Arterial hypertension–attributable mortality in Europe: implications for the Americas

Hypertension remains the leading modifiable risk factor for cardiovascular morbidity and mortality worldwide, accounting for over 10 million deaths annually [1]. In this issue, Zuin et al. present a population-level analysis of 30 European countries between 2012 and 2021, reporting more than 1.6 million hypertension-attributable deaths. During this period, the age-adjusted mortality rate (AAMR) increased by 1.6% per year. Lest one think this might be driven solely by a change in population demographics, especially ageing, Zuin et al. conducted a stratified analysis showing the steady increase in all strata, albeit with steeper rises among adults aged ≥70 years. There were no dramatic differences by sex either, with parallel increases in both groups. Some regional differences are notable, with mortality increased in Northern and particularly Eastern Europe, whereas trends plateaued in Western and Southern countries, underscoring persistent heterogeneity across the continent. While the tremendous global efforts to reduce hypertension are commendable, these findings are nonetheless deeply concerning and disheartening, given that hypertension is straightforward to diagnose and that effective, accessible therapies are widely available. The field has progressed quite steadily through the years, with the widespread advent of home blood pressure (BP) devices and the guidance provided by the STRIDE-BP registry [2]. Clinical trials have supported the use of single pill combinations which are widely available and produce potent BP lowering responses, as well as evidence for spironolactone as an effective fourth drug in resistant hypertension [3]. The race to develop new therapeutics is still ongoing, with clinical trials underway for drugs such as zilebesiran, a targeted approach to reduce hepatic angiotensinogen with RNA interference, highlighting the importance of continued research and development [4]. The European Society of Hypertension has produced guidelines in 2014 and 2018 (during the period of the study) to emphasize these messages and promote BP control [5,6]. Despite these measures, hypertension related mortality has slowly and steadily increased as reported by Zuin et al. These European patterns are mirrored by diverse trends in the Americas. In Latin America, hypertension contributes to 12–15% of adult deaths, with substantial variation in control across countries [7]. In the United States, hypertension-related cardiovascular mortality has increased steadily since 2000, with AAMR rising by 0.5% per year, disproportionately affecting socioeconomically disadvantaged and Black populations [8]. In Canada, historical declines in hypertension-attributable mortality, achieved through high levels of awareness, treatment, and control, have plateaued in recent years [9]. Awareness and control rates across the Americas remain heterogeneous: 83% of U.S. adults are aware of their hypertension and 51% have it controlled; in Canada, awareness is 77% with 58% controlled; and in Latin America, awareness is 63% with only 21% achieving control [10]. In the present study, though the administrative data reports increasing hypertension-attributable mortality, it does not reveal the underlying hypertension control data. We do not know whether the increased mortality occurred on a background of worsening BP control, or despite improving trends of BP control. This aspect is crucial to help focus public health resources appropriately. If BP control has faltered and plateaued or even worsened (as has happened in other parts of the world detailed above), then we need to focus renewed energy on diagnosing and therapeutic aspects. Conversely, if this has happened despite improving BP control, then other factors could be at play. It is unlikely that competing mortality from other causes (e.g., cancer or infections) has decreased over the same period of time though that could be one explanation for some regional differences. However, though Zuin et al. stratify by age and sex, it is quite possible that other factors including socioeconomic drivers, and other comorbid conditions that travel with hypertension might be the underlying the reported findings, which is postulated by the authors. This phenomenon is easily seen when comparing countries such as the United States vs. Canada in the Americas. Persistent disparities are influenced by gaps in healthcare coverage, therapeutic inertia, medication nonadherence, and socioeconomic and geographic factors, while population aging, multimorbidity, obesity, and other lifestyle-related risk factors continue to drive cardiovascular burden [11]. Encouragingly, declines in hypertension-attributable mortality are achievable when health systems implement sustained, multicomponent strategies. Croatia, which is included amongst the countries with reductions in hypertension-attributable mortality in Zuin et al., longstanding public health efforts over the past two decades have steadily improved awareness, treatment, and control, including a near tripling of antihypertensive medication use [12]. By 2023, these efforts were intensified through the “70/26 Mission” for hypertension and “Do you know what is your number?” efforts, addressing dyslipidemia and other cardiovascular risk factors. This engaged professional societies, patients, and governmental agencies to integrate prevention, health literacy, and adherence support [13]. Comparable strategies are underway in the Americas: the WHO/PAHO-led HEARTS program, active in 33 countries, has standardized treatment protocols, strengthened primary care, and implemented digital monitoring platforms [14]. Population-wide interventions in low-income countries have shown that within a single year, treatment coverage can increase from 52.9% to 88.2%, with BP control among treated individuals improving from 59.3% to 68.5% [15]. These examples highlight the capacity of multicomponent, system-level interventions to achieve rapid improvements in population-level blood pressure control. The findings by Zuin et al. underscore the urgent need to scale up evidence-based, integrated strategies to improve hypertension outcomes. Both Europe and the Americas demonstrate that substantial reductions in hypertension-attributable mortality are feasible when programs combine early detection, standardized treatment, adherence support, and management of concomitant risk factors. Prioritizing the expansion and sustainability of such multicomponent interventions is essential to reduce the burden of hypertension and its cardiovascular sequelae globally. ACKNOWLEDGEMENTS None. Conflicts of interest There are no conflicts of interest.

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