biomarkers can be
used to refine or restratify cardiovascular risk. We would
assume that complex molecular biomarkers based on
omics techniques will provide better individual prediction
than traditional unidimensional biomarkers such as lipids
or markers of cardiac damage (eg, the cardiac troponins).
Limited data are currently available about risk prediction
in hypertension with omics-based biomarkers.258,259,261
The so-called higher omics techniques—eg, proteomics
and metabolomics—will be best suited to describe the
current state of an individual, whereas genetic and
genomic biomarkers are better suited as risk markers. In
fact, because of the complex interplay between genes and
environment, the association between genetic and
phenotypic variants is not always very tight. Nevertheless,
findings from genome-wide association studies and
other genetic studies have robustly identified candidate
markers associated with the risk of having
hypertension.13,257 Functional analysis of regulated
pathways that emerge from these studies emphasises the
importance of renal salt and water handling (eg, in the
form of natriuretic peptides) and signalling.262 Whether
these genetic variants are also associated with the risk of
developing hypertension and associated organ damage
in a truly prospective fashion remains to be explored.
Summary of possible actions
In summary, the Commission identifies two basic
problems. First, fundamental phenotyping of individuals
with elevated blood pressure—including blood pressure
measurements, basic cardiovascular risk stratification,
and screening for secondary hypertension—is often not
done systematically. Second, further research is needed
to determine the additive beneficial effect of more
advanced phenotyping. In table 2, the different
subproblems with corresponding goals and actions are
listed, classifying the three actions dealing with the
fundamental phenotyping of individuals with elevated
blood pressure as essential.
Pharmacological prevention and treatment
Current evidence and problems
There is strong evidence that blood-pressure-lowering
drugs are beneficial for the prevention of major events
such as stroke, myocardial infarction, kidney failure, and
cardiovascular death. Compelling data are few, however,
concerning the role of antihypertensive treatment—in

Goals Actions Keywords

Poor measurement of blood
pressure
Poor identification of people at
high cardiovascular risk
Lack of diagnosis or delayed
diagnosis of secondary
hypertension
Lack of data on blood pressure,
cardiovascular risk, and arterial
ageing from childhood to
adulthood
Poor assessment of vascular
ageing in routine clinical
practice
Uncertainties about the clinical
use of omics-based biomarkers
Improve the quality of blood pressure measurement*
Increase the availability of standardised blood
pressure monitors*
Improve awareness of absolute cardiovascular risk as
a target for treatment*
Improve detection of clusters of cardiovascular risk
throughout the life course (eg, MetS)*
Improve detection of obstructive sleep apnoea*
Increase the diagnosis rate of secondary hypertension
by doctors*
Address the birth-cohort effect†
Update cardiovascular risk algorithms†
Promote the concept of early vascular ageing for
monitoring cardiovascular health
Evaluation and validation of the diagnostic and
prognostic value of omics-related markers
Certification and validation of monitors and endorsement of protocols Measurement quality
for measuring blood pressure by professional societies
Develop simple and inexpensive blood pressure monitors
Give preference for home, ambulatory, and automated unobserved
measurements to office measurements
Promote education on cardiovascular risk of patients, doctors, and Empowerment
health professionals
Reinforce targeting global cardiovascular risk rather than single risk
factor
Promote simple and robust algorithms for detecting secondary Secondary hypertension
hypertension
Increase the availability of relevant investigations in communities with
few resources
Favour management by multidisciplinary teams with appropriate
expertise
Capitalise on recent large existing cohorts, develop novel cohorts ··
including biomarkers, and adequate follow-up to ascertain
cardiovascular outcomes†
Promote the use of aortic stiffness as a robust and simple marker of ··
early vascular ageing
Develop simple and affordable devices to measure aortic stiffness†
Reference values for different ethnicities†
Capitalise on large existing cohort with adequate follow-up and ··
ascertained cardiovascular events†

*Essential goals. †Related to research.

Table 2: Identified problems and corresponding goals and actions relating to diagnosis

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 The Lancet Commissions
middle-aged and older individuals—to prevent dementia
or in slowing the progression of cognitive impairment.
In early trials into diastolic and systolic–diastolic
hypertension, blood-pressure-lowering drugs reduced,
on average, diastolic blood pressure by 5 mm Hg, the
risk of stroke by 42%, and the risk of coronary events by
14%.263 In subsequent trials on systolic hypertension in
individuals aged 60 years or older, the average reduction
in systolic blood pressure was 10 mm Hg, and the overall
risk reduction was 30% for stroke and 23% for coronary
events.264 Similar trends were observed in patients aged
80 years or older in the Hypertension in the Very Elderly
Trial42 who were actively treated aiming for a systolic
blood pressure lower than 150 mm Hg. The beneficial
effects of blood-pressure-lowering therapies to reduce
stroke, myocardial infarction, heart failure, and death
have also been shown in meta-analyses.27,265
Very recent evidence from the SPRINT trial39 and the
subsequent meta-analysis266 suggest that, at least in at-risk
populations without diabetes or a history of stroke, blood
pressure targets as low as 120 mm Hg systolic are associated
with further improved outcomes, although this blood
pressure target is associated with substantial adverse
effects.39 The lower target achieved in SPRINT should,
however, be interpreted in the context of the protocol for
blood pressure measurement used. Trials in patients with
type 2 diabetes that used a similar approach to aggressively
lower blood pressure including ACCORD41 and
ADVANCE267 showed smaller benefits on event rates than
did SPRINT. This was confirmed by findings from meta-
analyses.268,269
Drug treatment to achieve blood pressure of less than
140/90 mm Hg still seems to reduce all types of fatal and
non-fatal cardiovascular events, even in individuals with
mild hypertension and in those at low-to-moderate
cardiovascular risk.270 However, absolute risk reductions
with blood-pressure-lowering treatment are greater in
patients at higher levels of cardiovascular risk, and a
higher level of baseline risk is associated with a higher
absolute residual risk on treatment.271 It therefore remains
unclear whether patients with mildly elevated blood
pressure, in particular those at a younger age (ie, younger
than approximately 40 years of age in men and 50 years of
age in women), need pharmacological treatment.
Although reserving antihypertensive treatment for high-
risk patients with hypertensive maximises the cost–benefit
ratio, only treatment of patients at low-to-moderate risk
might prevent the increasing number of treatment
failures associated with late initiation of treatment.
Furthermore, antihypertensive treatment in people with
mild hypertension and at intermediate risk without
known cardiovascular disease has recently been supported
by a predefined subanalysis of the blood-pressure-
lowering part of the HOPE-3 trial.15 Individual treatment
decisions that take patients’ preferences into account will
be the best approach in some—but not all—health-care
systems.
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Some evidence suggests that the antihypertensive drugs
recommended by current guidelines (namely angiotensin-
converting enzyme inhibitors, angiotensin receptor
blockers, calcium channel blockers, and diuretics) achieve
similar global cardiovascular prevention.1,70,270 Nonetheless,
some of these drug classes have benefits in addition to
blood pressure reduction. Angiotensin-converting enzyme
inhibitors and angiotensin II receptor blockers are
particularly indicated in the presence of chronic kidney
disease, diabetes mellitus, or chronic heart failure.1,70 β
blockers are indicated in the presence of coronary heart
disease and chronic heart failure,1,70 but tend to be less
effective in the prevention of stroke.272–274 By contrast,
calcium channel blockers provide more protection against
stroke, but less protection against heart failure in overall
analysis275 and in several single active-comparison
trials.272,273,276 The combination of angiotensin-converting
enzyme inhibitors and angiotensin II receptor blockers
could be detrimental in clinical conditions277 other than
chronic heart failure,278 and hence is discouraged in the
management of hypertension.1,70 The combination of β
blockers and diuretics increases the risk of new-onset
diabetes mellitus.279,280 Findings from two trials have
suggested that the combination of angiotensin-converting
enzyme inhibitors and calcium channel blockers might be
superior to combinations of diuretics with either
angiotensin-converting enzyme inhibitors or β blockers,
at least in white populations.279,281
Although many large and well designed randomised
controlled trials are available on the benefits of
antihypertensive treatment, there is still insufficient
evidence on several clinically relevant questions for the
management of hypertension. Whom should we treat?
How should we treat? To which level should we treat and
which haemodynamic component should be used for
therapeutic evaluations? Which target should we treat?
Most data about the benefits and harms of
antihypertensive treatment derive from short-term
randomised controlled trials (follow-up typically 5 years),
whereas information about the accrual of benefits and
potential harms over the lifecourse of treatment is
lacking. In most individuals, treatment duration by far
exceeds the event horizon provided by most clinical trials.
The Commission therefore strongly suggests that
decisions about treatment should be made with the
lifecourse framework in mind, whereby not only
immediate cardiovascular benefits but also long-term
remote target-organ or metabolic harms are taken into
account in a unifying concept of lifecourse net clinical
benefit. Although all classes of antihypertensive drugs
reduce cardiovascular events, clinical trials and
observational data suggest not only differences across
antihypertensive drug classes with regard to general
efficacy and specific cardiovascular outcomess266 but also
differences regarding the risk of new-onset diabetes279 and
atrial fibrillation282 and the potential for renal protection283
in specific clinical scenarios. It is possible that the
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metabolically neutral class of angiotensin-converting
enzyme inhibitors is associated with greater lifecourse
net clinical benefit than the diabetogenic class of diuretics,
but in the absence of trial data with event horizons of
20–30 years this proposal is purely speculative. The
potential of big data to fill in this knowledge gap cannot
be overstated.284 The Commission strongly recommends
research into the lifecourse net clinical balance between
benefits and harms of different antihypertensive drugs
and of different blood pressure targets.
General treatment and adherence
Detection and management of hypertension in high-
risk populations, most notably in low-income and
middle-income countries, remains suboptimal. Despite
clear evidence for the benefits of blood pressure reduction
using low-cost and safe drugs, most individuals with
hypertension in the world are undetected, untreated, or
poorly controlled (figure 6).33,68,285 Accordingly there is an
urgent need to ensure access to affordable, high-quality
medicines globally. Indeed, the best-documented
antihypertensive therapies are now off patent and can,
therefore, be manufactured at very low cost, which will
be crucial in overcoming limitations to access, including
regulatory, political, and corporate factors.
Most patients with hypertension require more than
one drug to control their blood pressure.286 Single-pill
combinations of two or more antihypertensive drugs,
therefore, have the potential to reduce the number of
tablets that patients have to take, as demonstrated in the
ACCOMPLISH trial,281,287 and generally lead to improved
blood-pressure control.288 However, whether these
combinations are cost-effective and improve adherence to
therapy remains debated.289 Available combination pills are
based mainly on proprietary agents. The complex licensing
legislation for new formulations and combinations makes
it commercially unattractive to develop combination pills
based on less expensive, off-patent compounds.
Until more definitive data are available, we propose the
use of simplified algorithms supported by e-health
technologies both for initiation of drug monotherapy in
mild hypertension and combined therapy in more severe
grades. To facilitate drug therapy in patients with
hypertension worldwide, a core set of affordable, efficient,
evidence-based, high-quality drugs must be widely
available. The primary health-care team has to be
extended beyond physicians and should involve allied
health professionals and community workers to improve
hypertension management and to put into practice a
communication strategy with emphasis on prevention
and control of hypertension.290
One of the main causes for non-control of hypertension is
a lack of adherence by the patient. Low medication
adherence is common in patients with hypertension,
especially those with resistant hypertension; indeed,
the prevalence of poor adherence is reported to be as high
as 25–50% in patients with apparent resistant
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The Lancet Commissions
hypertension.291,292 Low adherence to antihypertensive
treatment has been consistently associated with poor blood
pressure293 and adverse cardiovascular prognosis.294 There
are significant differences in discontinuation of therapy
between antihypertensive drug classes, with angiotensin-
converting enzyme inhibitors, angiotensin II receptor
blockers, and calcium channel blockers showing the best
adherence.295 Significant heterogeneity in adherence to
antihypertensive therapy has also been reported between
drugs belonging to the same drug class.296 Objective
assessment of adherence to therapy is possible by testing
for the presence drug metabolites in body fluids, particularly
urine. Measurement methods such as high-performance
liquid chromatography coupled to tandem mass
spectrometry are sensitive,292 reproducible, relatively
inexpensive, and could help treatment decisions, particularly
in patients with difficult-to-control hypertension. However,
these drug metabolite screens provide only snapshot
information and—especially if done without informing the
patient—could substantially undermine the relationship
between doctor and patient. These extensive efforts to
assess adherence objectively are primarily for research and
only feasible in high-income countries.
The Commission is convinced that it is very important
for treatment adherence that the patient can see a clear
relationship between increase in antihypertensive
treatment and decrease in blood pressure. Therefore, we
recommend use of either ambulatory, home, or automated
unobserved blood pressure to initiate and titrate treatment
(rather than the highly variable office blood pressure,
which could mask the effectiveness of a drug).
A growing body of evidence suggests that a
multidisciplinary approach to improve adherence is
needed.297,298 This approach includes task sharing and
involvement of non-physician health workers and family
members, as well as educating the patient and reminders
to reinforce the importance of treatment adherence.
Different approaches can be used depending on the
economic, cultural, and social context (see section on
Empowerment as a tool).
Side-effects of antihypertensive treatment are another
major factor contributing to poor blood-pressure control.
Drug and drug-class-specific side-effects such as cough
associated with use of angiotensin-converting enzyme
inhibitors, peripheral oedema with dihydropyridine-type
calcium channel blockers, and tiredness with β-receptor
blockers are well recognised and cause treatment failure
in a proportion of patients with hypertension.299 Notably,
the combination of dihydropyridine calcium channel
blockers with angiotensin-converting enzyme inhibitors
significantly reduces the occurrence of peripheral oedema,
the most common adverse drug reaction usually leading
to discontinuation of the calcium channel blockers
(irrespective of their efficacy in lowering blood pressure).300
Hypotension—as a side-effect of antihypertensive
therapy—occurs largely independently of the choice of
antihypertensive drug class. In fact, especially in older
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individuals, episodes of systolic hypotension are
extremely common, affecting roughly 55% of patients
aged 75 years and older.301 There is a complex interplay
between hypotension, cerebral hypoperfusion, and poor
adherence to therapy as a result of impaired cognition
that add to the challenges of antihypertensive therapy,
especially in elderly people.
Pharmacological prevention
Antihypertensive therapy has a major role in the primary
and secondary prevention of cardiovascular and renal
diseases, both in the general population and in at-risk
populations such as those with diabetes or chronic
inflammatory diseases. Antihypertensive drugs are
therefore part of a concerted treatment strategy to tackle
cardiovascular risk factors such as hypertension, obesity,
dyslipidaemia, and hyperglycaemia. Preventive treatment
often starts with the assessment of biomarkers such as
blood pressure, bodyweight, cholesterol, and glucose
levels, followed by the targeted prescription of individual
drugs to address these risk factors. By contrast, the notion
of a polypill containing fixed doses of preventive drugs
such as antihypertensive drugs, statins, and aspirin,
which is prescribed irrespective of the exact individual
risk but rather depending on average population risk (eg,
based on an age threshold)302,303 has gained attention,
especially in low-income and middle-income countries
where the burden of cardiovascular diseases is high,
resources for diagnostic tests are scarce, and inexpensive
and standardised treatments are more likely than
individualised therapies to be taken up in clinical
practice.304 The beneficial effect of lipid-lowering treat-
ment with statins in patients with high cardiovascular
risk is well supported by several studies,121,305 but findings
from the HOPE-3 study306 showed that lipid-lowering
statin treatment also reduced cardiovascular events in
individuals with intermediate risk and no known
cardiovascular disease independently of blood pressure
and antihypertensive treatment. However, there is an
ongoing debate about indications, cost-effectiveness, and
composition of the polypill, making translation of this
concept into clinical practice very difficult.307
Primordial prevention of hypertension can be achieved
by prescribing antihypertensive drugs at a stage when
blood pressure is still within the normal range. The
classification as high normal blood pressure1,53 for blood
pressure ranges of 130–139 mm Hg systolic and
85–90 mm Hg diastolic has been introduced because
individuals in this range are more likely to progress to
hypertension compared with those with normal or
optimal blood pressure. Studies in individuals with high
normal blood pressure have shown with short follow-up
periods (2 years in TROPHY308 and up to 3 years in
PHARAO309) that incident hypertension can be prevented
or at least delayed. However, because of insufficient
long-term follow-up data, primordial prevention of
hypertension is open for further research. Such treatment
2684
is, however, well tolerated and provides a basis for
prevention trials in high-risk patients such as those with
atherosclerosis310 or chronic renal failure,311 for whom
there is some evidence that treatment of normotensive
individuals to systolic blood pressures below 130 mm Hg
can be associated with beneficial outcomes. However,
another approach was tested in the blood-pressure-
lowering part of the HOPE-3 trial15 in which people with
intermediate risk without known cardiovascular disease
were randomly assigned to candesartan 16 mg plus
hydrochlorothiazide 12·5 mg versus placebo for 5·6 years.
Significantly improved outcome, however, was only
observed in people with baseline systolic blood pressure
greater than 143·5 mm Hg (ie, in the top tertile of systolic
blood pressure among trial participants), thus not
supporting antihypertensive treatment in normotensive
individuals at intermediate cardiovascular risk—although
the study was not powered to detect benefits among
different subgroups defined by baseline blood pressure.
Therefore, the evidence base is not sufficiently robust for
primordial prevention to be universally accepted.53
Management of elderly individuals with hypertension
More than 30% of people older than 65 years fall at least
once annually,301,312,313 and antihypertensive treatment is a
major (and modifiable) risk factor for falls.314,315 The risk is
particularly high when more than three defined daily
doses of antihypertensive drugs are taken and is
independent of specific drug classes such as diuretics or
β blockers.315 Aggressive treatment of older people with
hypertension might not only increase their risk of falls
via episodes of hypotension, but also lead to poor
adherence to therapy and increased adverse drug
reactions.316 However, in the SPRINT trial39,40 there was no
increase in falls-related injuries requiring hospital
evaluation or admission. A useful strategy could be to
monitor blood pressure more carefully with automated
devices (when the patient is alone and relaxed), use
systematic home or 24 h ambulatory blood-pressure
measurements, and include standing blood pressure in
elderly people to identify patients with clinically
significant hypotension before any falls occur.
Another relevant aspect in older people with
hypertension is cognitive impairment, with the prevalence
of dementia increasing from 7% in subjects older than
65 years to 30% in subjects older than 80.317 Subjective
reports of memory loss begin about 2–3 years before
onset of dementia.318 Elevated blood-pressure levels in
middle-age have been associated with increased risk of
dementia in older age.319 Elevated blood pressure provokes
early damage of cerebral white matter microstructure320
and is associated with poor cognitive performance, even
at young ages.321 Thus, cerebrovascular injury should be
considered and monitored as target-organ damage in
hypertension in its own right322 to prevent the onset of
clinical overt dementia, to slow the progression of
cognitive decline, and to postpone the onset and
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exacerbation of behavioural symptoms that can often lead
to loss of independent living of patients and can be
devastating for caregivers. Antihypertensive treatment
can improve cerebral microcirculation through reduced
blood pressure and protective effects on arteries of
specific antihypertensive drugs.191 However, as with falls,
treatment that is too aggressive can result in hypotension
and cerebral hypoperfusion, thereby accelerating the
progression of cognitive decline in older individuals.37
We should acknowledge the lack of strong evidence
from randomised controlled trials on the protective role
of blood pressure reduction on cognitive dysfunction.
Clinical trials that include cognition as primary endpoint
are needed. The randomised controlled trials should
include predominantly older individuals and adopt
accurate and cost-effective tests to screen for cognitive
impairment.323 Such trials might clarify whether the
association between hypertension and cognition is causal
and which antihypertensive drugs are the most effective
in slowing progression of cognitive impairment and
postponing the onset of overt clinical dementia.
Furthermore, improved characterisation of pathways
linking hypertension to cognitive decline and dementia
could help to identify novel drug targets such as
accelerated arterial ageing,324 clearance of cerebral
parenchymal waste products (including β-amyloid) via
the perivascular circulation,325,326 and the response of the
cerebral vasculature to injury.327
Ethnic and cultural differences
With a few exceptions, most mortality and morbidity
trials into hypertension management have been done in
individuals of European descent, and limited trial data
are available to inform treatment specifically for those of
Asian, African, or Middle Eastern origin.
The challenges in understanding the ethnic and
cultural differences in cardiovascular disease are
substantial. Ethnicity is difficult to define and classify.
The biology of individuals is driven by complex sets of
gene–gene, environment–environment, and gene–
environment interactions,328 and some clear physiological
differences are apparent across ethnic groups (eg,
decreased renin concentrations329 and endothelial nitric
oxide bioavailability330 among those of African origin).
Among the environmental influences are socioeconomic
issues, but issues including widespread differences in
stress handling, smoking habits, nutrition, and caloric
and salt intake can have pronounced effects on the
prevalence of hypertension and development of target-
organ damage, including overt cardiovascular disease.331
As a consequence, the results of hypertension research
in individuals of European descent might not apply
directly to those of non-European ancestry.
As the world becomes more connected and increases
in prosperity, lifestyles characterised by reduced levels of
physical activity and unhealthy diets rich in fat, salt, and
sugar are more common everywhere. As a result, the
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The Lancet Commissions
prevalence of hypertension and diabetes mellitus
increases, with predictable adverse effects on
cardiovascular outcomes. To better manage the already
high but expanding need for antihypertensive treatment
in people of non-European descent, more ethnically
specific research is needed concerning genetic adaptation
as a promotor for cardiovascular risk factors, development
of target-organ damage, and, crucially, the optimal
pharmacological management of raised blood pressure.
However, ethnic differences in culture and lifestyle and
underlying socioeconomic conditions probably affect
cardiovascular events more than do genetics.
Lifestyle modifications
Nearly all guidelines recommend non-pharmacological
therapy or lifestyle modification as a first-line approach to
hypertension management. Lifestyle modification offers
universal appeal as an intervention because the costs, in
motivated individuals, are minimal and can lead to drug
step-down or withdrawal. However, in the absence of self-
motivation, achievement-sustained lifestyle modifications
require substantial resources over a longer period.
Furthermore, although the benefits of lifestyle modi-
fication in cardiovascular prevention are clear, evidence to
guide the use of individual-based lifestyle modification as
a stand-alone or add-on therapeutic intervention is
lacking, which is perhaps most evident for dietary
modifications. For example, investigators of the DASH-
Sodium trial138 and others have established that a low-
sodium diet can lead to substantial improvements in
blood pressure. Long-term follow-up data from the Trials
of Hypertension I and II137 also suggested that the long-
term risk of cardiovascular events might be reduced with
sodium reduction. Similarly, high potassium intake has
been purported to reduce blood pressure.332,333 Restriction
of salt intake has been demonstrated to reduce blood
pressure and cardiovascular events more in patients with
hypertension than in those without hypertension.16,90,137,334,335
Evidence of varying quality suggests that particular
foods (eg, beetroot, nitrate-containing foods and
beverages,92 garlic,336 and flaxseed337) can reduce blood
pressure levels. However, the usefulness of such foods to
lower blood pressure remains to be proven in large
cohorts. Ultimately, further research—including inter-
ventional studies—are needed to guide the use of dietary
modification in the treatment of hypertension.
Increased physical activity is another lifestyle modi-
fication for which there is reasonable consensus on value
as a preventive intervention but less guidance for its use as
therapy. Most recommendations suggest increased
physical activity in the management of hypertension and
extend logically from the large bodies of observational data
showing associations between decreased physical activity
and cardiovascular risk.338,339 Findings from meta-analyses
also suggest that exercise training reduces blood pressure
in healthy individuals340,341 and those with hypertension.342,343
Even in patients at high cardiovascular risk, the benefits of
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regular exercise could outweigh any risks by improvement
in cardiac structure and function.344 Nevertheless, there
remains a paucity of data about the optimal form (eg,
aerobic vs resistance or isometric training), type (eg,
swimming vs running), and thresholds at which maximum
benefit are achieved. Moreover, there is a pressing need for
strategies to optimise uptake of recommendations.
Finally, the evidence supporting the use of most
lifestyle modifications in therapy is typically from studies
that looked at these modifications individually. In
practice, however, lifestyle modification should be
systematic, and assessment of the efficacy of multiple
lifestyle modifications given together will be crucial.
Indeed, although the effects of individual lifestyle
modifications on blood pressure might be small, the
effect of several modifications together might prove more
effective than pharmacotherapy, at least in some patients.
Meta-analyses for this are already underway.345
Irrespective of the evidence gaps, the general consensus
is that people should be encouraged to engage in some
form of regular exercise to improve their cardiovascular
risk profile.
Targeting pathophysiology
Pathophysiology-based approaches to secondary hypertension
Many of the factors that regulate blood pressure through
the key mechanisms of cardiac output, volume status,
and vascular tone are known and include the sympathetic
nervous system, the renin–angiotensin–aldosterone
system, and renal function. In primary (essential)
hypertension, a large number of factors with fairly small
effects act together, whereas in secondary hypertension,
one or very few well defined factors with substantial
contributions to blood pressure dominate.
Individualised treatment that targets the specific cause of
hypertension substantially improves blood pressure control
in most patients with secondary hypertension and even
cures hypertension in at least a fifth of such patients. In
patients with primary aldosteronism, adrenalectomy in
cases of unilateral production of aldosterone and medical
therapy including aldosterone antagonists for bilateral
hyperaldosteronism are therapeutic options to control
blood pressure.346 Surgical resection can cure hypertension
in patients with a catecholamine-producing tumour.253
Although renal percutaneous transluminal angioplasty is
indicated in the first instance in patients with fibromuscular
dysplasia,255,347 randomised trial data have shown no benefit
of surgical revascularisation or stenting compared with
medical therapy in patients with atherosclerotic stenosis of
renal arteries.348–350 In patients with rare forms of monogenic
hypertension, such as Liddle’s syndrome and Gordon’s
syndrome, blood pressure control can be achieved and
hypertension can be controlled with lifelong treatment with
a single drug such as amiloride (Liddle’s syndrome) or a
thiazide-type diuretic (Gordon’s syndrome).351
However, despite decades of research, the indication
for adrenal surgical resection versus medical therapy for
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primary aldosteronism is still controversial, especially in
very elderly patients, and the benefit of interventional
treatment of renal artery stenosis remains under debate.
International randomised clinical trials are still required
to develop evidence-based indications for medical or
interventional therapies in different categories of
secondary hypertension.
Personalised treatment and management by multi-
disciplinary teams with appropriate expertise are
essential to achieve favourable outcomes in patients with
secondary hypertension. Lifelong specialised follow-up is
indicated, and in some cases (including catecholamine-
producing tumours caused by germline mutations of
SDHB) follow-up includes not only the patient (who is at
risk of recurrence and development of metastases) but
also their relatives (when genetic testing offers the
possibility to detect and treat asymptomatic disease in
family members).352 However, the profound knowledge
of the natural history of the different forms of secondary
hypertension and specific prognosis biomarkers needed
to precisely refine follow-up recommendations is
still lacking.
Pathophysiology-based approach to essential (primary)
hypertension
The mechanisms underlying the pathophysiology of
essential hypertension are complex and multifactorial.
Lessons learned from the treatment of patients
with secondary forms of hypertension can, however,
inform therapeutic approaches to those with
essential hypertension. Activation of the sympathetic
nervous system, which occurs in patients with
phaeochromocytoma, also plays an important part in the
initiation and maintenance of elevated blood pressure
and associated adverse effects in many patients with
essential hypertension.353 The close association between
the sympathetic nervous system and the renin–
angiotensin system in the pathophysiology of
hypertension has led to the development of mechanism-
based approaches to hypertension treatment, including
drugs and invasive procedures targeting the neurogenic
component of hypertension; however, further
investigation is needed before introduction of these
therapies into the clinical setting.354 With available
evidence linking excess aldosterone to disease
progression, resistant hypertension, and mortality,355
further studies to improve selectivity and tolerability of
drugs directly aimed at the aldosterone pathway are
needed.354 A reduction in blood pressure and sympathetic
activity has been demonstrated with invasive therapeutic
strategies such as baroreflex activation therapy and renal
denervation356–362 in treating patients with truly resistant
hypertension or those whose hypertension is
uncontrolled in the absence of other treatment options.
However, in the light of the similar blood-pressure
responses to renal denervation and sham control found
in the Symplicity Hypertension-3 trial,363,364 a better
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understanding of underlying pathophysiology is needed
before using these treatment approaches (for example,
insufficient ablation of the renal sympathetic nerves
might explain the lack of difference in blood pressure
noted in the trial). An approach which ablated a
combination of nerves, including the main renal artery
and branches, resulted in the greatest reduction in renal
sympathetic activity in an animal model,365 whereas renal
denervation done in all arteries including accessory renal
arteries produced a greater reduction in blood pressure
and sympathetic nerve activity compared with ablation
in the main renal artery alone in patients with resistant
hypertension.366 These findings might substantially
improve efficacy of renal denervation and reduce the
variability in blood pressure response to the procedure,
which should be assessed further in randomised, sham-
controlled clinical studies.
Although pathophysiological principles should be
explicitly considered within personalised management of
hypertension control, the contribution of individual
pathophysiological factors to a patient’s elevated blood
pressure is difficult to assess in clinical practice, where
comprehensive assessment of the sympathetic nervous
system and renin–angiotensin system to the same
standard as in clinical research studies is not feasible.
However, findings from the PATHWAY-2 study367 showed
that the blood pressure response to classes of
antihypertensive drugs could be predicted by plasma
renin concentration, a crude measure of the activity of the
renin–angiotensin system. Additionally, assessment of
haemodynamic profiles with non-invasive devices that are
simple to use seems to help in deciding on initiation of
treatment, choice of drugs, and monitoring of therapy.210
The potential cause and underlying mechanisms of
unresponsiveness to antihypertensive drugs in patients
who adhere to treatment need to be addressed in future
clinical trials. The role of lifestyle modifications including
stress management in the treatment of hypertension and
the question of whether behavioural and procedure-
based therapies can favourably modulate neurogenic
mechanisms and ultimately prevent hypertension and its
cardiovascular consequences still need to be explored
systematically.
Treatment of hypertension beyond the treatment of elevated
blood pressure
Treatment of hypertension currently focuses on blood-
pressure-lowering measures. However, in the future, we
suggest that additional therapeutic strategies beyond the
mere lowering of blood pressure will have to be explored
and applied.
Recent data suggest that the pathophysiology of
hypertension is more complex than originally thought
and involves processes such as endothelial dysfunction,368
inflammation,369 altered sodium handling,370 and oxidative
stress.46 Targeting of these mechanisms will, in most
cases, not immediately reduce blood pressure but rather
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The Lancet Commissions
counteract the substantially altered vascular phenotype
that truly characterises hypertension. The potential to
develop a cure for hypertension that at the same time
treats the phenotype of persistently elevated blood
pressure should be the ultimate aim.
In addition to traditional and emerging risk factors,
molecular biomarkers will help to characterise the
phenotype of hypertension in individual patients, pointing
towards the specific dysregulated pathways that can be
targeted with specific therapies, thereby paving the way
for personalised medicine in hypertension. In this sense,
biomarkers—for example, subclinical cardiovascular
phenotypes and target-organ damage—can be a target of
antihypertensive therapy, not as a symptom to be
minimised but as a definition of the condition that is
altered when it has been successfully treated.
Targeting haemodynamics
Haemodynamic assessment might help in the choice of
antihypertensive therapy by identifying individuals who
might benefit more from ad-hoc regimens (based on
matching the haemodynamic action of drugs with the
haemodynamic pattern of hypertension) and assisting in
the titration of the intensity of therapy to specific goals.
To achieve this goal, new methods that assess arterial
pressure and flow dynamics, beyond focus on
conventional upper-arm blood pressure, are needed.
Antihypertensive medications can have different haemo-
dynamic effects in the large central arteries (eg, aorta,
carotids) compared with the brachial artery where the blood
pressure cuff is applied. For instance, organic nitrates
lower central aortic systolic blood pressure more than
systolic brachial blood pressure.371–373 By contrast, β blockers
(primarily atenolol) less effectively lower central aortic
systolic blood pressure but have similar effects on brachial
systolic blood pressure compared with calcium channel
blockers, angiotensin-converting enzyme inhibitors, or
angiotensin II receptor blockers.191,193,374–376 Thus, assessment
of left ventricular hypertrophy and geometry and arterial
pressure waveforms to determine haemodynamic and
volume status, and central aortic loading conditions, can
efficiently refine hypertension management decisions, as
supported by findings from two randomised trials.195,377 The
BEAUTY study210 compared haemodynamic monitoring
using impedance cardiography (combined with a drug
selection algorithm) versus conventional drug selection for
the treatment of uncontrolled hypertension. Both strategies
resulted in similar reductions in ambulatory daytime and
office systolic blood pressure, although therapy based on
impedance cardiography therapy was associated with more
use of diuretics and fewer side-effects than conventional
management.
Blood pressure variability has been recognised as a
prognostic factor independent of the level of blood
pressure per se. Most of the evidence, however, relates
blood pressure variability with the risk of stroke,186 whereas
the association with other cardiovascular events seems to
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be less robust. Different ways to calculate blood pressure
variability, different modalities of variability (short term,
long term, day–night, and others378), and little evidence
about therapeutic approaches specifically directed to
change blood pressure variability hinder the translation of
a potentially useful concept to clinical practice. Different
effects of various drug classes on blood pressure variability
have, however, been described379,380 and could form a basis
for prospective evaluation in clinical trials.
At this point, it is clear that measurements of
haemodynamic patterns of hypertension are of interest to
elucidate mechanisms related to the pathophysiology of
hypertension in individual patients, and hold promise as
a therapeutic strategy in hypertension. However, further
investigations are needed before they can be recom-
mended for routine clinical use. In particular, trials
designed to target specifically central blood pressure at
any given level of brachial blood pressure are required.
Targeting subclinical organ damage
Targeting of biomarkers might be useful if improvements
in biomarker profiles are associated with improved
outcome.381 Left ventricular hypertrophy in hypertension
has previously been considered as adaptive, but the
presence of left ventricular hypertrophy is associated
with increased cardiovascular risk. More importantly,
treatments such as angiotensin-converting enzyme
inhibitors and angiotensin II receptor blockers382,383
decrease in left ventricular hypertrophy, which is
predictive of improved prognosis.384,385 It remains unclear
whether treatment guided by the level of left ventricular
hypertrophy adds incremental benefit over blood-
pressure-targeted treatment.
For detection of vascular and renal damage, urine
albumin–creatinine ratio is the most robustly studied
parameter. When increased, it is associated with
atherosclerotic disease, myocardial infarction, and
cardiovascular risk. Furthermore, any substantial reduction
is associated with improved prognosis,386 especially in
diabetes in some387 but not all trials.388 The major challenge
related to urine albumin–creatinine ratio is the variability
of this parameter with time and intervention.389,390 For other
subclinical markers, the evidence is more scarce.
Markers of large artery structure and function,213
especially carotid-to-femoral pulse wave velocity51 and
carotid distensibility,213,391 have demonstrated their added
value against cardiovascular risk scores. They appear
simple to use and are applicable in large groups. Reference
values are available217,392 and efforts have been made to
standardise measurements, but whether arterial markers
can be used to target therapy remains unclear. Similarly,
early brain damage can be detected by MRI through white
matter hyperintensities.233 However, by contrast with left
ventricular hypertrophy and urine albumin–creatinine
ratio, whether intervention can reverse these lesions is
unclear. Further information is needed before considering
cerebral lesions a target for therapy.
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An important problem is that target-organ damage is
slow to respond to treatment,393 thereby reducing its
value as a monitoring tool in the acute care of patients.
However, changes in target-organ damage can detect
failure or success of therapeutic strategies before the
development of myocardial infarction, stroke, or
cardiovascular death. Whether targeting of subclinical
organ damage rather than or in addition to blood
pressure provides additional benefit to the patient or to
society remains to be clearly demonstrated. For example,
the ongoing SPARTE trial394 will address the question of
whether arterial stiffness assessed as carotid-to-femoral
pulse wave velocity can be used as a surrogate endpoint.
The demonstration that such monitoring of treatment
is advantageous over the classic approach based on
blood pressure measurement should be tested in
clinical trials.
Summary of possible actions
There is a large arsenal of effective pharmacological
agents with established efficacy in the treatment
of hypertension. To improve the pharmacological
management of hypertension globally, a crucial first step
is to ensure universal access to affordable, high-quality
therapeutics. However, even with this access, therapy is
not always given optimally. We therefore recommend the
development of evidence-based decisional algorithms to
inform health-care professionals precisely on the required
diagnostic and therapeutic steps. Such algorithms should
be based on the most current evidence, be clear and
simple, and aim to standardise the diagnostic work-up
and therapy of almost all patients with hypertension.
Such algorithms will probably include predominant use
of generic drugs from major antihypertensive classes,
combination therapy as an initial treatment approach,
and measures to monitor treatment and improve
adherence. When coupled with better identification of
hypertensive individuals with the help of “more hands” in
health service through task sharing, these actions will
greatly improve blood pressure control and reduce the
global burden of hypertension and related cardiovascular
complications not only in individual patients but in whole
populations.
In addition to these recommendations, research is
needed to better understand the potential of targeted
therapy depending on age, ethnicity, and cardiovascular
risk on treatment, the utility of lifestyle modification in
therapy, and the benefits of monotherapy versus
combination therapy as an initial treatment strategy. It
will also be important to assess whether treatment based
on targets such as left ventricular hypertrophy,
haemodynamics, and biomarker-based approaches are
superior to blood pressure control for reduction of
cardiovascular risk in hypertension. Prior to the
development of hypertension, preventive therapeutic
strategies including the use of polypills or targeting
prehypertension also have the potential to delay the
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 The Lancet Commissions

natural lifecourse of hypertension, but require evidential
support.
Finally, the Commission sees a continued need for the
development of new drugs, both those that act on new
therapeutic targets and those that target existing
pathways but have improved pharmacokinetic or
pharmacodynamics profiles (table 3).
Empowerment as a tool
Introduction to empowerment
Education and empowerment are related tools that offer
great potential to improve the global management of
elevated blood pressure. Abundant evidence suggests
that early health education improves outcomes in terms
of primordial prevention; education can also be tailored
to improve interactions between patients, doctors,
health-care providers, pharmacists, and key participants
in the management of hypertension to maximise its
effectiveness.
Patient empowerment more specifically refers to the
process of shifting a patient’s mentality from a passive
recipient of health care towards an active role where they
understand their condition and their role in the health-
care process, and take self-initiated actions to benefit
their health.395,396 The many strategies for patient
empowerment include shared decision making, self-led
lifestyle modifications, self-administered treatment and
monitoring, and the provision of health information
(eg, biochemistry) directly to the patient. Irrespective of
the method, strategies that foster patient empowerment
have consistently been shown to increase patient
satisfaction, encourage adherence, and improve out-
comes in chronic diseases including hypertension.396–398
A complementary and essential relative of patient
empowerment is community empowerment, the process
of empowering communities of people—defined by
geographic proximity, shared common interests, or even
disease (eg, hypertension)—to take control over their
conditions and improve the quality of their lives and
collectively overcome inequities.399,400 Strategies for
community empowerment include provision of
education, technical information, and tools necessary for
action, ultimately enabling the community to define the
problem, determine the best solution, and implement
the response.300,401 However, a community-based pro-
gramme that includes stakeholders from the community
is not necessarily a community empowerment approach.
In community empowerment, an essential component is
leadership and control of the process by the community,
coupled with availability of essential resources and
capacity to act. An empowered community is confident,
inclusive, organised, cooperative, and influential. All of

Goals Actions Keywords

Lack of antihypertensive
drug availability
Lack of available health-
care professionals for
management
Lack of stratified
approaches to the
treatment of
hypertension
Poor adherence to
treatment
Limited information on
how to use lifestyle
modification as therapy
Brachial blood pressure
might be a suboptimal
measure to guide
treatment
Uncertain effect of
empowering patients to
take control of their
antihypertensive
management
Physician inertia in
increasing
antihypertensive
medication
Improve availability of affordable, high-quality, and
effective antihypertensive agents worldwide*
Increase capacity for management of hypertension
worldwide*
Optimise treatment initiation, goals, and
combinations according to age, ethnicity, and
cardiovascular risk*
Improve approaches to overcome poor adherence
Establish defined approaches to incorporate
culture-specific lifestyle modification into
management of hypertension
Determine whether treatment to alternative targets Assess the relative benefit of management based on target-organ damage†
improves cost efficacy and effectiveness of
antihypertensive treatment
Assess the benefits and determine optimal
implementation of self-treatment
Counteract physician inertia
Universal availability of at least one of each class of antihypertensive drug Medication access
Availability of single-pill combinations where resources permit
Development of novel therapeutics based on improved knowledge of pathophysiology†
Train community health workers to detect, initiate, and monitor treatment of Workforce
hypertension expansion
Expand health-care workforce by facilitating task sharing in the management of
hypertension
Harness existing data to provide rational information on optimisation of targets, Standardised
treatment initiation, and therapy based on age, ethnicity, and cardiovascular risk treatment
Support randomised controlled trials that focus on optimisation of BP targets, treatment
initiation, and therapy†
Harness information technology tools to facilitate patient adherence ··
Identify determinants of poor adherence†
Develop treatment approaches targeting causes of poor adherence†
Integrate existing knowledge into management strategies ··
Randomised controlled trial to determine optimal lifestyle modification approaches to
hypertension management†
··
Evaluate the relative benefit of management based on haemodynamics†
Assess the relative benefit of management based on biomarkers†
Randomised controlled trials to assess the effectiveness of self-treatment† ··
Promote education of doctors and health-care professionals through the availability of ··
simple guidelines for daily management of hypertension

*Essential goals. †Related to research.

Table 3: Identified problems and corresponding goals and actions relating to pharmacological treatment

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 The Lancet Commissions
these aspects, when brought to bear on preventing and
controlling hypertension,402 can result in effective and
sustainable changes in a community’s health trajectory.
Education
In addition to population-wide education strategies,
patients and individuals at risk of hypertension represent
an audience potentially receptive to more focused
educational initiatives. Education in such populations
might be expected to improve communication between
provider and patient, and ultimately empower the patient
to play an active role in managing their risk factors and
disease. Indeed, abundant and long-standing evidence
suggests that patient education improves outcomes in
hypertension.403–406 Physicians who spend more time with
patients and engage more in lifestyle and prevention
education generally prescribe less medication. However,
long-term follow-up of this strategy is needed to measure
the effect on patient outcome.407 Despite this evidence, and
the fact that virtually all practice guidelines for hypertension
advise lifestyle modifications as first-line treatment,
educational initiatives are not universally implemented,
even in patients with hypertension. In one study,408 only
55% of young adults with hypertension had documented
evidence of lifestyle education after diagnosis.
A major gap in knowledge is the lack of clarity about what
constitutes effective lifestyle counselling for hypertension.
For example, how many sessions, of what duration, over
what period of time, and in what format are most effective?
Systematic reviews of educational interventions in patients
with hypertension are underway and could ultimately
provide some clarity in this area.409 In addition to this
consideration, health-care delivery systems are unlikely to
adequately deliver patient education in the clinical
environment. Conventionally, physicians are seen as being
central to oversee lifestyle change,410 but this strategy might
not be the best approach.411 The World Development
Indicators on Health Systems412 indicate that there are only
0·1 physicians and 0·5 nurses for every 1000 people in low-
income countries, and even in high-income countries the
available 3·1 physicians and 8·6 nurses per 1000 are
insufficient to carry out this important task effectively. It is,
therefore, understandable that major reports and guidelines
on prevention of cardiovascular disease state the im-
portance of an integrated approach or shared responsibility
involving numerous stakeholders to ensure successful
implementation of preventive strategies.68,87,119,123,410,413
Community health workers, pharmacists, nurses,
physiotherapists, dietitians, and other allied health
professionals are probably better positioned than medical
doctors to provide consistent and substantive lifestyle
education. Introducing or strengthening community
linkages and resources creates new opportunities for the
delivery of health information and patient-centred disease
management. In parallel, continuing education of all health
workers remains crucial to ensure delivery of optimal care
based on current knowledge. Experience with trained
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non-physician community health workers in Pakistan,
South Africa, and Iran has shown that lay health workers
could effectively deliver health-promotion materials, detect
high blood pressure, and reduce blood pressure levels in the
population.414–416 Indeed, team-based care and task sharing
with nurses, pharmacists, and medical assistants are
effective in improving blood pressure control, particularly
when coupled with education on medication,417–420 which
could also be extended to other professions.421,422
Primary-care physicians must also ensure that they are
applying best practice based on the best available
knowledge. For future physicians, the university medical
training curriculum must sufficiently address current
guidelines and also include novel approaches such as
patient empowerment, self-treatment, and the use of
new technologies. International and national professional
societies should also work together to produce consistent
guidelines, because real or perceived inconsistencies are
a likely cause of therapeutic inertia.423
Self-monitoring of blood pressure
Self-monitoring empowers individuals to engage in their
own management of blood pressure, leading to many
possible benefits, including more active treatment by
doctors,424 facilitation of discussion with doctors,
improved patient–doctor relationships, greater possibility
for adhering to antihypertensive therapy, and reduction
of blood pressure.425–429 Self-monitored blood pressure
must be done with a standardised protocol to minimise
the potential for erroneous readings from extrinsic (eg,
device validation) and intrinsic (eg, level of relaxation)
factors affecting reading quality. The widespread
availability of educational material on self-monitoring
should make this information easily accessible to patients
and doctors. Despite all the potential advantages of self-
monitoring, there are still evidence gaps relevant to both
patients and clinicians. Patients lack education about
what they should be concerned about and how to act;
physicians have insufficient clarity about how to optimise
the use of self-monitoring in the clinical encounter, and
need better guidance in interpreting self-monitored
values (including how to handle differences from clinic
blood-pressure measures).425 Future developments in
wearable devices that are appropriately validated could
overcome some of these hurdles. For health-care systems,
an expanding number of monitors now include
technology for the immediate communication of a
patient’s home-measured blood pressure reading to the
doctor’s office or another third party. Clinical protocols,
capacity, and response systems need to be developed to
support timely, appropriate, and meaningful feedback to
patients to improve control. The use of these devices in
self-titration is described further below.
Self-administered treatment
Self-administered treatment provides an important
opportunity to improve management of chronic diseases
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such as hypertension.430 This approach seeks to shift
patients from mere receivers of drugs prescribed by the
physician to active participants in the shared decision
making regarding their treatment.431 For this approach to
be effective, patients should be given advice based on the
best available scientific evidence, with alternative
approaches and outcomes presented so they can choose
the treatment strategy that is most suitable for them.
The patient’s individual goals are prioritised while
ensuring that they understand the short-term and long-
term consequences of their choices.432
Only a few studies have assessed self-management and
self-titration in hypertension. One pilot study433 assessed
the effectiveness of self-management and self-titration
with a web-based system; blood pressure was effectively
reduced, but there were barriers to implementation of
the system including the patients’ lack of trust in the
protocol.433 Findings from the SETHI434 and TASMINH2435
trials further showed that self-monitoring and self-
titration could engage patients in their treatment,
resulting in improved blood-pressure control and
reductions in cardiovascular risk up to 12 months after
initiation. Further clinical trials will be necessary to
better identify the target populations, develop algorithms
or procedures for drug adjustment, and evaluate the
most effective duration of the intervention. There is also
a need for specific training for both patients and doctors
and to monitor progress regularly. It is possible that
self-titration could reduce clinical inertia (ie, resistance to
change), but this notion remains to be proven.
Technology
Mobile and internet technologies already play an
important role in the management of hypertension by
educating patients and supporting disease management;
this role is expected to grow alongside a global increase
in availability.
App and web-based content provide an opportunity to
reach both the patient and the general population,
especially in low-income and middle-income countries.
By providing resources that are available to patients at all
times, there is increased opportunity to educate and
influence a patient’s lifestyle outside of the clinic at times
when they are more receptive to change. However,
such approaches must adhere to current clinical
recommendations. Investigators of a study436 that
assessed whether internet content accurately reflected
the American Academy of Paediatrics recommendations
for infant sleep safety found that less than half of all high-
traffic websites were consistent with recommendations,
with a substantial influence of low-accuracy retail-
product sites and blogs.436 Accordingly, the hypertension
community will need to guard against the circulation of
outdated or erroneous educational material within the
plethora of available health-related content. One possible
approach would be for international and national
professional societies to collaborate in endorsing a
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The Lancet Commissions
consistent message through the creation of a universally
recognised seal of approval to ensure confidence in the
quality of the content.
Information and communications technology systems
are a potential key to empowerment in hypertension
care. These technologies can empower patient-centred
medicine with enhanced access and continuity of health
care, management planning according to the best
available scientific evidence through computerised
decision-support technology, and tools to promote self-
management including patient-guided services such as
electronic or mobile health applications and
telemedicine.437,438 Information and communication
technologies can also reduce medical errors and improve
response to adverse events. There is also emerging
evidence that telehealth and e-counselling services could
be effective addenda to pharmacological interventions or
as a preventive strategy in hypertension.439,440
Finally, we have to consider the potential of mobile and
wearable technologies, which are increasingly integrated
into life, to enhance self-monitoring and treatment.
Wearable technologies that assist in fitness monitoring are
increasingly popular and could motivate individuals to
improve their overall lifestyle. Hypertension-specific
wearable technology is now emerging and could ultimately
increase awareness, engagement, and, potentially, self-
monitoring. To fully engage patients, this technology
should be easy to use, without the need for complicated
access or operation, while providing feedback on
hypertension control in real time.441 One successful model
of such an approach was deployed by Logan and
colleagues,441–444 who used a system of Bluetooth home
blood-pressure monitoring connected to a pre-
programmed smartphone working through a central
server to receive messages to inform the patient about the
status of their blood pressure control. In patients with
diabetes and hypertension, this system significantly
reduced systolic and diastolic blood pressure compared
with patients who were only controlled by home blood-
pressure measurement after 1 year. Interestingly, the
higher rate of blood pressure control was not related to
higher use of blood pressure medications. The system
seemed to be well accepted by patients and did not increase
the number of visits to the doctor. There are also some
promising results about the efficacy of mobile technologies
for blood pressure control even for patients with low
literacy living in low-income or middle-income countries,
who reported a high level of satisfaction with care.445
Summary
It is clear that there are several approaches to the
management of hypertension that encourage patient
engagement and empowerment and improve dialogue
between patient and provider. An important consideration
for such strategies will be the need for both educated
patients and responsive health-care teams and providers
to ensure the persistence of empowered behaviours.
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It should be noted that, to date, the benefits of these
patient empowerment strategies have typically been
evaluated only over fairly short periods of time
(ie, <2 years). The effects of these interventions could
conceivably diminish over extended periods of time.
Accordingly, for chronic diseases such as hypertension it
will be important to assess the long-term feasibility, cost-
effectiveness, and benefits of any approach. It will also be
important to incorporate empowerment and technology
into hypertension management within the context of
available resources. Pioneering approaches, particularly
those involving expensive technology in resource-rich
locations, can inform future universal application.
Blood pressure and health systems
The economics of managing blood pressure
Blood pressure control was identified as a leading target
of the 2013 WHO Global Monitoring Framework to
reduce deaths from non-communicable diseases by
25% by 2025.446 Elevated blood pressure is a main
indicator of high risk for cardiovascular disease, and
many premature deaths can be averted cost-effectively
through community and clinic-delivered interventions.
Because most deaths related to non-communicable
disease are projected to occur in the future in low-income
and middle-income countries, specific consideration of
the benefits and costs of hypertension prevention and
control in resource-limited countries is warranted.
However, a comprehensive health system initiative to
prevent and treat hypertension would need to encompass
efforts to address other important cardiovascular risk
factors such as smoking, excessive alcohol intake,
unhealthy diet, hyperlipidaemia, obesity, and inactivity.
Economic analysis can guide priority setting related to
blood pressure management. Hypertension management
can be cost-effective, with an estimated annual cost per
person of implementing simple population management
programmes (including distribution of base blood
pressure diagnostic tools and at least one of eight essential
medicines to lower cardiovascular disease risk in
medium-risk or high-risk patients) of less than US$1 in
low-income countries, less than $1·50 in lower-middle-
income countries, and $2·50 in upper-middle-income
countries.18,447 A multidrug package targeting hypertension
and cardiovascular disease in 23 low-income and middle-
income countries has been estimated to reduce
cardiovascular death rates by 1·5% per year at an average
annual cost of $1·08 per person.448 With a large proportion
of the population in low-income and middle-income
countries having elevated blood pressure, hypertension
management for even half of patients at moderate to high
risk in these settings could avert an estimated 0·77 million
deaths, or 15·4 million disability-adjusted life-years at a
ratio of $23 in benefits per $1 spent.449 Population-level
drug treatment for elevated blood pressure is highly cost-
effective,450 based on the assumption of a linear
relationship between reduction in blood pressure and
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cardiovascular events reduction estimated to be cost
saving.451 Salt reduction was identified by WHO as a “best
buy” for non-communicable disease prevention and
control, particularly as some of the relevant strategies can
be implemented at very low cost.452 South Africa, Brazil,
Argentina, and Chile are countries with industry
agreements to reduce salt in processed food, and
approaches to change behavioural patterns can be used
where salt is added at the table, as in India.
Health systems in relation to elevated blood pressure
A health system is a broad term that includes elements
from population surveillance to clinical care to public health
infrastructure, as well as the financing to support it.453
The population-level impact of interventions pertaining
to blood pressure management depends on the strength
of the health system that delivers them. In low-resource
settings where primary care systems are underdeveloped,
public systems will need to incorporate new capacity for
hypertension management, and explore efficiencies by
linking with existing systems for addressing other
diseases, such as HIV/AIDS, which might help alleviate
administrative and delivery costs.454 Even in high-income
countries where delivery systems for primary care are
already established, these systems have to be updated
through financing and delivery reform to ensure they
remain effective and can deliver improved outcome. For
chronic diseases to be managed successfully, delivery
systems must be designed to avoid patterns of patient
use that are episodic and acute in nature, supporting,
instead, planned patient visits and continuity of care.
There are hallmarks of health-care delivery systems that
will improve the control of hypertension relevant to all
health systems, high income or low. These include
standardisation of treatment, team-based care, broad scale
availability of affordable medications, and community
engagement.455 The Innovative Care for Chronic Conditions
Model proposed by WHO provides a framework for
organising chronic care delivery, emphasising the
importance of preventing the fragmentation of services
from inpatient, to outpatient and pharmacy services, to
prevention and community efforts.456 The Chronic Care
Model, which emphasises proactive, planned, patient-
centred, and team-based care, and connections between
clinics and communities, has been shown to improve
outcomes.457 Creating registries of patients with hypertension
can allow for efficient management approaches across the
continuum of care delivery points, allows for system
accountability, and has been used in effective models.458
These aspects need to be implemented to achieve success in
reducing the burden of blood-pressure-related disease.
Access to medication is another key requirement.
Assuring sustained broad-scale access to affordable
medications is challenging and approaches vary by
country depending on health-system organisation and
financing. In general, procurement and distribution
processes should be carefully reviewed. Use of generic
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formulations, simplified packages, or polypills, and wide
distribution mechanisms such as primary health or
outpatient facilities, can help scale up distribution in
low-resource settings. In the Americas, the Pan American
Health Organization’s Strategic Fund provides a model
of regional support for drug availability by offering
member states technical assistance with management of
the drug supply chain and drug quality, creating a capital
account to prevent stock-outs during emergencies, and
negotiating favourable prices for drugs on their products
list, including medications to treat hypertension.459
The promise and potential scale of universal health
coverage throughout the world is expected to improve
outcomes for non-communicable diseases. Universal
health coverage is defined by WHO as “ensuring that all
people have access to needed promotive, preventive,
curative and rehabilitative health services, of sufficient
quality to be effective, while also ensuring that people do
not suffer financial hardship when paying for these
services”.460 Universal health coverage involves three
coverage dimensions—health services, finance, and
population—and is a dynamic, continuous process
that changes in response to shifting demographic,
epidemiological, and technological trends, as well as
people’s expectations.25
The 2013 WHO World Health Report encourages global
adoption of universal health coverage, which has most
recently been introduced in Thailand and Mexico, and is
under consideration in India.461,462 The 2009 health reform in
China emphasised the role of efficient health-care delivery
for chronic diseases, including hypertension.463 The WHO
and World Bank global monitoring report, Bringing universal
health coverage (universal health coverage) into focus, for the
first time quantified and tracked progress in universal
health coverage in key areas of financial protection and
health services coverage for populations as a whole, as well
as subpopulations living in rural areas and the poor.
Strong health information systems are also necessary to
advance the conditions for hypertension prevention,
treatment, and control.464 Although there is no single cross-
national surveillance system for cardiovascular disease and
hypertension, several surveys, registries, cohort studies,
and vital statistics can be used by different stakeholders to
gather different kinds of information about these
conditions. Technological advances in health-care systems
and electronic health-care records can be used for
surveillance and monitoring of health-care interventions
in hypertension, including randomised trials testing the
effects of different public health policies. As noted earlier
in this Commission report, data necessary for even the
most descriptive surveillance needs of prevalence are
lacking. Government investment in health information
systems at all levels is necessary to inform and advance
efforts to prevent and control hypertension throughout the
world. Monitoring the new objectives of the Sustainable
Development Goals, for example promoting wellbeing and
ensuring universal health coverage, presents an
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The Lancet Commissions
opportunity to focus on strengthening countries’ health
information systems, using an integrated, comprehensive
approach based on each country’s individual needs.25
In summary, national health systems can influence the
global burden of hypertension. However, continuing
commitment is needed by national governments to
prioritise the protection and promotion of health and
wellbeing of their citizens by ensuring best practices are
implemented.465
Global health initiatives to reduce elevated blood pressure
Several initiatives are underway worldwide focusing on
health systems improvement within the context of
hypertension prevention, treatment, and control. Million
Hearts is a national initiative from the USA to affect
population health, aiming to prevent 1 million heart
attacks and strokes in the USA by 2017 through health-
system strengthening by increasing focus on
cardiovascular prevention and by improving access to
effective cardiovascular health care. The Centers for
Disease Control and Prevention and Centers for Medicare
& Medicaid Services, co-leaders of Million Hearts within
the US Department of Health and Human Services, are
collaborating with other federal agencies and private-
sector organisations to make a long-lasting impact against
cardiovascular disease. Million Hearts aims to prevent
heart attacks and strokes by improving access to effective
care and improving quality of care for the ABCS of heart
health: aspirin (when appropriate), blood pressure
control, cholesterol management, and smoking cessation.
It focuses clinical attention on the prevention of heart
attack and stroke, encouraging the public to lead a heart-
healthy lifestyle, and improving the prescription and
adherence to appropriate medications for the ABCS.466,467
The Global Standardized Hypertension Treatment
Project was originally developed across the Americas in
2012 with a focus on strengthening of clinical health
systems. The initiative focused pharmacological manage-
ment, with a core set of antihypertensive medications,
ensuring their availability through efficient procurement
mechanisms, using patient registries to monitor blood
pressure control using standard treatment protocols, and
encouraging team-based care and patient empower-
ment.455 Demonstration projects have been initiated in
two countries, Barbados and Malawi, to improve control
of hypertension through improved management in
primary health-care settings in Barbados and using an
existing HIV/AIDS platform in Malawi. Results from
these projects are expected in 2017. The project framework
and activities have been expanded to include lifestyle
components, and it is being integrated into a global
initiative, Global HEARTS.
China’s Shandong province (population 96 million),
where hypertension and excessive sodium intake in adults
are major public health problems, provides an example of
hypertension control with population approaches such as
sodium reduction through lifestyle changes. Most salt in
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Lack of standardised,
comprehensive
knowledge about blood
pressure levels
Lack of system
accountability for blood
pressure control
The action to endorse WHO/World Health Assembly NCD Global Monitoring Framework is closely connected to the key action on universal access to measurement of blood pressure, whereas the action to ensure
accountability of the health system to collect, monitor, and respond appropriately to blood pressure levels is closely connected to the key action on expanding the capacity of the clinical workforce engaged in
management of blood pressure. These two health-care system actions are later combined to one key action. NCD=non-communicable disease.*Essential goals.
Table 4: Identified problems and corresponding goals and actions relating to health systems
2694
the diet is added at the table or during cooking. The
Chinese Ministry of Health and the Shandong Government
collaboratively launched the Shandong–Ministry of Health
Action on Salt Reduction and Hypertension in 2011,
introducing expanded blood-pressure screening and
treatment, and driving changes in social norms by
supporting health-promoting environmental policies.
These strategies were implemented in concert with a
surveillance system, funding mobilisations, and
strengthening of local capacity of health services. Provincial
and local government agencies and health-sector teams
target interventions in household and educational settings
such as elementary schools, and also prehypertension and
hypertension populations from a representative study
cohort selected by a complex, four-stage cluster sampling468
with strategic partners such as food industry, businesses,
and restaurants to reduce sodium intake. Mid-term
evaluation reported a decrease in the per-person seasoning
salt intake in Shandong from 12·5 g to 11·58 g per day.469,470
By contrast, in the UK—where most dietary sodium
consumption is through packaged and restaurant foods—a
government-led initiative included a focus on reducing the
amount of sodium in processed foods. Results are
promising.144 The Institute of Medicine recommended a
similar strategy to sodium reduction in processed foods in
the USA. Areas of future research that could benefit low-
income and middle-income countries in particular include
country-specific cost–benefit analysis of different
hypertension interventions. This strategy could help to
optimise resource allocations in low-resource settings, and
inform decisions to invest in strengthening of health
systems (table 4).
Key actions and implementation
Setting the scene for a multifaceted approach
10·4 million people are estimated to die each year because
of elevated blood pressure.65 The costs in terms of
morbidity and mortality, as well as economic and societal
costs, are substantial. The causes of hypertension are
complex, as are the solutions. Hypertension is often the
product of a lifelong interplay of individual and
environmental factors, starting even before birth. Thus,
Goals Actions
All countries create, maintain, and act on Endorse the WHO/World Health Assembly NCD Global Monitoring Framework
a national surveillance system that Advocate for appropriate resourcing of surveillance systems
regularly captures blood pressure and Create accessible reports
related measures of risk*
Health system collects, monitors, and Develop efficient health-care delivery systems that monitor blood pressure levels for their
responds appropriately to blood pressure populations and act appropriately
levels* Develop task-sharing approaches that effectively deliver care in resource-constrained settings
Connect health-care delivery centres with appropriate community points of blood pressure
measurement
the approach to this growing public health problem is
multifaceted. First, there is a need to respond immediately
to those at highest risk for related complications—those
with evident hypertension and perhaps subclinical or
even clinical cardiovascular disease—through evidence-
based clinical treatment, delivered effectively by health
systems designed to assure successful control for every
patient. However, even if expertly delivered to all, such an
approach is inefficient and does not thoroughly address
the true breadth of the problem. The size of the
hypertension problem, the previous relative failure of
individual non-pharmacological prevention and the large
proportion of undiagnosed and untreated patients with
essential hypertension, underlines the need for solutions
focused on population-based approaches including public
health. The pipeline of future patients includes virtually
every human being. Even those who reach middle-age
without hypertension have a more than 90% chance of
developing the condition during their remaining
lifetime.471 Aggressive population-wide interventions that
fundamentally include changes to the social and
economic living environments will dynamically shape
how populations behave, and will directly affect
primordial and primary prevention. Such approaches are
crucial and must be a part of any strategic approach that
will successfully address the management of hypertension
at the global level. Primary prevention will include early
information on the importance of a healthy lifestyle and
help to make appropriate lifestyle changes. However, for
real impact, policies are required that will improve the
socioeconomic environment, strategically framed on
improving the population living environment as a whole.
This approach must include intentions to reach people
of all ages in the environments where they live,
work, and play.
Population-level interventions will require multisectoral
engagement from government, industry, non-govern-
mental organisations, and civil society as a whole. The
solutions we develop must be multidimensional,
transforming the communities (reaching individuals
indirectly) in which we live into health-promoting environ-
ments, and supporting innovations and improvements not
Keywords
Health-system
strengthening
··
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 The Lancet Commissions

only in the health-care systems from which we access care,
but also in the broader socioeconomic environment (eg,
food systems and availability).
Essential goals and related key actions
The Commission has identified ten essential goals and
related key actions that, not surprisingly, overlap to a
large extent with current global health initiatives within
the field of hypertension (table 5). The key actions are
not prioritised among each other because they are
complementary, and the balance between strength of
evidence and potential benefits are inherently different
between selective pharmacological intervention in
high-risk patients versus broad implementation of
health-promoting programmes. In essence, the key
actions aim to stimulate goal-oriented dialogue,
bridging concepts and strategies from public health,
health-care systems, and clinical practice. The
Commission approaches the hypertension problem at
many different levels through improvement of public
knowledge (to motivate healthy living including
checking blood pressure); the environment (to support
healthy living); education of health workers (to increase
capacity and quality of detection and management);
access to affordable, good-quality antihypertensive
drugs; and health-care systems (to monitor and
coordinate the actions).
Key actions within prevention, in relation to current
global initiatives
Introduction
Many doctors consider preventive measures against
hypertension to be ineffective, time-consuming, and
with poor results. The time-pressured and stressful
lifestyles that are increasingly the norm create
environments that promote hypertension, encouraging
easy or less expensive options such as sedentary
behaviours and consuming cheap, salty, sugary, and
fatty foods. Because many of the changes required to
address these challenges are social and political rather
than medical, this report is not intended to be read
exclusively by scientists and health-care professionals
but instead aims for a broader audience—including
various industries, policy makers, and civil society.
Hence, the fundamental key action would be to strongly
support policies and strategies that enhance changes in
the broader socioeconomic environment with the
greatest likelihood of population-wide benefits for
cardiovascular health (figure 7).
Creating a health-promoting environment
The key to global prevention and control of hypertension
is to support global adoption of health-promoting diets
high in vegetables, fruits, legumes, whole grains, and
quality proteins, with no introduction to tobacco and no

Key actions Keywords

Prevention: lifestyle and environmental changes
Unhealthy environment Strategies and policies to accelerate socioeconomic improvements Make healthy food choices easier, combat tobacco, and promote Health-promoting
and development of health-promoting environments; accelerate physical activity in daily living environment
the implementation of accepted health-promoting policies
Lack of understanding about Early and sustained education about healthy lifestyles and blood Educate and empower health workers and teachers to instil Healthy behaviours
unhealthy lifestyle pressure (new technology) healthy lifestyles
Low awareness Ensure universal access to blood pressure measurement through Tailored education about hypertension throughout the life course Measurement access
inexpensive monitors and surveillance
Diagnosis and evaluation
Poor measurements Certification and validation of monitors and endorsement of Develop simple, inexpensive blood pressure monitors; preference Measurement
protocols for measuring blood pressure by professional societies for home, ambulatory, automated, and unobserved blood pressure quality
measurement
Poor cardiovascular risk Promote education of patients, doctors, and health professionals Reinforce targeting of global cardiovascular risk rather than single Empowerment
assessment risk factors
Poor or delayed diagnosis of Simple protocols for detecting secondary hypertension in Improve the availability of relevant investigations Secondary
secondary hypertension communities with few resources hypertension
Pharmacological prevention and treatment
Lack of available health-care Expand the capacity of the clinical workforce through task sharing Health system collects, monitors, and responds appropriately to Workforce expansion
professionals and the use of endorsed education of community health workers blood pressure levels (accountability)
Lack of good-quality and Universal availability of at least one of each class of Availability of single-pill combinations where resources permit Medication access
effective antihypertensive drugs antihypertensive drug
Lack of stratified treatment Information about optimisation of blood pressure targets, Support RCTs that focus on optimisation of treatment targets, Standardised
treatment initiation, and therapy based on ethnicity, age, and risk initiation, and choice taking into account ethnicity, age, and risk† treatment
Blood pressure and health-care systems
Promote and ensure capacity and accountability of the health Promote and ensure accountability of the health system to Health-system
system to conduct surveillance and monitoring respond appropriately to blood pressure levels strengthening

RCT=randomised controlled trial. †Related to research.

Table 5: Summary of main problems and key actions

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 The Lancet Commissions

or low alcohol use, and to encourage an active lifestyle. Technological applications in food systems, social media,
Success will require the adoption of policies that create and wearable and mobile technology
urban environments with working, living, and leisure Much more could be done to apply technology in food
conditions that support increased physical activity systems: for example, such efforts could ensure the
throughout the day. Similarly, increased year-round consumption of fruit and vegetables all year round.
availability of healthy, low-cost foods known to promote Especially in low-income and middle-income countries,
cardiovascular health—such as potassium-rich advanced technologies to facilitate distribution of foods to
vegetables—and decreased availability or increased all communities and basic technologies such as
pricing of unhealthy food items are an additional key refrigeration will result in increased consumption of
aspect of a healthy environment. Progressive regulatory fresh, nutritious foods, known to be beneficial in
and taxation schemes offer the opportunity both to improving vascular health. Technology already exists to
improve health directly and to generate funds that can be enforce and monitor food regulations, but can be applied
used to implement other high-value preventive strategies more widely to, for example, monitor the real-time
without immediate financial return. Such initiatives measurement and transmission of contents of packaged
should be driven by the health community, politicians, foods. Social media offers unprecedented potential to
teachers, city planners, architects, and a range of other affect systemic change in the understanding, prevention,
non-medical professions with strong civic and political and management of hypertension at all lifecourse stages.
leadership, because the financial benefits achieved will More than 3 billion people worldwide are active internet
take decades to accrue, but will be very large. users, with about 70% maintaining social media accounts.
Improved success of social media campaigns to educate,
Health literacy monitor, and control hypertension, but also to improve
Governments and civic society should encourage community health behaviour, can be achieved by improved
community-based strategies that promote health literacy, collaboration between different health professional
including early and continuous education on organisations (eg, specialists in hypertension, heart
hypertension as a so-called silent killer, and emphasise disease, stroke, kidney disease, cancer) and social-media
how a healthy lifestyle can help to avoid elevated blood public health platforms. For example, coordination of
pressure. Health-literacy education should empower efforts to existing activities such as World Health Day and
teachers to encourage children, through education, to World Hypertension Day can also help to attract
make healthy life choices, such as being active, avoiding widespread engagement.
smoking and alcohol, and eating fruits and vegetables The Commission recommends a close collaboration
regularly—all known to have a direct effect on between a wide range of stakeholders such as
cardiovascular health. Ideally, every child on the planet governments, the mobile communications industry,
should finish school as a health-literate adult. health-care professionals, the pharmaceutical industry,
and professional societies to not only develop and
distribute inexpensive, validated, and certified blood
Health–disease continuum pressure monitors, but also to ensure correct use through
simple mobile apps and online education endorsed by
organ damage Loss of QOL
Subclinical target- CV disease

the professional societies. In parallel, the Commission

Individualised strategies

Create a healthy environment

through strategies that accelerate
proposes that governments and health-care systems
socioeconomic improvements Avoidable threshold 3: respond to the national goals, targets, and indicators
development of clinical disease
and implementation of accepted outlined in the Sustainable Development Goals and the
health-promoting policies
WHO Global Monitoring Framework.

Avoidable threshold 2:
Universal access to development of subclinical
Key actions within diagnosis and evaluation in relation
measurement of blood pressure taget-organ damage to current global initiatives
Elevated BP

through inexpensive monitors

Population-based strategies

and establish global surveillance Better characterisation of individual phenotype will not
Universal understanding of
only improve hypertension risk assessment and help
Avoidable threshold 1: unhealthy and healthy lifestyles and guide the choice of intervention, but can also act to
development of elevated BP
blood pressure through endorsed, empower people towards greater ownership of their
early, and sustained education using
Healthy

new technologies condition and adherence to recommended intervention.

Enhanced phenotypic characterisation, including
Lifecourse identification of secondary hypertension, will also serve to
Childhood Early adulthood Middle-age Advanced age Elderly (>80 years) strengthen the quality of health information systems for
hypertension prevention, treatment, and control. Thus,
Figure 7: Key actions within prevention
The blue line represents the general lifecourse. The horizontal black dotted lines represent three avoidable clinical
important goals will be to ensure widespread access to
thresholds. The three green boxes represent the key actions within prevention. CV=cardiovascular. QOL=quality of valid and endorsed blood pressure devices, as well as
life. BP=blood pressure. enabling greater focus on global cardiovascular risk

2696 www.thelancet.com Vol 388 November 26, 2016


management instead of single risk-factor focus, and also
simplifying protocols to improve detection of secondary
hypertension (figure 8). A method to help achieve these
goals will be to provide widely accessible and professional-
society-endorsed educational material by dissemination
to the general community and treating doctors.
Provider-led efforts in education, empowerment, and
lifestyle interventions are often restricted to the time that
a patient is in the clinic (when they might not be receptive
to such efforts), whereas online resources have unlimited
availability and provide great opportunity for widespread
education. Endorsement and promotion of online
educational material by professional societies related to
hypertension should help to disseminate appropriate
information and advocate against erroneous material.
This endorsement should be consistent with national
and international recommendations and can serve as a
reassurance that the content being accessed is based on
the most up-to-date clinical knowledge. Resources for
patients and doctors about blood pressure measurement
should be with preference for home blood pressure,
ambulatory blood pressure, and automated, unobserved
blood pressure methods.
In a similar manner, professional societies could also
give consideration to providing a seal of approval or
certification of blood pressure devices meeting appropriate
accuracy standards, which is particularly important given
the rapid developments in wearable technologies marketed
without validation testing according to current inter-
national expectations.162 Active warnings on substandard
devices can be provided. These options would help to
safeguard measurement quality more broadly and might
even provide a potential source of revenue for professional
societies. The seal of approval could, in turn, be used by
manufacturers for marketing. Mechanisms to manage
cross-society coordination and harmonisation of
messaging in these efforts will be needed. It will also be
important to develop resources that are accessible and
empowering to doctors, including simplified guidelines
with truncated flow charts addressing management of
global cardiovascular risk and identification of secondary
hypertension to aid examination and treatment decisions.
All material endorsed by professional societies related to
hypertension should be produced with standardised
instructions that are clear and easy to follow for the end
user, to enable wide uptake into different health-care
services beyond those that focus on cardiovascular disease
(eg, HIV/AIDS services) and into under-resourced regions.
Key actions within pharmacological prevention and
treatment in relation to current global initiatives
Introduction
Our recommendations relate to affordable therapies,
monitoring and self-monitoring of treatment, composition
of health-care teams, risk assessment, and decisional
algorithms (figure 9). The Commission encourages the
scientific community, health-care providers, funding
www.thelancet.com Vol 388 November 26, 2016
The Lancet Commissions
bodies, and the pharmaceutical industry to join forces and
address these issues jointly and urgently. Not all questions
have been solved and a consensus on the exact research
question or implementation steps has to be reached as a
first step. We can therefore only highlight the areas that
need urgent attention.
Ensure access to affordable, high-quality medicine worldwide
As the best-documented antihypertensive therapies are
now off patent, a minimum recommendation is that at
least one of each class of antihypertensive medication
should be available to all individuals around the world.
Limitations to access include regulatory, political, and
corporate factors. Where resources allow, single-pill
combination therapy should be available. Future research
should focus on the development of novel therapeutic
approaches based on improved understanding of
underlying pathophysiology. Combination therapy
should also be expanded. Within antihypertensive
classes, there should be a focus on improving pharma-
cokinetic profiles. Such changes could further reduce
side-effect profiles and improve adherence.
Modest investments in strategies to improve the
availability and uptake of effective blood-pressure-lowering
medications, including investments in the development of
systems that identify people who will benefit from therapy
and deliver appropriate treatment, promise huge benefits
that would probably be extremely cost-effective. Global,
concerted action between governments, industry, civil
society, and international organisations has made HIV
therapy available at affordable costs to patients in low-
income and middle-income countries, and similar efforts
are currently underway for treatment of hepatitis C.472
There is no reason why concerted strategies with the goal
Health–disease continuum
organ damage Loss of QOL
Subclinical target- CV disease
Better identification of people Individualised strategies
with secondary hypertension
through endorsed and simple flow
Avoidable threshold 3:
development of clinical disease
charts
Better quality of blood Avoidable threshold 2:
pressure measurements development of subclinical
through endorsed protocols, target-organ damage
Elevated BP
Population-based strategies
and certified and validated
monitors
Better identification of people
Avoidable threshold 1:
at high risk through endorsed
development of elevated BP
education of patients and
health-care professionals
Healthy
Lifecourse
Childhood Early adulthood Middle-age Advanced age Elderly (>80 years)
Figure 8: Key actions within diagnosis and evaluation
The blue line represents the general lifecourse. The horizontal black dotted lines represent three avoidable clinical
thresholds. The three blue boxes represent the key actions within diagnosis and evaluation. CV=cardiovascular.
QOL=quality of life. BP=blood pressure.
2697
 The Lancet Commissions
to make quality treatment available worldwide should not
be successful in hypertension.
Extend health-care workforce task sharing
An extension of existing health-care workforce capacity
can be achieved at modest cost by promoting team-based
care and task sharing. Especially in low-income and
middle-income countries, where health-care professionals
are too scarce to effectively reach the population at risk, it
is crucial to engage communities and train community
health workers to detect and initiate treatment of
hypertension. Data showing this approach to be feasible
and effective are accumulating. Even well-resourced
countries have suboptimal recognition of blood-pressure-
related cardiovascular risk, and inconsistent assessment
and monitoring. Accordingly, more comprehensive
strategies using approaches beyond opportunistic
screening at medical visits for other purposes are required.
The approaches successfully used in childhood vaccination
for infectious disease offer lessons in this regard. New
models need to be developed and carefully assessed in
clinical trials. Through task sharing and alternative
community points of blood pressure measurement, we
need to develop efficient systems for health-care delivery
that are held accountable for monitoring blood pressure
levels in their populations and for acting appropriately.
Evidence-based decisional algorithms and stratified treatment
strategies
For the PATHWAY studies see Although the current management of hypertension is
www.bhsoc.org/research/ based on principles regarding assessment of absolute risk
pathway-project
and blood pressure reduction that are supported by strong
evidence, many important parts of antihypertensive
treatment are often applied on the basis of individual
Health–disease continuum
organ damage Loss of QOL
Subclinical target- CV disease
Universal access to affordable,
high-quality, and effective
antihypertensive drugs through Avoidable threshold 3:
development of clinical disease
collaboration between all major
stakeholders
Expand the workforce engaged in Avoidable threshold 2:
development of subclinical
the management of blood pressure
target-organ damage
through task sharing and the use of
Elevated BP
endorsed education of community
health workers (includes health-care
system accountability) Treatment approaches stratified
according to age, cardiovascular risk,
Avoidable threshold 1:
development of elevated BP and social, cultural, and ethnic
differences through endorsed education
of health–care professionals and
Healthy
initiation of new research
Childhood Early adulthood Middle-age Advanced age
Figure 9: Key actions within pharmacological prevention and treatment
The blue line represents the general lifecourse. The horizontal black dotted lines represent three avoidable clinical
thresholds. The three red boxes represent the key actions within pharmacological prevention and treatment.
CV=cardiovascular. QOL=quality of life. BP=blood pressure.
2698
Individualised strategies
Population-based strategies
Lifecourse
Elderly (>80 years)
provider experience. Examples of these provider-related
choices are most promising lifestyle modifications; when
to add pharmacological antihypertensive treatment; use
of lifetime cardiovascular risk versus 10-year risk; initial
medical treatment strategies (eg, choice of drugs,
monotherapy vs combination therapy); titration strategies;
and monitoring of treatment success (monitoring blood
pressure alone or alongside target-organ damage).
Algorithms developed by professional societies and
health-care institutions based on the best evidence are
rarely adopted or applied consistently across institutions
by all providers.
This Commission sees the urgent need to develop and
implement simple algorithms that inform health-care
professionals precisely on the required diagnostic and
therapeutic steps. Such algorithms should be evidence
based, or evidence from pragmatic and prospective
clinical studies could be used. The potential for cost
savings through standardisation of diagnosis and therapy
extends to the more targeted use of specialist services for
the minority of patients with complex issues, whereas
most patients could be managed by general practitioners
and allied health-care professionals in partnership, with
appropriate means for patient empowerment and self-
monitoring.
Implementation of simple evidence-based algorithms
that standardise evaluation and treatment of hypertension
will indirectly identify areas with less evidence and create
a perfect basis for investigator-initiated prospective
studies on treatment strategies. The PATHWAY studies
show that investigator-initiated studies of treatment
strategies are possible and can lead to clear answers. This
Commission, therefore, encourages the scientific
community to develop and define treatment strategies
and then test them in clinical trials. Furthermore, the
knowledge of the effects of age, social background,
culture, and ethnicity on antihypertensive treatment is
scarce. Therefore, the Commission encourages establish-
ment of international collaborations to combine existing
population surveys and create large web-based
registries—using cloud computing technology—based
on data generated by patients’ use of widely available,
easy to use, certified apps, following the simple evidence-
based algorithms mentioned above.
Key actions within health-care systems
Reducing raised blood pressure is one of the key targets
of the WHO Global Monitoring Framework aimed at
decreasing deaths from non-communicable diseases
globally. Strengthening health systems, which encom-
passes all of those structures responsible for advancing
health from population surveillance to public health and
clinical care delivery, is an essential overarching goal
required not only for preventing and controlling
hypertension but to advance population health at large.
All of the key actions noted earlier in this report
ultimately rely upon highly functioning health systems
www.thelancet.com Vol 388 November 26, 2016
 The Lancet Commissions

to be implemented successfully and sustainably. This
includes actions related to creating health-promoting
environments, to assure access to affordable quality
medications, and to establish care delivery systems that
produce equitable and accountable health outcomes.
Universal health coverage, which ensures everyone
access to the benefits of the health system without
financial hardship related to payment, is a recognised
prerequisite, and strongly supported by this Commission,
WHO, and the UN. Many different actions have to be
implemented in parallel to improve management of
hypertension globally. Therefore, it is necessary to
develop surveillance models, taking advantage of new
technologies that can measure the needs of the
population, assess the functioning of the health system,
and guide improvements in the system. Government
investment in health information systems at all levels is
essential to combine these many streams of actions
against hypertension in one comprehensive approach
under the framework of health systems.
A multifaceted approach to the key actions
Hypertension and all its associated complications are
products of a lifelong interplay of individual and
environmental factors, and, therefore, a multifaceted
approach to this growing global problem is essential. The
key actions proposed by the Commission (figure 10) are
targeted at different populations, age groups, groups of
health professionals and social workers, and groups of
individuals at different stages of hypertension; the
actions are either dominated by programmes and system
change when evidence is convincing and by research
when evidence is missing.
The key actions of this report follow from the
identification of the most pressing needs on a global level.
Hypertension will—at some point in life—affect almost
every individual in the world, many of whom live in
countries with very few economic resources. Therefore,
the key actions in this report are mostly key actions at the
population level. Furthermore, in light of the massive
burden of hypertension in low-income and middle-income

Health–disease continuum

Individualised strategies
Better identification of people
Loss of QOL

Treatment approaches stratified according to age,

CV disease

cardiovascular risk, and social, cultural, and ethnic with secondary hypertension
differences through endorsed education of health- through endorsed and simple flow
care professionals and initiation of new research charts

Avoidable threshold 3:
development of clinical disease
Universal access to affordable, high-quality,
and effective antihypertensive drugs through
Subclinical target-

collaboration between all major stakeholders

organ damage

Expand the workforce engaged in the

Better identification of people at high
risk through endorsed education of patients
and health-care professionals
Elevated BP
Avoidable threshold 2:
development of subclinical
target-organ damage
management of blood pressure through
task sharing and the use of endorsed
education of community health workers
(includes health care system
accountability)

Better quality of blood pressure Universal access to measurement of blood pressure

measurements through endorsed protocols, through inexpensive monitors and establish global
and certified and validated monitors surveillance

Avoidable threshold 1: Promote and ensure capacity and accountability

development of elevated BP of the health system to conduct surveillance and
monitoring, and respond appropriately to blood
Population-based strategies

pressure levels
Healthy

Create a healthy environment through

strategies that accelerate socioeconomic
improvements and implementation of
accepted health-promoting policies
Universal understanding of unhealthy and healthy
lifestyles and blood pressure through endorsed, early,
and sustained education using new technologies
Lifecourse

Childhood Early adulthood Middle-age Advanced age Elderly (>80 years)

Figure 10: Summary of all key action points

The blue line represents the general lifecourse. The horizontal black dotted lines represent three avoidable clinical thresholds. The green, blue, or red boxes represent the key
actions within prevention, diagnosis and evaluation, and pharmacological prevention and treatment. CV=cardiovascular. QOL=quality of life. BP=blood pressure.

www.thelancet.com Vol 388 November 26, 2016 2699

 The Lancet Commissions
countries, we have explicitly pursued a globally feasible
approach, partly by leveraging new technologies.
Overall, the Commission suggests intervening in
parallel throughout the spectrum of risk from population
level to patients at high cardiovascular risk. The proposed
interventions (the key actions) consist of a mixture of
research, development, programmes, and system change
all leading to the creation of a health-promoting
environment (figure 1). They build on the idea of
empowerment: empowerment of individuals through
broad health education, which is a prerequisite for an
individual to make informed choices and to take
ownership of their condition; empowerment of
communities with socioeconomic difficulties to offer
medical care to all individuals at risk of developing
hypertension and cardiovascular disease; and em-
powerment of the medical community by offering
simpler and more efficient tools to manage hypertension.
Global technical package for hypertension
As noted in the introduction to this report, the ultimate
aim of this Commission is to generate a globally unifying
campaign to prevent raised blood pressure, improve the
management of elevated blood pressure, and reduce the
impact of hypertension all over the world. The
Commission has identified ten key actions that are
additive and synergistic. They range from population-
based environmental policies aimed at shifting the
population distribution of blood pressure downward by
supporting healthier lifestyles and behaviours, to more
individualised approaches targeted at high-risk groups
with hypertension and increased cardiovascular risk.
Interventions aimed at individuals include effective and
good-quality antihypertensive treatment with the aim to
reduce the size of the upper population distribution tail
of blood pressure. As such, the Commission recognises
the importance of bridging public health, health-care
systems, and clinical practice. The actions we have
identified are many, and full implementation will require
diligence and persistence over time.
Although the details of roll-out will be refined over time
with input and leadership from a variety of stakeholders
from local to global, we believe it is useful to reflect on
approaches used by other major global efforts to advance
health. Public health programmes, including smallpox
eradication, tuberculosis control, tobacco control, polio
eradication, and others, have made progress by addressing
six key areas: innovation to develop the evidence base for
action; a technical package of a small number of high-
priority, evidence-based interventions that together will
have a major impact; effective performance management,
especially through rigorous, real-time monitoring,
evaluation, and programme improvement; partnerships
and coalitions with public-sector and private-sector
organisations; communication of accurate and timely
information to the health-care community, decision
makers, and the public to effect behaviour changes and
2700
engage civil society; political and partner commitment to
obtain resources and support for effective action including
related health-system strengthening initiatives such as
universal health coverage.473 In cardiovascular prevention it
is crucial to reduce risk factors, including high blood
pressure, tobacco smoking and second-hand smoke
exposure, exposure to air pollution, high BMI, physical
inactivity, alcohol use, and diets low in fruits and vegetables
and high in sodium and saturated fats both at individual
(clinical) and population levels. The Commission supports
the WHO Global Monitoring Framework initiative to
reduce the high-value prevention targets, which can be
effectively addressed through implementing the so-called
best buys for prevention of non-communicable diseases.452
The Commission proposes a unifying implementation
plan, articulated as a technical package, designed to
support two general and interelated areas: prevention
and treatment. Each area will include selected high
priority and scalable interventions that can mobilise,
commit, and boost international and national capabilities.
The prevention-related technical package would cover
improved public understanding of unhealthy and healthy
lifestyles and blood pressure and its consequences, policy
and environmental approaches to promote health and
support healthy behaviours, and improved access to
effective health-care delivery systems and use of
preventive and clinical services, and better cross-talks
between community programmes and clinical services.
We envisage the treatment package to include standard
protocols for investigation (diagnosis and risk
stratification), treatment (stratified and risk based), and
monitoring, and team-based care, task sharing, and
workforce development, with decentralised, community-
based, and patient-centred care, and training and capacity
building. The treatment package should also include
access to affordable medications, technology, and health
care, with promotion of access to a high-quality core set
of medications, including fixed-dose combination pills at
affordable cost to improve adherence. Finally, the
treatment package should include enhanced surveillance,
patient registries, and information systems to monitor
trends in hypertension management, ensure
accountability and equitable outcomes, and promote
interoperable information systems to monitor imple-
mentation needs and effectiveness of interventions.
Future plans after this report
It is the intention and the ambition of The Lancet and the
Commission on hypertension that this report should be a
step towards an enhanced collective action to implement
suggested actions to improve the management of blood
pressure and reduce the impact of elevated blood
pressure globally. With this report in hand, the
Commission will contact hypertension organisations
including the international, regional, and national
societies, as well as other relevant international agencies
(including cardiology, neurology, and nephrology
www.thelancet.com Vol 388 November 26, 2016

societies) to propose global alliance. With the support of
these professional societies, together we will carry
forward the mission to draw up a broad-based campaign
of advocacy and action, involving governments, industry,
civic and consumer organisations, and health
professional bodies. The Commission will call for
relevant international, national, and subnational
agencies, policy makers, researchers, public-health
practitioners, development agencies, and donors to
champion the recommendations of the report. The
campaign will not just be a health campaign, but a much
broader multisectoral campaign, bringing together of all
elements of society to address the lifelong health burden
of elevated blood pressure using the lifecourse strategy
described in the report. This goal cannot be realised
without accelerated and substantial commitment from
donors and national governments.
Contributors
All authors contributed to strategic planning, literature search, data
interpretation, and the writing and revision of the report.
Declaration of interests
MHO reports grants from Centers for Disease Control and Prevention,
during the conduct of the study, and personal fees from Boehringer
Ingelheim, outside the submitted work. PB reports grants from Servier,
and grants and personal fees from Withings, during the conduct of the
study. JAC reports grants and personal fees from BMS, Fukuda Denshi,
and Microsoft Research, and personal fees from OPKO Healthcare,
Vital Labs, and Merck, during the conduct of the study. JAC is named
inventor in a patent application (pending) for the use of inorganic nitrate
and nitrite in heart failure and preserved ejection fraction. VP reports
grants from Abbvie, Astellas, Bayer, Baxter, GSK, Bristol-Myers Squibb
Company, Eli Lilly, Servier, Pfizer, and the National Health and Medical
Research Council; personal fees from Servier; other support from
Janssen, Boehringer Ingelheim, AstraZeneca, Novo Nordisk, Pharmalink,
and Relypsa, outside the submitted work. ERR reports grants from
Amgen, Sanofi, and Unilever, outside the submitted work. GS reports
grants from AtCor Medical, and personal fees from Fukuda-Denshi,
Servier, Daiichi-Sankyo, Menarini, Novartis, and Guidotti, outside the
submitted work. JES has received equipment and support in kind for
research projects related to blood pressure from AtCor Medical and IEM
GmbH. JGW reports personal fees from Daiichi-Sankyo, MSD, Novartis,
Pfizer, Sanofi, and Servier, outside the submitted work. All other authors
declare no competing interests. The findings and conclusions in this
report are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention.
Acknowledgments
We are extremely grateful to Prof Neil Poulter, Prof John Chalmers,
Prof Stephane Laurent, and Prof Majid Ezzati for face-to-face critique and
advice during preparation of the report. The International Society for
Hypertension, Odense University Hospital, University of Southern
Denmark, and US Center for Disease Control generously provided
financial support for Commission meetings. And we are grateful to
Prof Rhian Touyz and the local organisers of the 50th Anniversary ISH
meeting in Seoul for providing time in the programme to present and
discuss the report of the Commission. We thank Manan Pareek
(Department of Internal Medicine, Holbæk Hospital and Centre for
Individualized Medicine in Arterial Diseases, Odense University Hospital,
University of Southern Denmark, Denmark, and Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA,
USA) for his help with the references and general technical support.
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