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Target Dose That Was Utilized in the Rts Reviewed for Jnc 8

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Insight into claret pressure targets for universal coverage of hypertension services in Iran: the 2017 ACC/AHA versus JNC eight hypertension guidelines

  • Mahboubeh Parsaeian3,
  • Bahram Mohajer4,
  • Mitra Modirianiv,
  • Naser Ahmadiiv,
  • Moein Yoosefiiv,
  • Parinaz Mehdipour4,
  • Shirin Djalalinia5,
  • Nazila Rezaei4,
  • Rosa Haghshenas4,6,
  • Forough Pazhuheian4,
  • Zahra Madadifour,
  • Mahdi Sabooni7,
  • Farideh Razi8,
  • Siamak Mirab Samieevii &
  • Farshad Farzadfar ORCID: orcid.org/0000-0001-8288-4046 four,6

BMC Public Health volume twenty, Article number:347 (2020) Cite this article

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Abstract

Background

Nosotros compared the prevalence, awareness, handling, and control of hypertension in Islamic republic of iran based on two hypertension guidelines; the 2017 ACC/AHA –with an aggressive blood pressure target of 130/80 mmHg- and the commonly used JNC8 guideline cutting-off of 140/xc mmHg. We shed calorie-free on the implications of the 2017 ACC/AHA for population subgroups and high-take a chance individuals who were eligible for non-pharmacologic and pharmacologic therapies.

Methods

Data was obtained from the Iran national STEPS 2016 report. Participants included 27,738 adults aged ≥25 years as a representative sample of Iranians. Regression models of survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension.

Results

The prevalence of hypertension based on JNC8 was 29.nine% (95% CI: 29.2–xxx.6), which soared to 53.vii% (52.9–54.4) based on the 2017 ACC/AHA. The per centum of sensation, treatment, and control were 59.2% (58.0–sixty.3), 80.2% (78.nine–81.4), and 39.ane% (37.4–40.seven) based on JNC8, which dropped to 37.i% (36.ii–38.0), 71.three% (69.ix–72.seven), and nineteen.vi% (18.3–21.0), respectively, past applying the 2017 ACC/AHA. Based on the new guideline, adults anile 25–34 years had the largest increment in prevalence (from 7.3 to 30.7%). They besides had the everyman awareness and handling rate, contrary to the highest control charge per unit (36.v%) betwixt age groups. Compared with JNC8, based on the 2017 ACC/AHA, 24, 15, 17, and 11% more than individuals with dyslipidaemia, high triglycerides, diabetes, and cardiovascular affliction events, respectively, fell into the hypertensive category. Yet, based on the 2017 ACC/AHA, 68.2% of individuals falling into the hypertensive category were eligible for receiving pharmacologic therapy (versus 95.7% in JNC8). LDL cholesterol< 130 mg/dL, sufficient concrete activity (Metabolic Equivalents≥600/week), and Trunk Mass Index were found to alter claret pressure by − 3.56(− four.38, − two.74), − 2.04(− 2.58, − one.50), and 0.48(0.42, 0.53) mmHg, respectively.

Conclusions

Switching from JNC8 to 2017 ACC/AHA sharply increased the prevalence and drastically decreased the awareness, treatment, and control in Islamic republic of iran. Based on the 2017 ACC/AHA, more young adults and those with chronic comorbidities vicious into the hypertensive category; these individuals might benefit from before interventions such as lifestyle modifications. The low command rate among individuals receiving treatment warrants a critical review of hypertension services.

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Groundwork

Hypertension (HTN) is the leading modifiable take chances cistron for premature morbidity and mortality in the world and Islamic republic of iran. The prevalence of HTN is rising globally [1]. In 2000, 26.4% of the globe'southward adults had HTN, which is expected to reach 29.two% by 2025 [2]. Amongst Iranians anile 25–70 years, 24.1% were living with HTN in 2011 [3]. The fact that a large proportion of the population is living with HTN and its costly comorbidities make it a wellness priority and a tracer for measuring progress towards Universal Health Coverage (UHC).

The definition of hypertension, which determines a cut-off for hypertension diagnosis, directly affects the estimates fabricated for the UHC of hypertension i.e. prevalence, sensation, treatment and control, and subsequently, the handling costs incurred by health systems for hypertension control. Following the release of the 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Claret Pressure in Adults with the cutting-off of 130/fourscore mmHg [iv], a reasonable claret force per unit area (BP) target for the effective coverage of hypertension has become a heated contend [five]. For several years, guidelines such equally the JNC8 (with 140/90 mmHg every bit its cut-off for hypertension) were used to determine the prevalence, awareness, treatment, and control of hypertension [six].

Studies have shown that switching from JNC8 to the 2017 ACC/AHA increases the prevalence of hypertension [7, eight]. Nonetheless, bear witness on the implications of the 2017 ACC/AHA guideline on the awareness, handling, and control of hypertension is under-developed [9]. Despite the potential health benefits of the 2017 ACC/AHA guideline [7, 8], adopting this guideline to enhance hypertension control in low- and middle- income countries (LMICs) is under question – given its economic impacts [10]. Co-ordinate to Watkins, the burden of the possibly higher numbers of individuals that shift from the 'elevated' and 'prehypertensive' into the 'hypertensive' categories (based on the 2017 ACC/AHA guideline) is hardly bearable by the already-overburdened health systems of LMICs [11]. This counterargument warrants more empirical findings per state in order to judge the brunt of embarking on the 2017 ACC/AHA hypertension guideline.

In this study, we estimated the prevalence, awareness, handling, and control of HTN, based on the two 'JNC8' and '2017 ACC/AHA' guidelines. We shed light on the implications (and benefits) of adopting an intensified claret pressure command recommended past the 2017 ACC/AHA, for unlike subgroups of Iranian populations and loftier-risk hypertensive adults using the ten-year atherosclerotic cardiovascular affliction (ASCVD) risk score. We compared the proportion of hypertensive individuals eligible for pharmacologic therapy based on both guidelines and discussed the implications in terms of the potential costs imposed on the Iranian health organization to provide handling to adults eligible for pharmacologic therapy.

Methods

Research design

We used the data collected in the 'Iran STEPS 2016' report. The WHO STEPwise approach to Surveillance (STEPS) provided the grounds for conducting the Iran STEPS 2016 report [12]. The Iran STEPS 2016 study included a representative sample of the Iranian population from urban and rural areas of xxx provinces, which were selected based on a multistage random sampling method. All Iranians aged > 18 years who were living in Iran at the time of information collection were eligible for inclusion in the study. The original report questionnaire was constructed by the WHO STEPS. It was translated into Persian and was culturally adjusted through learning from the application of the questionnaire in the earlier STEPS studies conducted in 2005, 2006, 2007, 2008, 2009, and 2011. During this evolution process, the consistency, validity, and reliability of the questionnaire were assessed. Information was collected by trained interviewers through in-person interviews. The methods employed in the Iran STEPS 2016 study which include details on the sampling design, the validity and reliability of the written report questionnaire, the interview guide, and data drove methods are presented elsewhere [xiii]. The interview guide was non developed for the nowadays study, only for the Islamic republic of iran STEPS 2016 study.

Measures

Event definitions

The main outcomes consisted of prevalence, awareness, treatment, and control of HTN. Nosotros distinguished hypertension based on the JNC8 and the 2017 ACC/AHA guidelines. Based on JNC8, we considered individuals with systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg as hypertensive; whereas, based on 2017 ACC/AHA, those with SBP ≥ 130 mmHg or DBP ≥ 80 mmHg [4] were considered hypertensive. Furthermore, the cocky-reported use of antihypertensive drugs in the last 2 weeks was considered as the presence of HTN for both definitions [14]. According to the WHO STEPS manual, trained personnel measured blood pressure on the right upper-arm three times, having had the participant rest for 5 min in a seated position [12]. An average of the last two measurements was considered as the claret force per unit area measure. Sensation was accounted to be present if an individual answered 'Yes' to the question 'Have you always been diagnosed with hypertension by a physician or a health professional?' Treatment was defined equally the self-reported use of antihypertensive drugs among aware individuals. Hypertension control referred to an average SBP < 130 & DBP < 80 mmHg based on the 2017 ACC/AHA and an average SBP < 140 & DBP < 90 mmHg based on the JNC8.

Covariates

Covariates included demographic, socio-economical status (SES), lifestyle, wellness insurance coverage, and cardiovascular disease (CVD) risk factors. Demographic factors included age, gender, marital condition, and identify of residence. Age groups consisted of 25–34, 35–44, 45–54, 55–64, 65–74, and 75+ years. Marital status included two groups; unmarried/divorced/widow and married. SES comprised of wealth status and the years of schooling. Wealth status was measured by the wealth index [xv] and was grouped into the poorest, poor, average, rich, and richest. Based on the years of schooling, participants were categorized into four groups; participants with no schooling, i–6 years, 7–12 years, and higher than 12 years of schooling. Insurance coverage referred to basic and complementary health insurance. Bones wellness insurance refers to a minimum coverage of essential wellness services by public health insurance organizations. Complementary health insurance is a coverage policy provided by private insurers that pays for surcharges of medical services not covered by basic health insurance or services delivered by private providers [16].

Lifestyle factors consisted of smoking, alcohol consumption, intake of fruits and vegetables, salt intake, and physical activity. Smoking has a dichotomy of statuses: never-smoker/non-smoker and current daily cigarette smoker. Smoker referred to a person who smoked cigarettes on a daily basis at the time of the survey. Never-smoker/not-smoker referred to a person who had never smoked or had quitted smoking. Since evidence on the relationships between smoking and hypertension is controversial, we relied on [17] comparison the outcomes between old-smokers and never-smokers versus current-smokers. Furthermore, merely 70 (0.26%) study participants reported using tobacco products other than cigarettes; whereas, 2911 (ten.72%) study participants reported that they were electric current cigarette smokers. Consequently, smoking other tobacco products was not included in the analysis and our analysis focused on cigarette smoking. In terms of alcohol intake, we classified the participants into alcohol drinkers and non-drinkers. An alcohol drinker referred to a person who had consumed whatever type of booze product during the last 12 months before the time of the survey, regardless of the duration or frequency of consumption. Non-drinker referred to a participant who had consumed no alcohol during the same period of time. The intake of fruits and vegetables was estimated for 24 h (24-h). Nosotros considered v portions of fruits and vegetables, consisting of two portions of fruits and three portions of vegetables, as a sufficient daily intake based on the dietary guidelines [eighteen]. One portion of fruits referred to 80 grand of fruits. In order to brand the portion size comprehensible to the report participants, 'i medium-sized fruit, like a medium-sized apple, or ¼thursday of a cup of dried fruits' was considered 1 portion of fruits. One portion of vegetables equalled 'ane cup of raw leafy vegetables, like spinach, or half a cup of cooked vegetables'.

The 24-h table salt intake was estimated from spot-urine samples using the Tanaka equation [nineteen]:

$$ 2.54\div grand\times 23\times 21.98\times {\left\{ spot\ sodium\;\left( mmol/l\right)/\left[ spot\ creatinine\;\left( mg/ dL\right)\times 10\right]\times \left[-2.04\times age\;(years)+14.89\times weight\;(kg)+16.14\times height\;(cm)-2244.45\correct]\right\}}^{0.392} $$

All spot urine samples were collected in the morning betwixt 8.00–10.00 a.m., and transferred to a fundamental laboratory unit of measurement according to the 2016 STEPS report protocol [13]. The detailed methods and results of applying the Tanaka equation to the Iran STEPS 2016 data have been published elsewhere [xx]. We analysed the relationships between table salt intake and outcomes using salt intake as a continuous and dichotomized variable. Since only 2% of the study sample had a salt intake of < v chiliad/24-hour interval, we considered ten g/day as the cut-off. The complementary assay of relationships between daily salt intake and blood pressure among hypertensive, aware, treatment-receiving, and under-control individuals is presented in Additional File 1. Physical activity was measured using the WHO Global Concrete Activeness Questionnaire (GPAQ) version ii with a cut-off of metabolic equivalents (METs) ≥ 600/week every bit sufficient [21]. Body Mass Index (BMI) had 4 levels; underweight (< 18.v kg/chiliadtwo), normal (18.v–24.9 km/m2), overweight (25.0–29.9 kg/chiliad2), and obesity (≥30 kg/m2). CVD risk factors consisted of dyslipidaemia, high triglycerides, diabetes mellitus (DM), and self-reported history of CVDs, i.eastward. myocardial infarction and/or stroke [four]. Dyslipidaemia referred to either total cholesterol ≥200 mg/dL, loftier-density lipoprotein (HDL) cholesterol < 35 mg/dL, or depression-density lipoprotein (LDL) cholesterol ≥130 mg/dL. High triglycerides referred to fasting triglycerides ≥200 mg/dL [22]. DM referred to HbA1c > 48 mmol/mol or fasting blood sugar (FBS) > 126 mg/dL or self-reported DM [23].

Statistical analysis

We calculated the ratio and 95% confidence interval (95% CI) of prevalence, sensation, handling, and command based on cut-offs recommended by the JNC8 and 2017 ACC/AHA. We synthetic univariate and multiple logistic regression models to account for the effects of covariates on prevalence, awareness, treatment, and control based on the 2017 ACC/AHA but. We calculated the number and percentage of individuals eligible for pharmacologic therapy based on both JNC8 [half-dozen] and the 2017 ACC/AHA. The number of individuals eligible for nonpharmacologic therapy was simply determined based on the 2017 ACC/AHA, which comprised elevated, HTN stage one, and HTN stage ii adults. Based on 2017 ACC/AHA, ii groups were eligible for pharmacologic therapy: a) individuals with BP ≥140/ninety, and b) those with BP ≥130/lxxx who had x-year atherosclerotic CVD (ASCVD) risk≥10%. The number of adults eligible for pharmacologic therapy was as well determined based on JNC8 [6]. Among individuals with BP ≥ 120/eighty mmHg, associations between blood force per unit area and lifestyle factors, weight, BMI, concrete activity, intake of fruits and vegetables, 24-h intake of salt, LDL cholesterol, and booze consumption were tested.

Given the multistage clustering structure, a complex survey analysis was used to obtain summary measures and statistical models. Nosotros weighted samples according to the 2015 Iranian National Population Census. Logistic regression models with a survey blueprint was used to analyse associations between the outcomes and covariates. We analysed the information using Stata 13 and R 3.4.i statistical software programs.

Results

The written report sample included 27,738 participants who were aged ≥25 years. Of these, 573 (two%) were excluded from the analyses due to missing values of SBP or DBP measurements. In the end, 27,165 participants were considered for analysis, of whom about lxx% were between 25 and 54 years quondam.

We found that adopting 2017 ACC/AHA markedly increased the prevalence. Based on JNC8, the prevalence was 29.ix% (95% CI: 29.2–30.6), which soared to 53.7% (52.ix–54.4), based on the 2017 ACC/AHA (Table S1). Likewise, the prevalence rate sharply increased by age from younger to older groups, reaching its summit at 82.iv% amidst those ≥75 years old (Odds Ratio (OR): 7.97 [6.29–10.10]) (Table S1). Based on the 2017 ACC/AHA, the largest increase in prevalence was observed in the 25–34-year-old historic period group; the prevalence increased from seven.3% based on JNC8 to 30.vii% based on the 2017 ACC/AHA.

The prevalence percent was lower among females (OR: 0.74 [0.67–0.82]) and rural dwellers (OR: 0.90 [0.80–1.00]). Among the wealth groups, the richest group had the everyman prevalence (OR: 0.69 [0.58–0.82]). The prevalence also significantly decreased from 73.7% among illiterates to 44.ii% among those with > 12 years of schooling (OR: 0.66 [0.55–0.79]). Prevalence significantly increased from normal BMI to overweight (OR: 1.60 [one.44–i.78]) and obese (OR: ii.22 [1.97–2.51]). It was significantly college among those with dyslipidaemia (OR: 1.15 [1.05–i.26]), high triglycerides (OR: 1.31 [1.15–ane.49]), DM (OR: one.58 [one.37–1.82]), and CVD history (OR: 1.77 [1.28–2.45]). Past lowering the blood pressure cut-off point past x mmHg to 130/80 mmHg, 24, 15, 17, and eleven% more individuals with dyslipidaemia, high triglycerides, diabetes, and CVD events, respectively, fell into the hypertensive category. For instance, based on the JNC 8, 71.5% of individuals with previous CVD events were considered hypertensive, which increased to 82.5% based on the 2017 ACC/AHA (Table S1).

Based on the JNC8, 59.2% (58.0–sixty.3) of hypertensive individuals were aware; whereas, according to the 2017 ACC/AHA, 37.1% (36.2–38.0) were aware (Table S2). Based on the 2017 ACC/AHA guideline, awareness significantly increased past age, from 9.7% in the youngest to 67.nine% in the oldest group (OR: 13.23 [nine.54–18.37]). A larger proportion of females (45.i%) were aware (OR: 1.59 [1.39–ane.81]) compared to males (28.9%). Awareness declined with increases in years of schooling, reaching its lowest among the well-educated grouping (OR: 0.58 [0.46–0.73]). Patients with a higher sensation were more probable to have complementary insurance coverage.

Sensation was significantly higher among the overweight (OR: 1.39 [1.19–ane.62]) and obese (OR: ane.71 [1.44–2.03]) groups. Individuals with salt ≥10 grand/day were less likely to be aware (OR: 0.87 [0.77–0.98]) and one gram/24-hour interval common salt decreased the odds of awareness (OR: 0.96 [0.94–0.99]) (meet also Additional File 1). Awareness was significantly higher amidst individuals with DM (OR: 1.76 [1.52–2.05]) and a history of CVD (OR: two.51 [1.79–three.52]).

Based on the JNC8, 80.2% (78.9–81.4) of hypertensive individuals were receiving treatment, which decreased to 71.iii% (69.9–72.vii) when the 2017 ACC/AHA guideline was considered (Tabular array S3). Based on the 2017 ACC/AHA, the ratio of treatment–receiving individuals increased by historic period (Table S3). The ORs of treatment increased from 2.83 (1.56–5.17) among the 35–44-twelvemonth-old age grouping to 13.38 (6.83–26.24) amidst those ≥75 years one-time. Treatment percentage increased with insufficient concrete action (OR: ane.21 [1.00–1.47]). Diabetics were more than probable than non-diabetics to take received more handling (OR: 1.79 [1.43–ii.24]). Naturally, 92.2% of patients with CVD history were receiving treatment (OR: iii.02 [one.79–5.11]).

The command charge per unit of HTN was 39.1% (37.four–40.7) based on the JNC8. Information technology dropped to 19.half dozen% (18.three–21.0) based on the 2017 ACC/AHA (Tabular array S4). Control significantly decreased from 36.5% amid the 25–34-year-old age group (Table S4) to 17.1% among the 55–64-year-old age group (OR: 0.27 [0.09–0.79]). Subsequently, control insignificantly increased amongst individuals older than 65 years. Control was significantly associated with complementary health insurance coverage (OR: ane.forty [1.06–1.86]). In terms of lifestyle factors, individuals with a lower control were more probable to be obese (OR: 0.56 [0.38–0.82]). Having a CVD history significantly increased HTN control (OR: 2.06 [i.35–3.14]).

Based on the 2017 ACC/AHA, 68.ii% of the hypertensive individuals or 37.2% of the unabridged sample had either BP ≥140/90 or BP ≥130/lxxx with x-year ASCVD risk ≥ten%, thus were eligible for pharmacologic therapy. Whereas, based on JNC8, 95.7% of hypertensive individuals and 28.half dozen% of the entire sample were eligible for pharmacologic therapy (Tabular array i). We likewise found that amidst participants with BP > 120/80 mmHg, 97.ix% were eligible to reduce their salt intake to < 5 g/day, 89.6% consumed insufficient amounts of fruits and vegetables, 69.4% were overweight or obese, and 57.2% were physically inactive.

Table 1 Frequency and proportion of participants eligible for pharmacologic and nonpharmacologic therapy*

Full size table

The effects of lifestyle factors on SBP among adults eligible for pharmacologic and non-pharmacologic therapy are presented in Table 2. LDL cholesterol < 130 mg/dL had a big issue size, − 3.56 (− 4.38, − 2.74) mmHg. Simply one unit increase in BMI increased SBP by 0.48 (0.42, 0.53) mmHg. Beingness physically agile significantly lowered SBP (− 2.04 (− 2.58, − ane.fifty)) mmHg. The effect sizes of sufficient intake of fruits and vegetables and common salt intake ≥ten g/day were − i.67 (− 2.49, − 0.86) and ane.52 (0.90, 2.13) mmHg, respectively.

Table 2 Predicting factors of claret pressure among participants eligible for pharmacologic and nonpharmacologic therapy

Full size table

Word

Switching from JNC8 to the 2017 ACC/AHA created a precipitous rise in the prevalence and a desperate reject in awareness, treatment, and command of HTN. Based on the 2017 ACC/AHA, one-half of the report samples brutal into the hypertensive category. Two-thirds of adults in the hypertensive category were unaware, indicating that they were undiagnosed. About one-3rd of those with sensation remained untreated, and among those treated, less than 20% were under control.

The increase in prevalence upon using the 2017 ACC/AHA guideline in Islamic republic of iran is consistent with a like increment in prevalence upon using this guideline in other countries e.g. Nepal [21], China [9], and the United States [24, 25]. Past adopting the new guideline, the largest increase in prevalence was observed amongst young and middle-anile individuals, which has also been reported in People's republic of china [ix].

The prevalence and awareness of hypertension in Iran (compared based on the cut-off of 140/90 mmHg) resemble findings reported in other middle-income countries [26, 27]. Despite a higher handling rate in Iran, the control rate stood at 39.1%, which is nevertheless noticeably lower than Turkey, with 53.9% in 2012, and Lebanon, with 54% in 2014 [28].

Increases in age significantly increased prevalence, awareness, and treatment simply decreased the control rate. The likelihood of an increase in prevalence grew by a higher BMI (overweight and obese), college triglycerides, dyslipidaemia, diabetes, and previous CVD history. Studies also reported a higher prevalence amongst the overweight, obese [29, 30], diabetics, and those with a history of CVD [31]. Higher awareness and handling rates were besides observed amongst those with comorbidities of diabetes and CVD [31]. This indicates a college likelihood of diagnosis and treatment in individuals living with such comorbidities.

Based on the 2017 ACC/AHA, a larger ratio of comorbid patients cruel into the hypertensive category (24, xv, 17, and 11% more individuals with dyslipidaemia, loftier triglycerides, diabetes, and CVD events, respectively). Under this guideline, many high-risk adults might exist covered by pharmacologic therapies and exist protected against the progression of CVD and diabetic renal diseases [v, 32].

Based on the 2017 ACC/AHA, the proportion of participants with BP > 120/fourscore mmHg who were eligible for nonpharmacologic therapy was high. 97.9% of participants with BP > 120/fourscore mmHg need to lower their salt intake to < 5 g/twenty-four hour period every bit recommended by the WHO [33]; 89.vi% need to consume sufficient fruits and vegetables, and 69.4% demand to lose extra weight.

Though the Tanaka formula provided statistically amend estimates for sodium intake in Iran [20], all three common formulas used to estimate sodium intake (Kawasaki, Tanaka, and INTERSALT) were systematically biased with overestimation at lower levels and underestimation at higher levels of sodium intake [34]. In the light of this evidence, we noted that the level of table salt intake in Iran was much higher than the five g/twenty-four hours cut-off recommended by WHO, therefore even in the presence of underestimation of sodium intake calculation, sodium intake levels exceeded the recommended common salt intake level. Thus, the percentage of those eligible for reducing common salt intake remained quite big.

Lifestyle factors, LDL cholesterol, physical activity, and BMI had large effect sizes on lowering BP. Based on these findings, non-pharmacologic therapy in hypertensive patients may exist considered to alter these lifestyle factors. The modification of these lifestyle factors could exist a recommended therapy for low chance adults (ASCVD < 10%) who fall into the hypertensive category nether the new guideline.

We contribute to a better agreement of the brunt of hypertension based on two distinctive guidelines. Considering the more aggressive cut-off point of 130/90 mmHg resulted in a greater prevalence and lower effective coverage of hypertension. The largest increase in prevalence was observed in adults aged 25–34 years. Given the big population of this historic period group (16.viii 1000000) in Iran, the number of adults who autumn into the hypertensive category remarkably increment from i.2 1000000 to v.ii meg using the 2017 ACC/AHA. Despite the lowest awareness and treatment rates in this young group, their command rate was highest among all age groups. This implies that targeting younger groups brings well-nigh greater benefits for hypertension UHC programs and for the society through maintaining health among the working besides every bit the reproductive population of the country [35]. Given this potential benefit for Iran, the use of the 2017 ACC/AHA might also benefit other middle-income countries with similar population profiles [9].

Though adopting 2017 ACC/AHA led to a college prevalence, withal not all adults falling into the hypertensive category were eligible for antihypertensive medications [5]. Based on the 2017 ACC/AHA, 37.ii% of Iranian adults anile > 25 years (17.2 meg adults) were eligible for pharmacologic therapy and based on JNC8 28.6% (thirteen.4 million adults) of them were [36]. With a minimum unit-cost of handling around $38 per person [37], pharmacologic therapy would annually cost $653 million and $510 1000000, respectively, under the 2017 ACC/AHA and JNC8 for all Iranian adults anile > 25 years. Thus, the treatment costs incurred for pharmacotherapy by the health system under the 2017 ACC/AHA guideline was merely marginally higher than the treatment costs under the JNC8.

We found that hypertension was very poorly controlled in Iran. Control is by nature a co-creational outcome. Both patient behaviour and an constructive construction and process of care play roles in improving this outcome. Based on our findings, patient adherence to a healthy lifestyle and complementary insurance may improve the control rate [29, 30, 38]. We, even so, telephone call future research to examine other dimensions of constructive structures and processes due east.k. evidence-based care plan [39,40,41] and continuity of care [42, 43] to ameliorate hypertension command.

This enquiry had several limitations, including the challenge of causal inferences from cantankerous-exclusive data and potential misclassifications of covariates. Nosotros claim no causal relationships as making causal inferences from cross-sectional surveys is challenging. However, some of our criteria exercise help infer causal relationships; we relied on a compelling theoretical causal model with regards to examining the determining factors for the prevalence, awareness, treatment, and control of hypertension. This was followed past the associations observed between the focal variables equally well as property that the examined covariates and the causes logically precede these four outcomes [44].

We are as well aware that there are potential misclassifications of covariates, particularly common salt intake and smoking. Nosotros classified the participants based on 10 g/day cut-off for salt intake rather than the v g/mean solar day recommended cutting-off signal. Nosotros did so every bit a rather small number of our participants had salt intakes of less than 5 g/mean solar day.

With regards to our classification of smoking condition, we classified never-smokers with former-smokers in the same group, which may affect the magnitude of furnishings this group has on the outcomes. The health outcomes of a former-smoker might still exist influenced by his/her previous smoking history, which may offset the positive effects of the never-smoker on the wellness outcomes of interest [45]. Furthermore, the effect of smoking status might be incompletely represented past our data choices. We focused on cigarette just and other tobacco products were excluded from our analysis.

The external validity of our findings tin can be reasonably maintained by the multistage random proportional to size sampling employed. Participants were from all provinces (except one province) and from both urban and rural areas. Given this, the validity of inferences well-nigh the identified relationships might exist, though not assuredly, maintained over variations in persons or times [46].

Conclusions

This manuscript applied a more progressive approach toward the measurement of prevalence, sensation, treatment, and control of hypertension services. The prevalence of hypertension markedly increased by the 2017 ACC/AHA guideline and at the same fourth dimension awareness, handling, and control sharply declined. Based on the 2017 ACC/AHA, more than one-half the adults aged ≥25 years became hypertensive, which were mostly represented past the 25–34 historic period group. Since the control rate among younger adults was higher than among older adults, adopting the 2017 ACC/AHA guideline may do good the immature population of Iran and in the aforementioned fashion other middle-income countries with similar population profiles.

The new guideline lowers the cutting-off value for diagnosis and puts a college proportion of adults in the hypertensive category. Under this guideline, more individuals with high triglycerides, diabetes, and CVD events barbarous into a hypertensive category. Thus, by adopting the 2017 ACC/AHA a larger proportion of high-take chances populations would be eligible for UHC programs. All the same, non all adults falling into a hypertensive category would need or receive antihypertensive medications; a big proportion of them tin can exist treated through lifestyle modifications, based on the issue sizes reported in this written report for LDL cholesterol, physical action, and BMI.

Based on either guideline, Iran has improved the per centum of hypertension handling; however, the awareness and particularly the control of hypertension remain a challenge. To improve the control rate, efforts should be made to improve both patient behaviour and the quality of healthcare services.

Availability of data and materials

The datasets analysed during the current study are non publicly available due to national rules and regulations just are available from the respective author on reasonable request.

Abbreviations

2017 ACC/AHA:

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Direction of Loftier Claret Pressure level in Adults

BMI:

Body mass index

CVD:

Cardiovascular disease

DBP:

Diastolic blood pressure

DM:

Diabetes mellitus

GPAQ:

Global Physical Activity Questionnaire

HbA1c:

Glycated haemoglobin (A1c)

HTN:

Hypertension

JNC8:

The Eighth Joint National Commission on Prevention, Detection, Evaluation, and Treatment (JNC8) guidelines for the Management of Loftier Blood Pressure in Adults

LDL:

Depression-density lipoprotein

MET:

Metabolic equivalents

NIMAD:

Iran National Institute for Medical Research Evolution

OR:

Odds Ratio

SBP:

Systolic claret pressure

SDG:

Sustainable development goal

SES:

Socioeconomic status

STEPS:

World Health Organization (WHO) STEPwise arroyo to Surveillance

UHC:

Universal Health Coverage

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Acknowledgements

We wish to thank all organizations and individuals involved in the funding, planning, design, and information collection of the Iran STEPS 2016 study.

Funding

The Iran STEPS 2016 written report, that provided data for this enquiry, was supported past Islamic republic of iran'due south National Institute of Health Research, Tehran Academy of Medical Sciences, under contract number 241/m/93/259.

Author data

Affiliations

  1. National Institute of Health Enquiry, Tehran Academy of Medical Sciences, Tehran, Iran

    Mahdi Mahdavi

  2. Erasmus Schoolhouse of Wellness Policy and Management, Erasmus University Rotterdam, Rotterdam, Holland

    Mahdi Mahdavi

  3. Department of Epidemiology and Biostatistics, School of Public Wellness, Tehran University of Medical Sciences, Tehran, Iran

    Mahboubeh Parsaeian

  4. Not-Communicable Diseases Research Eye, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

    Bahram Mohajer, Mitra Modirian, Naser Ahmadi, Moein Yoosefi, Parinaz Mehdipour, Nazila Rezaei, Rosa Haghshenas, Forough Pazhuheian, Zahra Madadi & Farshad Farzadfar

  5. Deputy of Enquiry and Technology, Ministry building of Health and Medical Education, Tehran, Iran

    Shirin Djalalinia

  6. Endocrinology and Metabolism Research Middle, Endocrinology and Metabolism Clinical Sciences Institute, Tehran Academy of Medical Sciences, Tehran, Iran

    Rosa Haghshenas & Farshad Farzadfar

  7. Reference Health Laboratory, Ministry of Health and Medical Education, Tehran, Iran

    Mahdi Sabooni & Siamak Mirab Samiee

  8. Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

    Farideh Razi

Contributions

Formulation and pattern of the study: MM1, MP, FF, BM. Statistical analysis: MP, MM1, BM. Manuscript training and revision: MM1, MP. Information conquering and analysis: MM2, NA, MY, PM, SD, NR, RH, FP, ZM, MS, FR, SMS. All authors accept read and canonical all versions of the manuscript.

Writer's information

Mahdi Mahdavi works every bit an banana professor of health policy in Iran's National Institute of Wellness Research (NIHR), Tehran University of Medical Sciences (TUMS), Tehran, Islamic republic of iran. Before joining NIHR he was working as a PhD student and researcher at the Erasmus School of Wellness Policy and Management (ESHPM), Erasmus Academy Rotterdam, The Netherlands.

Corresponding author

Correspondence to Farshad Farzadfar.

Ideals declarations

Ideals approval and consent to participate

The Iran STEPS 2016 written report was evaluated and approved by the ethics committee of Iran's National Institute for Medical Research Development (NIMAD) under registration lawmaking 'IR.NIMAD.1394.032.' Before the interviews and measurements, all participants provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Supplementary data

Boosted file 1:

Complementary analysis of relationships between daily salt intake and the outcomes. Table S1. Prevalence of hypertension based on the 2017 ACC/AHA and JNC8 hypertension guidelines and individual characteristics associated with prevalence according to the 2017 ACC/AHA guideline. Tabular array S2. Percentage of hypertension sensation based on the 2017 ACC/AHA and JNC8 hypertension guidelines and individual characteristics associated with awareness according to the 2017 ACC/AHA guideline. Tabular array S3. Percentage of hypertension treatment based on the 2017 ACC/AHA and JNC8 hypertension guidelines and private characteristics associated with handling according to the 2017 ACC/AHA guideline. Table S4. Percentage of hypertension control based on the 2017 ACC/AHA and JNC8 hypertension guidelines and individual characteristics associated with hypertension control according to the 2017 ACC/AHA guideline.

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Mahdavi, M., Parsaeian, M., Mohajer, B. et al. Insight into blood pressure targets for universal coverage of hypertension services in Iran: the 2017 ACC/AHA versus JNC 8 hypertension guidelines. BMC Public Health 20, 347 (2020). https://doi.org/x.1186/s12889-020-8450-1

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  • DOI : https://doi.org/10.1186/s12889-020-8450-one

Keywords

  • Hypertension
  • JNC8 hypertension guideline
  • 2017 ACC/AHA hypertension guideline
  • Effective coverage
  • Prevalence
  • Awareness
  • Treatment
  • Control
  • Iran

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