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      Age-specific association between blood pressure and vascular and non-vascular chronic diseases in 0·5 million adults in China: a prospective cohort study

      , FFPH a , * , * , , DPhil a , b , * , , Prof, FRCP a , * , , MSc a , b , , DPhil a , b , , MSc c , , PhD a , b , , PhD a , , DPhil a , , MSc c , , MD d , , MD d , , Prof, MD e , , PhD a , , Prof, FRS a , , Prof, FRS a , , Prof, MPH f , ** , , , Prof, DPhil a , , China Kadoorie Biobank collaborative group

      The Lancet. Global Health

      Elsevier Ltd

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          The age-specific association between blood pressure and vascular disease has been studied mostly in high-income countries, and before the widespread use of brain imaging for diagnosis of the main stroke types (ischaemic stroke and intracerebral haemorrhage). We aimed to investigate this relationship among adults in China.


          512 891 adults (59% women) aged 30–79 years were recruited into a prospective study from ten areas of China between June 25, 2004, and July 15, 2008. Participants attended assessment centres where they were interviewed about demographic and lifestyle characteristics, and their blood pressure, height, and weight were measured. Incident disease was identified through linkage to local mortality records, chronic disease registries, and claims to the national health insurance system. We used Cox regression analysis to produce adjusted hazard ratios (HRs) relating systolic blood pressure to disease incidence. HRs were corrected for regression dilution to estimate associations with long-term average (usual) systolic blood pressure.


          During a median follow-up of 9 years (IQR 8–10), there were 88 105 incident vascular and non-vascular chronic disease events (about 90% of strokes events were diagnosed using brain imaging). At ages 40–79 years (mean age at event 64 years [SD 9]), usual systolic blood pressure was continuously and positively associated with incident major vascular disease throughout the range 120–180 mm Hg: each 10 mm Hg higher usual systolic blood pressure was associated with an approximately 30% higher risk of ischaemic heart disease (HR 1·31 [95% CI 1·28–1·34]) and ischaemic stroke (1·30 [1·29–1·31]), but the association with intracerebral haemorrhage was about twice as steep (1·68 [1·65–1·71]). HRs for vascular disease were twice as steep at ages 40–49 years than at ages 70–79 years. Usual systolic blood pressure was also positively associated with incident chronic kidney disease (1·40 [1·35–1·44]) and diabetes (1·14 [1·12–1·15]). About half of all vascular deaths in China were attributable to elevated blood pressure (ie, systolic blood pressure >120 mm Hg), accounting for approximately 1 million deaths (<80 years of age) annually.


          Among adults in China, systolic blood pressure was continuously related to major vascular disease with no evidence of a threshold down to 120 mm Hg. Unlike previous studies in high-income countries, blood pressure was more strongly associated with intracerebral haemorrhage than with ischaemic stroke. Even small reductions in mean blood pressure at a population level could be expected to have a major impact on vascular morbidity and mortality.


          UK Wellcome Trust, UK Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, Chinese Ministry of Science and Technology, and the National Science Foundation of China.

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          Most cited references 16

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          Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002.

          The present article aims to provide accurate estimates of the prevalence, awareness, treatment, and control of hypertension in adults in China. Data were obtained from sphygmomanometer measurements and an administered questionnaire from 141 892 Chinese adults >/=18 years of age who participated in the 2002 China National Nutrition and Health Survey. In 2002, approximately 153 million Chinese adults were hypertensive. The prevalence was higher among men than women (20% versus 17%; P<0.001) and was higher in successive age groups. Overall, the prevalence of hypertension was higher in urban compared with rural areas in men (23% versus 18%; P<0.01) and women (18% versus 16%; P<0.001). Of the 24% affected individuals who were aware of their condition, 78% were treated and 19% were adequately controlled. Despite evidence to suggest improved levels of treatment in individuals with hypertension over the past decade, compared with estimates from 1991, the ratio of controlled to treated hypertension has remained largely unchanged at 1:4. One in 6 Chinese adults is hypertensive, but only one quarter are aware of their condition. Despite increased rates of blood pressure-lowering treatment, few have their hypertension effectively controlled. National hypertension programs must focus on improving awareness in the wider community, as well as treatment and control, to prevent many tens of thousands of cardiovascular-related deaths.
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            Use and misuse of population attributable fractions.

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              Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis.

              The effect of different classes of antihypertensive drugs on incident diabetes mellitus is controversial because traditional meta-analyses are hindered by heterogeneity across trials and the absence of trials comparing angiotensin-converting-enzyme (ACE) inhibitors with angiotensin-receptor blockers (ARB). We therefore undertook a network meta-analysis, which accounts for both direct and indirect comparisons to assess the effects of antihypertensive agents on incident diabetes. We undertook a systematic review up to Sept 15, 2006, and identified 48 randomised groups of 22 clinical trials with 143,153 participants who did not have diabetes at randomisation and so were eligible for inclusion in our analysis. 17 trials enrolled patients with hypertension, three enrolled high-risk patients, and one enrolled those with heart failure. The main outcome was the proportion of patients who developed diabetes. Initial drug therapy used in the trials (and the number of patients with diabetes of the total number at risk) included: an ARB (1189 of 14,185, or 8.38%), ACE inhibitor (1618 of 22,941, or 7.05%), calcium-channel blocker (CCB, 2791 of 38,607, or 7.23%), placebo (1686 of 24,767, or 6.81%), beta blocker (2705 of 35,745, or 7.57%), or diuretic (998 of 18,699, or 5.34%). With an initial diuretic as the standard of comparison (eight groups), the degree of incoherence (a measure of how closely the entire network fits together) was small (omega=0.000017, eight degrees of freedom). The odds ratios were: ARB (five groups) 0.57 (95% CI 0.46-0.72, p<0.0001); ACE inhibitor (eight groups) 0.67 (0.56-0.80, p<0.0001); CCB (nine groups): 0.75 (0.62-0.90, p=0.002); placebo (nine groups) 0.77 (0.63-0.94, p = 0.009); beta blocker (nine groups) 0.90 (0.75-1.09, p=0.30). These estimates changed little in many sensitivity analyses. The association of antihypertensive drugs with incident diabetes is therefore lowest for ARB and ACE inhibitors followed by CCB and placebo, beta blockers and diuretics in rank order.

                Author and article information

                Lancet Glob Health
                Lancet Glob Health
                The Lancet. Global Health
                Elsevier Ltd
                14 May 2018
                June 2018
                14 May 2018
                : 6
                : 6
                : e641-e649
                [a ]Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
                [b ]Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
                [c ]Chinese Academy of Medical Sciences, Beijing, China
                [d ]Qingdao Municipal Center for Disease Control and Prevention, Qingdao, China
                [e ]National Center for Food Safety Risk Assessment, Beijing, China
                [f ]Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
                Author notes
                [* ]Correspondence to: Dr Ben Lacey, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK ben.lacey@
                [** ]Prof Liming Li, School of Public Health, Peking University Health Science Center, Beijing 100191, China lmlee@

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                © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

                This is an open access article under the CC BY license (



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