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

BMJ 2006; 332 doi: (Published 16 March 2006) Cite this as: BMJ 2006;332:629
  1. Hugh Tunstall-Pedoe, emeritus professor of cardiovascular epidemiology (h.tunstallpedoe{at},
  2. John Connaghan, research assistant1,
  3. Mark Woodward, professor of biostatistics2,
  4. Hanna Tolonen, research fellow3,
  5. Kari Kuulasmaa, head of unit3
  1. 1 Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital, Dundee DD1 9SY
  2. 2 George Institute for International Health, PO Box M201, Sydney, NSW 2050, Australia
  3. 3 International Cardiovascular Disease Epidemiology Unit, Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute (KTL), 00300 Helsinki, Finland
  1. Correspondence to: H Tunstall-Pedoe
  • Accepted 24 December 2005


Objective Declining mean systolic and diastolic blood pressures were observed in most populations of the World Health Organization MONICA (monitoring trends and determinants in cardiovascular disease) project from the mid-1980s to mid-1990s. We tested whether pooled results would show mean change associated with decline in high readings only, resulting from better antihypertensive medication, or with similar falls in low, middle, and high readings, implying other causes.

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

Setting 38 populations in 21 countries across four continents.

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

Main outcome measures Changes in the population in mean systolic and diastolic blood pressure, and in low, middle, and high readings—the 20th, 50th, and 80th centiles—and the differences between these changes.

Results Individual populations differed considerably, but pooling the 38 population results gave mean changes in systolic blood pressure of −2.2 mm Hg in men, −3.3 mm Hg in women, and in diastolic blood 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 middle blood pressure readings were so similar to those in high readings and in the mean that no effect from improving treatment of hypertension was detected. Results in contrasted subgroups were consistent.

Conclusions Blood pressure fell across 38 MONICA populations at all levels of readings, with no differential fall in high readings attributable to better control of hypertension. Despite the importance of medication to individuals, in that decade other determinants of blood pressure lowering must have been more pervasive and powerful in whole populations.


  • Embedded Image Supplementary data, explanations for the tables, and a methodological appendix are on

    The MONICA population survey data book is available in the public domain from and in the CD Roms from the monograph; both contain lists of MONICA sites and key personnel, and significant sponsors. The survey data book originates with WHO MONICA Project investigators and thousands of participants.

  • Contributors HTP conceived the study, organised and participated in the analyses, drafted and rewrote the manuscript, and is guarantor of theresults. JC carried out the data extractions from the data book and the analyses of individual data, and contributed to the manuscript. MW carried out critical reviews of the statistical analyses and the manuscript. HT was responsible for the survey data book which was the basis of the study. KK is overall guarantor of the WHO MONICA project data, led the production of the data book, and criticised the study design and the manuscript. All authors share responsibility for the final drafts.

  • Funding Work in Dundee, including that of John Connaghan, was supported from a British Heart Foundation programme grant.

  • Competing interests None declared.

  • Ethical approval Responsibility, and effected by principal investigators, in each population. This analysis is of anonymised data.

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