Pattern of declining blood pressure across replicate population surveys of the WHO MONICA project, mid-1980s to mid-1990s, and the role of medication

doi:10.1136/bmj.38753.779005.BE

BMJ 2006;332:629-635 (18 March), doi:10.1136/bmj.38753.779005.BE (published 10 March 2006)

Research

Pattern of declining blood pressure across replicate population surveys of the WHO MONICA project, mid-1980s to mid-1990s, and the role of medication

Hugh Tunstall-Pedoe, emeritus professor of cardiovascular epidemiology¹, John Connaghan, research assistant¹, Mark Woodward, professor of biostatistics², Hanna Tolonen, research fellow³, Kari Kuulasmaa, head of unit³

¹ Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, ² George Institute for International Health, PO Box M201, Sydney, NSW 2050, Australia, ³ International Cardiovascular Disease Epidemiology Unit, Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute (KTL), 00300 Helsinki, Finland

Correspondence to: H Tunstall-Pedoe h.tunstallpedoe{at}dundee.ac.uk

Abstract

Objective Declining mean systolic and diastolic blood pressureswere observed in most populations of the World Health OrganizationMONICA (monitoring trends and determinants in cardiovasculardisease) project from the mid-1980s to mid-1990s. We testedwhether pooled results would show mean change associated withdecline in high readings only, resulting from better antihypertensivemedication, or with similar falls in low, middle, and high readings,implying other causes.

Design Independent, random sample, cross sectional populationsurveys, each end of the MONICA decade.

Setting 38 populations in 21 countries across four continents.

Participants Design target in each survey of 200 participantsin each 10 year age and sex group from age 35 to 64

Main outcome measures Changes in the population in mean systolicand diastolic blood pressure, and in low, middle, and high readings—the20th, 50th, and 80th centiles—and the differences betweenthese changes.

Results Individual populations differed considerably, but poolingthe 38 population results gave mean changes in systolic bloodpressure of -2.2 mm Hg in men, -3.3 mm Hg in women, and in diastolicblood pressure of -1.4 mm Hg in men and -2.2 mm Hg in women(overall average -2.26 mm Hg, population median -1.55 mm Hg).Antihypertensive medication, associated with high readings,rose by 0.5% to 11.4%. However, average falls in low and middleblood pressure readings were so similar to those in high readingsand in the mean that no effect from improving treatment of hypertensionwas detected. Results in contrasted subgroups were consistent.

Conclusions Blood pressure fell across 38 MONICA populationsat all levels of readings, with no differential fall in highreadings attributable to better control of hypertension. Despitethe importance of medication to individuals, in that decadeother determinants of blood pressure lowering must have beenmore pervasive and powerful in whole populations.

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