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ASIMPLEMEASURETOSAVELIVES#checkyourpressureASIMPLEMEASURETOSAVELIVES#checkyourpressureMMM18OVERVIEWProfessorNeilPoulterMMMChiefInvestigator&DrThomasBeaneyMMMLeadStatisticianAUGUST2019[Neil]GoodmorningfromLondon,everybody.
MynameisNeilPoulter,andnexttome,mycolleague.
[Tom]I'mTomBeaney.
[Neil]Thetwoofus,overthenext40minutesorso,aregoingtogiveyouanoverviewofMayMeasurementMonth2018.
Wewishyouavery,verywarmwelcomeforjoiningus.
1ASIMPLEMEASURETOSAVELIVES#checkyourpressureINTRODUCTIONMMMObjectives:ReminderMMM17:RecapofkeyresultsMMM18:Overviewofglobal,regionalandcountrynumbersMMM18:KeydescriptivestatisticsMMM18:VariationinbloodpressureacrossreadingsMMM18:NumberswithhypertensionMMM18:Associationsofsystolic/diastolicbloodpressureMMMPublicationsNextforMMM[Neil]Thisistheplanofwhatwe'regoingtodointhenext40minutes.
WhistlethroughtheobjectivesofMayMeasurementMonthtoremindyou.
Aquickrecapoftheresultsfrom2017.
Thenanoverviewoftheglobal,regional,andcountrynumbersandthekeydescriptivestatisticsfromMMM2018.
Thenwe'lllookatthevariationinbloodpressureacrossthereadingsin2018andthenumberswithhypertension.
Andthenlookatsomeoftheassociationsbetweensystolicanddiastolicbloodpressurethatwewereabletomeasureinthe2018campaign.
Andthenwe'llmoveforward,we'llgiveyouasummaryofwhatpublicationshavebeenproducedsofarinrelationshiptoMMMandwhatourplansareforthefutureandwhatwillfollowotherthanforpublications-whatelseisgoingtohappeninMayMeasurementMonthgoingforward2ASIMPLEMEASURETOSAVELIVES#checkyourpressureTHANKYOUFROMTHEMMMGLOBALPROJECTTEAM[Neil]Beforewedoanyofthat,I'dliketojustwishyouahugethankyouforthoseofyouwhohavebeeninvolved.
Someofyou,Iknow,willhavebeeninvolvedwith2017,'18,and'19.
Some,forvariousreasons,maynothavebeenabletodoiteveryyearandmayhaveonlyjustjoinedthisyear.
Butwhoeveryouare,thankyousomuchforyourhugeefforts.
Thiscouldnotpossiblyhappenwithoutthemassiveeffortsofvolunteerssuchasyourselves,andwecan'tthankyouenough.
Thisistheteam,someofwhomyoumayormaynotrecognize,butthisisourglobalprojectteam.
Wemeetregularlyviateleconferencesandjustoccasionallyface-to-face.
Wehaveregularcommunicationsamongstourselvestomakesurethatthisprojectkeepsgoing,tryingtosteeritintherightway,thankstoyourmassiveefforts.
Thankyoufromthebottomofourhearts.
Youhavereallymadethisintotheproject,whichIthinkhasnowestablisheditselfaroundtheworldasbeingveryimportant.
Thankyou.
3ASIMPLEMEASURETOSAVELIVES#checkyourpressureMMMOBJECTIVES:REMINDER1.
Increaseawarenessofthehealthissuesaroundhypertension–inthepublicandhealthcarearenas2.
Createscientificevidencetoinformandinfluencehealthpolicy–toincreaseglobalaccesstoBPscreening3.
Screenafurther1million+peopleeachyear,whoideallyhaven'thadtheirBPmeasuredforover1year,andcollectqualitydata[Neil]Okay,here'sareminderofourobjectives.
Theprimaryobjectivewasverysimple.
Wewantedtoincreaseawarenessofthehealthissuesaroundhypertensionamongstthepublicandinthoseinvolvedwithhealthcare.
Atthesametime,wewantedtocreatescientificevidencethatwouldinformandinfluencehealthpolicyandtherebygoontoincreaseglobalaccesstobloodpressurescreeningbecauseweknowit'snotgoodenough.
Andthenthethirdthingwastoscreen,eachyear,atleastamillionpeopleormore,andbydesign,ideallypeoplewhohadn'thadtheirbloodpressuremeasuredforoverayear.
We'llcomebacktothat.
Andwewantedtogetqualitydata.
Buildingontheinitialsurvey,wewantedtogetmoredataandbetterqualitydatatohelpchangepolicy.
4ASIMPLEMEASURETOSAVELIVES#checkyourpressureASIMPLEMEASURETOSAVELIVES#checkyourpressureMMM17KEYRESULTSRECAP[Neil]Soatthispoint,I'llhanditovertoTomwhocangiveyouthekeyresultsfrom2017.
5ASIMPLEMEASURETOSAVELIVES#checkyourpressureMMM2017RECAP1.
2millionscreenedOver100000withuncontrolledBP(46.
3%)80countriesOfthoseuntreatedOfthosetreated123Over150000withraisedBP(17.
3%)[Tom]Thankyou,Neil.
Sojusttorecapwhatwefoundin2017.
Wescreened1.
2millionpeopleacross80countriesin2017.
Ofpeoplewhowerenotonanymedicationfortheirbloodpressure,wefoundover150,000whohadaraisedbloodpressure,sothesearepeoplewhohavehypertension,butwereuntreated.
Andthatwasabout17.
3%ofallofthosewhowerenotonmedication.
Andthenwefoundover100,000peopleofthepeoplewhowereonmedicationfortheirbloodpressure,whohadanuncontrolledbloodpressure.
Andthatwasabouthalfofallthosewhowereonmedication,sojustunderhalf-46.
3%.
Theseweretheresultsfrom2017andwe'llnowlookatwhatwesawin2018.
6ASIMPLEMEASURETOSAVELIVES#checkyourpressure2018:NOTESONMETHODOLOGYDatacollectedonapp,ExcelandhandwrittenformsDatasubmittedviaapporExcel186,927viaappDatacleanedandstandardizedcentrallyCountrieswithfewerthan10participantsexcludedOpportunisticscreening,notrandomised[Tom]Justafewbitsonthemethodologyfortheresultsin2018.
Wecollecteddataonanapp,somedatacamethroughonExcelfiles,andmanywerealsoonhandwrittenforms,someofwhichwerethentransferredtoExcel.
Wehadabout186,000thatcamethroughontheapp,whichwasabout12%ofthetotal,whichwashigherthan2017whenwehad8%.
Thedatawascleanedofteninlocalcountriesandthensenttous.
Andthenthere'sthecleaningprocessthatwerunthroughhere.
Lotsofteammemberswereinvolvedinthecleaningprocess,asyoucanimagine,withthenumbersthatwehad.
Andweexcludedcountriesthathadfewerthan10participantsonthebasisthatweweren'tsure,werethesegenuinescreeningsites,orweretheyperhapsincorrectlyenteredAndanimportantnoteisthatinthedatathatwehadcomingin,peoplewerenotrecruitedtothestudyinarandomlysampledway.
Thiswasopportunisticscreening.
Wewerescreeningpeopleinavarietyoflocationssoweshouldn'ttaketheresultsthatweseetobethetrueunderlyingprevalence.
Andthiswasbydesign.
Weweretryingtoscreenasmanypeopleaspossible.
Weweren'ttryingtorandomlysamplewithapopulation-basedscreeningcampaign.
7ASIMPLEMEASURETOSAVELIVES#checkyourpressure2018:NOTESONMETHODOLOGYMeanof2ndand3rdBPreadingusedinanalyticalcomparisonsMultipleimputationusedtoimputethemeanof2ndand3rdreadingwhereonly1or2readingsrecorded(basedonage,genderandregion)HypertensiondefinedasaBPof140/90mmHgormoreand/orreceivinganti-hypertensivetreatmentMeasuresofassociationadjustedforage,gender,andanti-hypertensivemedication[Tom]Intermsofhowweanalysedthedata,wecollectedthreebloodpressurereadingsforalmosteveryone.
Andweusedthemeanofthesecondandthirdreadinginouranalysis.
Ifwedidn'thavethesecondandthirdreading,thenweusedatechniquecalledmultipleimputation.
Andweworkoutwhatthesecondandthirdreadingwouldhavebeenbasedontheotherreadings.
Andwetakeintoaccountpeople'sage,theirgender,theircountrytheycomefrom,whilewedothat.
Andwe'veusedthestandarddefinitionofhypertension,whichisusedinmostpartsoftheworld,whichisabloodpressureofabove140systolicorabove90diastolic,orinthosepeoplewhoareonanti-hypertensivemedication.
Andwealsotookcontrolratesatthesamelevel.
Soanyonewhowasontreatmentandwhosebloodpressurewasabove140/90wassettobeuncontrolledinthisstudy.
Andfinally,wewillcomeontosomeofthemeasuresoftheassociation.
Andwehaveadjustedtheseforthekeyfactors,whichwe'llcomeonto.
8ASIMPLEMEASURETOSAVELIVES#checkyourpressureASIMPLEMEASURETOSAVELIVES#checkyourpressureMMM18RESULTS[Tom]Sotodiscusstheresults,whatdidwefindin20189ASIMPLEMEASURETOSAVELIVES#checkyourpressure2018PARTICIPATINGCOUNTRIES[Tom]Now,intheinterestoftime,I'mnotgoingtogothrougheverysinglecountry.
We'veincludedonlythosewithover1,000participantsinthesetables.
Again,Iwon'ttalkthroughalltheindividualcountries,astherearesomany,butifyouwanttopauseitandhavealookatyourowncountry,thenpleasedo.
Youcansee,thisisbyregionwiththecountriesthatcontributedthemostwithinthoseregions.
SoIndiahadoverathirdofamillionintotal;China,almost300,000;andthePhilippines,177,000.
Sothosewerethetopthreecountriesintermsofparticipantsin2018.
10ASIMPLEMEASURETOSAVELIVES#checkyourpressure1,504,963MMM18:REGIONALTOTALSEurope,80564NorthernAfricaandMiddleEast,93,465Sub-SaharanAfrica,151,924Americas,189,560South-eastAsiaandAustralasia,293,948EastAsia,304,423SouthAsia,391,079[Tom]SohowmanynumbersineachregionWell,inEurope,wehad80,000;and93inNorthernAfricaandtheMiddleEast;150,000inSub-SaharanAfrica;190,000intheAmericas,soNorthandSouthAmerica.
Wehadalmost300,000inSoutheastAsiaandAustralasia;300,000inEastAsia;andthenalmost400,000downinSouthAsia,whichcomestoacombinedtotalofjustover1.
5million.
So25%morethanwehadin2017,soahugenumber.
Ifyouthinkofthetwoyears,thenwe'vescreened2.
7millionpeople.
11ASIMPLEMEASURETOSAVELIVES#checkyourpressureCOUNTRIESWITH>1000SouthAsia39107926.
0%India34523423.
0%Pakistan250761.
7%Nepal155611.
0%Bangladesh52080.
4%EastAsia30442320.
3%China(mainland)28834219.
2%-Taiwan153651.
0%-HongKong7160.
1%South-eastAsia&Australasia29394819.
6%Philippines17717611.
8%Indonesia912226.
1%VietNam173321.
2%Malaysia48660.
3%Australia33520.
2%[Tom]Now,intheinterestoftime,I'mnotgoingtogothrougheverysinglecountry.
We'veincludedonlythosewithover1,000participantsinthesetables.
Again,Iwon'ttalkthroughalltheindividualcountries,astherearesomany,butifyouwanttopauseitandhavealookatyourowncountry,thenpleasedo.
Youcansee,thisisbyregionwiththecountriesthatcontributedthemostwithinthoseregions.
SoIndiahadoverathirdofamillionintotal;China,almost300,000;andthePhilippines,177,000.
Sothosewerethetopthreecountriesintermsofparticipantsin2018.
12ASIMPLEMEASURETOSAVELIVES#checkyourpressureCOUNTRIESWITH>1000Americas18956012.
6%Argentina704184.
7%Colombia355482.
4%Venezuela286491.
9%Brazil124130.
8%Ecuador119220.
8%Mexico101390.
7%Chile93440.
6%Paraguay22850.
2%Uruguay14250.
1%Guatemala12070.
1%Jamaica10650.
1%Honduras10410.
1%[Tom]MovingontotheAmericas.
WehadlargenumbersfromArgentina,over70,000.
13ASIMPLEMEASURETOSAVELIVES#checkyourpressureCOUNTRIESWITH>1000Sub-SaharanAfrica15192410.
1%Kenya495483.
3%DemocraticRepublicofCongo187191.
3%Angola144331.
0%Malawi107910.
7%Cameroon88830.
6%CaboVerde80080.
5%Ghana69070.
5%Nigeria63980.
4%RepublicoftheCongo61690.
4%Mauritius54710.
4%Botswana45990.
3%SouthAfrica29650.
2%Benin20350.
1%Zambia17360.
1%Niger11220.
1%[Tom]InSub-SaharanAfrica,almost50,000fromKenya,and19,000almostfromtheDRC.
Thisis,asweweresaying,justthecountriesover1,000.
Sotherearemorecountriesherethatwe'renotdisplaying.
14ASIMPLEMEASURETOSAVELIVES#checkyourpressureCOUNTRIESWITH>1000NorthernAfricaandMiddleEast934656.
2%Sudan407792.
7%UnitedArabEmirates313162.
1%Oman126890.
8%Libya72790.
5%Europe780685.
2%Armenia211121.
4%Georgia107560.
7%Spain76460.
5%Albania70460.
5%Poland64500.
4%Italy55540.
4%Slovenia48830.
3%England27120.
2%Austria21670.
1%Wales19500.
1%Russia19310.
1%Belgium11770.
1%Romania10910.
1%Switzerland10500.
1%[Tom]AndherearetheresultsforNorthernAfricaandtheMiddleEast,andEuropeaswell.
15ASIMPLEMEASURETOSAVELIVES#checkyourpressureKEYATTRIBUTESParticipatedinMMM2017105009(7.
0%)Knownhypertensionoronmedication277794(82.
0%)onmedication338813(25.
0%)[Tom]Somovingontothecharacteristicsofthepeoplewhowescreened.
Oneareawe'reinterestediniswhodidwescreenlastyearin2017,andarewereallyidentifyingnewpeoplewhenwe'rescreeningWell,weare,andwefound105,000peoplewerescreenedin2017,whichmeans93%ofthosewescreenedin2018werenewlyscreened.
Sowearereallyreachingouttonewpeople,anditshowsthatthescreeningsitesarebeingsetupindifferentlocationsandintermsofbuildingawarenessofbloodpressure,Ithinkthisisareallyimportantpoint.
SoMMM18wasreachingnewpeoplecomparedtoMMM17.
Andnewin2018washowmanypeoplewereawareofhavinghypertension,andwecombinedpeoplewhosaidtheywereawareandpeoplewhosaidtheywereonmedication.
Andwefoundthatathirdofamillionpeople,aboutaquarterofallthosescreened,wereeitherawaretheyhadhypertensionorwereonmedication,andofthose,about82%wereonmedication.
Soonly18%ofthosewhowereawareofhavinghypertensionwerenotonmedication.
Sorelativelysmallnumberglobally.
16ASIMPLEMEASURETOSAVELIVES#checkyourpressureREGIONALATTRIBUTESRegionAge(mean,years)WomenMenOnmedicationSouthAsia42.
541.
2%58.
8%19.
6%EastAsia48.
753.
4%46.
6%18.
5%South-eastAsiaandAustralasia46.
865.
0%35.
0%19.
8%Americas50.
359.
4%40.
6%32.
7%Sub-SaharanAfrica40.
052.
8%47.
2%9.
0%NorthernAfricaandMiddleEast35.
942.
4%57.
6%10.
1%Europe49.
660.
4%39.
6%28.
6%Worldwide45.
352.
8%47.
2%19.
8%[Tom]Comingontothecharacteristicsacrossdifferentregions.
Iwon'tgothroughallthesenumbers,astherearequiteafew.
Butwe'vegotquitearangeofagesacrossregions.
Soglobally,themeanageis45,butitrangesfromarelativelyyoungageof36inNorthernAfricaandtheMiddleEastupto50intheAmericas.
Similarly,we'vegotawidesplitofgendersacrossdifferentregionsfrom40%womeninSouthAsiatoalmosttwothirdsinSouth-EastAsia.
Androughlyhalfwhenwelookworldwide.
Andintermsoftheproportionofscreeneeswhowereonanti-hypertensivemedication,wehaveabout9%inSub-SaharanAfrica,muchhighernumbersintheAmericas,soalmostonethird,whichmayreflectthedifferentialscreeningsites,whetherpeoplecamefrommoreruralcommunitiesormorehospital-basedscreeningsights.
Overallglobally,about20%wereonmedication.
17ASIMPLEMEASURETOSAVELIVES#checkyourpressurePARTICIPANTCHARACTERISTICS20%Onmedication20%Onmedication4.
1%PreviousMI4.
1%PreviousMI6.
6%Fasting6.
6%Fasting2.
8%Previousstroke2.
8%Previousstroke11%Currentsmoker11%Currentsmoker7.
4%Diabetic7.
4%Diabetic59%Measuredonleftarm59%Measuredonleftarm1.
7%Pregnant1.
7%Pregnant6.
4%1-3drinks/month6.
4%1-3drinks/month3.
9%1ormoredrinks/week3.
9%1ormoredrinks/week[Tom]Intermsofsomeoftheothercharacteristicsofthepopulationswescreened.
Iwon'tgothroughallthese,suchasdiabetes,stroke,MI,andlifestylefactorslikewhetherpeopleweresmoking,andwhetherpeopleweredrinking.
Andwehaveanideaofhowregularlypeopleweredrinking.
Whetheritwasoneormoretimesaweek,orlessthanweekly,ornotatall.
18ASIMPLEMEASURETOSAVELIVES#checkyourpressureSITEOFMEASUREMENT16.
4%7.
9%4.
2%33.
6%Hospital/clinic506109Pharmacy63800Workplace118974Publicarea(outdoors)24731414.
3%Publicarea(indoors)2159571.
4%Other21726331083sitelocationsunknown[Tom]Anothervariablewecollectedfor2018,whichwedidn'thavein2017,waswherethebloodpressureswererecorded,andwe'vegotavarietyofscreeningsites.
Soyoucanseeaboutonethirdweretakeninahospital-orclinic-basedsetting,4%inpharmacies,8%intheworkplace,andalmostonethirdindifferentpublicspaces,soeitherindoororoutdoorpublicareas.
Andabout1.
4%"other",whichwereonesweweren'tsureabout.
Andwehadprettygoodcoverageintermsofknowingwherethoselocationswere,butaboutathirdofamillionwerenotrecorded.
Still,we'vegotabout1.
2millionpeoplewhereweknewthelocationofthebloodpressurerecording,whichisvaluableinformation.
We'llcomeontolookingatthatlateron.
19ASIMPLEMEASURETOSAVELIVES#checkyourpressureBPVARIATIONACROSS3READINGS124.
8/79.
1122.
9/77.
9121.
8/77.
1122.
5/77.
7Reading2Reading3Meanof2&3Of1124202(74.
8%)individualswithall3readings38.
4%35.
6%34.
4%33.
5%MeanBPHypertension40.
5%126.
5/79.
435.
5%124.
3/78.
4Reading1[Tom]Somethingwelookedatin2017andlookedagainatin2018washowdobloodpressuresvaryacrossthreereadings.
Sowetookthree,andweseeaverystrongandstatisticallysignificantdifferenceonaveragebetweenreadingsone,two,andthree.
Yourbloodpressuretendstogodownandinterestingly,ifyoulookattheproportionswhohavehighbloodpressure,wehaveabout38%withhighbloodpressurebasedonifwewerejusttouseasinglereading.
Nowifweusethemeanofthesecondandthird,whichiswhatwedid,theproportionis33.
5%.
Sowe'vegotalargedifferenceof5%intotalacrosstheworld,ifweusejustthefirstreadingandmeanofthesecondandthird.
5%maynotsoundahugedeal,butifyou'reaccountingfor1.
5millionpeople,that'sactuallyabout75,000peoplejustinMayMeasurementMonthwhowouldhavebeendiagnosedwithhypertensionbasedonthesinglereadingcomparedtoifweusethesecondandthird.
Andwethinkthisreallysupportstheideathatweshouldbedoingatleasttwo,andprobablythreereadings,whenwe'rediagnosinghighbloodpressureintheabsenceofanABPMorhomebloodpressurereadings,ifweweretousejustclinicreadings.
[Neil]Iwasjustgoingtosay,Ithinkthisisimportant,Tom,becauseofguidelinesandtheyareinconsistentinwhattheyrecommend,andsomeofthemajorguidelinesthatmanycountriesfollow,saygetthreereadingsandtakethemeanofthosethree.
Ifyoudothat,you'llhavespuriouslyhighlevelsofhypertension.
SoasTompointsout,ifyouaregoingtobasethediagnosisofhypertensionononesetofreadings,andIthinkwe'reallagreedthat'snotideal,butifyouaregoingtodothat,thenwhatwecanseeisdoingitthreetimes,themeanofthesecondandthirdisgoingtogiveyouthemostconservative,andthereforethemostlikely,definitionofhypertension,themostaccurateprevalenceanddiagnosticability.
Butonequestion,Tom,thathasn'traised,andthatisthatifyourfirstreadingisnormal,itmightbethatwemightinthatsetting,notneedtogoon,andwe'regoingtoinvestigatethat,seewhetheryouneedtodothesecondandthird-ifthefirstone'sclearlynormal,what'sthepointincarryingonWe'regoingtoinvestigatethatinsubsequentanalyses.
[Tom]Yeah,sothat'saprojectthat'scurrentlyunderwayandhopefullywillbedonefairlysoon.
Justtoshowthisisn'taflukeof2018.
Ifwe,inredwe'vegotthenumbersfrom2017.
Andactually,it'saverysimilarpatternwherethebloodpressuregoesdownbetweensubsequentreadingsandthemeanofthesecondandthirdwasalsothelowestwithaboutagaina5%differenceinthetotalproportionwithhypertension.
Sotheseareconsistentwithwhatwefoundin2017,importantly.
20ASIMPLEMEASURETOSAVELIVES#checkyourpressureTOTALWITHHYPERTENSIONRegionTotalwithhypertensionPercentageSouthAsia13217333.
8%EastAsia9349930.
7%South-EastAsia&Australasia10414835.
4%Americas7657440.
4%Sub-SaharanAfrica3760324.
8%NorthernAfricaandMiddleEast2457926.
3%Europe3350441.
6%Worldwide50207933.
4%[Tom]HowmanypeoplehadhypertensionoverallRemember,hypertensionisnotjustthosewitharaisedbloodpressurebutalsopeoplewhoareontreatmentfortheirbloodpressure.
Sointotalwefoundonethirdofalltheparticipantshadraisedbloodpressure,so502,000people.
Nowyou'llnoticethenumberhereisveryslightlydifferent,butthesearethenumbersaftermultipleimputationwhereasthenumberswesawinthepreviousslidewerebeforeimputation.
Sojustslightlydifferentnumbersthere,butverysimilar.
Andyoucanlookandseethedifferencesbetweenregions–I'vejusthighlightedherethelowestandthehighest.
SoweseethelowestproportionsinSub-SaharanAfrica,andthehighestinEurope.
21ASIMPLEMEASURETOSAVELIVES#checkyourpressureTOTALWITHHYPERTENSION–NOTONMEDICATIONRegionTotalwithhypertensionPercentageSouthAsia5694818.
0%EastAsia3826915.
4%South-EastAsia&Australasia5197521.
5%Americas2254316.
6%Sub-SaharanAfrica2514118.
0%NorthernAfricaandMiddleEast1668419.
5%Europe1272621.
3%Worldwide22428518.
3%[Tom]Nowifwewanttocompareofpeoplewhoarenotonmedication.
SoIsupposeoneproblemwehave,isindifferentsiteswe'llhavedifferentnumbersofpeopleonmedicationpartlybasedonwheretheirscreeningsiteswere.
Ifyourecordpeople'sbloodpressuresinahospital,it'smorelikelyyou'regoingtofindpeopleonmedication.
Sowhatwe'vedoneisstratifypeoplebasedonwhetherthey'reonmedication.
Ifwelookat,ofwhoaren'ttakingmedication,howmanyarefoundtohaveraisedbloodpressure,Ithinkthey'reremarkablysimilaracrossthedifferentregionsintheworld.
Overall,18%werefoundtohavehighbloodpressure,anditrangesfrom15.
4%inEastAsiato21.
5%inSouth-EastAsiaandAustralasia.
Relativelysimilarinnumbers.
22ASIMPLEMEASURETOSAVELIVES#checkyourpressureTOTALWITHUNCONTROLLEDBP(ONTREATMENT)RegionTotaluncontrolledPercentageSouthAsia2229029.
6%EastAsia2034536.
8%South-EastAsia&Australasia2674051.
3%Americas2111839.
1%Sub-SaharanAfrica683654.
9%NorthernAfricaandMiddleEast326941.
4%Europe1061651.
1%Worldwide11121440.
0%[Tom]Nowifwelookatpeoplewhoareonmedication,sowe'relookingatthecontrolratesforbloodpressure,weseesomemorevariabilitybetweenregions.
Sointotal,wefindthat40%areuncontrolled.
Whichmeansthat60%,sohigherthanweprobablyexpected,60%ofpeoplearecontrolledofthoseontreatment.
Andthisrangesfromalmost30%inSouthAsiaupto55%uncontrolledinSub-SaharanAfrica.
Soquiteawiderangeofcontrolratesacrosstheworld.
23ASIMPLEMEASURETOSAVELIVES#checkyourpressureKEYPROPORTIONSFORTHOSEWITHHYPERTENSIONRegionProportionwithhypertensionProportionofhypertensivesawareProportionofhypertensivesonmedicationProportionofthoseonmedicationwithcontrolledBPProportionofallhypertensivescontrolledSouthAsia33.
8%59.
5%56.
9%70.
4%40.
0%EastAsia30.
7%64.
0%59.
1%63.
2%37.
3%South-EastAsia&Australasia35.
4%50.
8%50.
1%48.
7%24.
4%Americas40.
4%76.
7%70.
6%60.
9%43.
0%Sub-SaharanAfrica24.
8%43.
6%33.
1%45.
1%15.
0%NorthernAfricaandMiddleEast26.
3%35.
7%32.
1%58.
6%18.
8%Europe41.
6%71.
0%62.
0%48.
9%30.
3%Worldwide33.
4%59.
5%55.
3%60.
0%33.
2%[Tom]I'mawarethere'slotsofnumbersonthistable,andthisissimilartothetablewepublishedforthe2018results.
Butthisgivesallthekeyfigures.
Sothecolumnontheleftistheonewe'vealreadydiscussed,proportionswithhypertension,soIwon'tgooverthatoneagain.
Butwehaven'tmentionedawarenessacrossthedifferentregions,butifwecompare,we'vegotawiderangeofresultsforawareness,so76%inAmericas,35%inNorthernAfricaandMiddleEast.
Overall,about60%ofthosewithhypertensionwereawareofhavinghypertensionworldwide.
AndfinallyIwanttocommentonthelastcolumn,whichistheproportionofallhypertensivescontrolled,andyoucanseethatonly33%worldwidearecontrolled.
Sothevastmajorityofhypertensivesareuncontrolled.
Again,we'vegotawiderangeindifferentcountriesfromjust15%inSub-SaharanAfricato43%intheAmericas.
Soawiderangeofthetotalnumberscontrolled.
24ASIMPLEMEASURETOSAVELIVES#checkyourpressureMMM18GLOBALSUMMARY1.
5millionscreenedOver220000withraisedBP(18.
3%)Over110000withuncontrolledBP(40.
0%)89countriesOfthoseuntreatedOfthosetreated123Over200000unawareofraisedBP(40.
5%)Ofthosewithhypertension4[Tom]Sojusttosummarisetheresults,ifwecompareto2017,we'venowscreened1.
5millionin89countries,somorescreeneesinmorecountries.
Wedetectedover220,000peoplewithraisedbloodpressure,ofpeoplenotontreatment,theproportionissimilartowhatwefoundin2017.
Andtheuncontrolledrates,sopeoplewhoareontreatment,was110,000,slightlylowerthanwefoundin2017.
Socontrolrateswereslightlybetterin2018.
Andfinally,awareness.
Wefound200,000peoplewereunawareoftheirraisedbloodpressure.
Sothat'speoplewhohavehypertension,40%wereunawareofhavingit.
Thosearethekeyresultsfor2018.
25ASIMPLEMEASURETOSAVELIVES#checkyourpressureASIMPLEMEASURETOSAVELIVES#checkyourpressureKEYASSOCIATIONS[Tom]We'regoingtocommentbrieflyonsomeoftheassociationswe'veseen.
26ASIMPLEMEASURETOSAVELIVES#checkyourpressureMEASURESOFASSOCIATION:AGEANDGENDERExcludingthoseonmedication[Tom]We'vegotsuchavastdatabasehere,wecanreallylookatdatabasesinmultiplesubgroups.
Thesehaveonlybeenadjustedforageandgenderandmedication,butthere'salotmorewecandowhichwe'lltalkaboutlateron.
Hereyoucanseethetrendinbloodpressurewithage.
Systolictendstogoup.
Males,whichistheblueline,haveaslightlyhighersystolicbloodpressure.
Womenovertakemenataroundtheageof75,whichisfairlyconsistentwithwhatwesawbeforeandwhatotherstudieshaveshown.
Withthediastolic,youseethisU-shapedcurve,wherethediastolicbloodpressurepeaksaroundtheageof55to60,andthenslowlyplateausorthereisaslightdeclinethere.
27ASIMPLEMEASURETOSAVELIVES#checkyourpressureMEASURESOFASSOCIATION:COMORBIDITIES[Tom]Wecanlookatcertaincomorbiditiesandweseethepeoplewhowereknowntohavehypertension,whichisattheverytop.
Sothediastolic,whichisthebluecircle,relativelysmaller,andthediastolictendstobeaboutfourhigher,andthesystolic,whichisthereddot,tendstobeatsevenmillimetresofmercuryhigher.
Andyou'vealsogottheconfidenceintervalsoneitherside,andbecausewehavesomuchdatahere,we'vegotquiteahighdegreeofprecisionintermsoftheestimates.
Andyoucanseethatthosewithdiabetes,MI,andpreviousstroketendtohaveslightlylowerbloodpressures,unexpectedly,andwe'renotentirelysurewhythatmightbe.
Itcouldbethatsomeofthesepeopleareonmedication-theymaybeonabetablocker,forexample,whichisn'tcodedasbeingonananti-hypertensive.
Itmaybethatthesepeoplearecontrolledbetter,they'remoreaggressivelytreated,andthat'saccountingforthelowerrates.
Neil,doyouhaveanyothersuggestionsonwhywemightseethis[Neil]Wellit's,asyousayTom,wecan'tbecertain,anditmayreflect–thisisso-calledascertainmentbias-thesortpeoplewhocometogetitcheckedmaybeconcerned,theymaybethetypeofpersontakestheirtabletsverycarefullyandlooksafterthemselves.
Anditmaybethatsomeoftherecordingofanti-hypertensiveagents,forexample,ACE-inhibitors–peoplethataregivenanACE-inhibitorarenotnecessarilybecauseoftheirraisedbloodpressure,sothepatientsdon'tknowthat.
Sothatmaybe,Isuppose,abiasinhowwecollectedthedata.
Anditisn'texactlywhatwefoundin2017either,isitSothere'ssomevariabilityinhere.
Thesearecomparedwithnormotensivesinthepopulation,isthatrightTomOrhowdoesthis…[Tom]These,sorry,arecomparedto,soifwetakediabetesasanexample,it'sdiabetescomparedtonon-diabetes,yes.
[Neil]Sotheanti-hypertensivemedication-thosewhoareonthathavegotmuchhigherthanthosewhoarenottakinganti-hypertensivemedication.
[Tom]Yes,theyhave.
Although,thisisbecausethosepeople,bydefinition,havehypertensionareonitforareason,soit'sslightly,it'snotaprobablyafaircomparison,inaway.
[Neil]No,butitreflectsthefactthatthebloodpressuresaren'tcontrolledwellenough.
[Tom]Exactly,itdoes,yeah.
Soideally…[Neil]They'renotbeingturnedintonormotensivepeople.
[Tom]No.
Sotherestillremainsthatgapintreatment.
[Neil]Wementionedearlieraboutcontrol,aboutbeing140/90,andeveryonewillbeconsciousof,firstofall,theAmericannewdefinitionofhypertension,whichIdon'tthinktheEuropeanshaveaccepted-Idon'tthinktheywill-andweshouldstickwiththatthreshold,Ithink,of140/90.
Thecontrolthathasintheguidelinesprettymuchcomedown,andthat'ssomethingthatinfutureyears,Ithinkwe'llpresentcontrolat140/90,becausethat'sthefirstthingweneedtodo,butthenalsocontrolat130/80insubsequentanalyses.
[Tom]We'recurrentlydoingfurtheranalyseslookingatsubgroupsfordiabetes,MI,andstroke.
Sohopefullywe'llbeabletoseeinmoredetailwhythisdifferencethatweseeinthisgraphoccurs.
28ASIMPLEMEASURETOSAVELIVES#checkyourpressureMEASURESOFASSOCIATION:PARTICIPANTCHARACTERISTICS[Tom]Wecanlookatothercharacteristicsofthoseparticipants.
Ijustwanttohighlightalcohol.
We'vegotthreelevels:eitherpeopledon'tdrinkatall,theydrinkonetothreetimespermonth,oroneormoretimesperweek.
Weseeafairlydose-dependentincreaseinbloodpressurebasedonalcoholintake.
Soifyou'redrinkingmorethanoneaweek,yourdiastolicandsystolicareovertwomillimetreshigher.
Soarelativelysmalldifference,butitisthere,anditisdose-dependent.
[Neil]Younoticealsothere,theleftarmversustherightarm.
Weshowedthatlasttime.
Wehaven'tmadeabigdealaboutitthistime,butagain,it'sasmalldifference,butit'shighlysignificant.
Andthisisabouttherightarmmeasurementstendstobehigherthantheleftarmmeasurements.
Possiblyreflectingthesizeoftherightarm-morepeopleareright-handedthanleft-,thereforetheirrightarmtendstobebiggerthereforethebloodpressuresare,whereaswementioninthe2017publication,therearealsopotentialanatomicalexplanationswhichwementionedinthere.
Andtheotherstuffthatgivesconfidenceinthedata,inpregnancy,asyouexpect,thebloodpressuresarelowerinpregnantwomencomparedtothosenon-pregnantstandardizedfortheothervariables.
[Tom]Justcomingbacktoarm.
Mostguidelineswouldrecommendyousticktoasinglearmwhenyou'retakingthebloodpressurereadingsifthat'spossible.
[Neil]Yes.
Ithinkinanidealworld,youmeasureitinboth,andifthere'sabigdifference,youshouldusetheonethat'shigher.
Intherealworldoutthere,Idon'tthinkmanypeopledothat.
Perhapstheyshouldinhypertensionclinics,butIdon'tthinktheydo.
[Tom]Ittendstobebasedonwhereyourtableandchairis.
[Neil]Yeah,absolutely.
29ASIMPLEMEASURETOSAVELIVES#checkyourpressureMEASURESOFASSOCIATION:BODYMASSINDEX[Tom]SonowlookingatBMI,weseeaverystronglinearrelationshipbetweenbothsystolicanddiastolic.
Sosystolicishereinthered,anddiastolicintheblue.
SothesearethestandardWHOcategoriesofBMI,andyouseequitelinearrelationshipsherewithweight.
[Neil]That'sextraordinaryisn'tit,becauselotsofthesedata,theBMI,aproportion-Ican'trememberwhatproportion-wereestimated.
Theseweren'tjustnecessarilymeasured,wedidn'thavethecapacityinallthesitestomeasureheightandweight.
Sosomeoftheseareestimated,anddespitethat,youseethatabsolutelysuburblinearrelationship,whichgivesyoualotofconfidenceinthedatathatarebeingcollected.
Soit'sabigthankyoutoeverybody,again.
Thishighlightswhatexcellentdataisbeingcollected.
[Tom]Itis,andwediddoacomparisonofthosethatwereestimatedcomparedtothosethatweremeasured,andtherewasnodifference.
SotheBMIsthatwereestimatedwereveryaccurate.
30ASIMPLEMEASURETOSAVELIVES#checkyourpressureMEASURESOFASSOCIATION:SITEOFMEASUREMENT[Tom]Anewfactorthatwelookedatin2018waswherethebloodpressuresweremeasured.
We'vegotarangeofbloodpressureshereaccordingtothedifferencesiteofmeasurement,andifyourememberfromearlier,aboutonethirdweretakeninthehospitalorclinicsetting,sowe'veusedthatasthebaseline.
Andthepharmaciestendedtohavethelowestbloodpressuresoutofallthesites,andworkplacesthehighest.
Again,whatexplainsthis,well,coulditbeworkrelatedstress-peopleatworkaremorestressedandtheirbloodpressure'sslightlyhigher.
Pharmacies,notsurewhatthatcouldbebutitcouldbethatpeopletendtobemorerelaxed,possibly,orit'sreflectingthetypeofparticipantswhoaregoingtothesesites.
[Neil]Ithinkwecouldlookatthepulseratescouldn'tweoftheworkplacemeasurementsandseeifthat'sdifferent.
Wecouldlookat-asyou'llsee,there'sassociationwiththepulserate,sothat'ssomethingwecouldlookat.
[Tom]Certainly,andwehavecollectedthatdataaswell.
31ASIMPLEMEASURETOSAVELIVES#checkyourpressureMEASURESOFASSOCIATION:HEARTRATE[Tom]Soifwecomeontothisnextslide,wecanseetheassociationofheartratewithbloodpressure.
Inthebluewe'vegotthediastolicandtheredisthesystolic.
Sowithdiastolic,youseeaverystraightlinebetweenthebloodpressureandheartrate.
Whereasforsystolic,moreunusuallyyouseethisU-shapedcurve.
Sobloodpressureisslightlylowerinthe60to69heatratecategorycomparedtotheunder60s,andagain,we'renotentirelysurewhythatmightbe,butthisisbasedonahugeamountofdata.
Wedoneedtothinkseriouslywhythatmightbe.
Itcouldbethatsomepeopleareon,again,onmedicationsthatarenotaccountedfor,suchasabeta-blocker.
Otherwisewe'renotsurebasedonthephysiologywhatmightexplainthis.
[Neil]No,we'dloveanygoodthoughtsfromanybodyabouthowtoexplainthisaway,butIthinkifyou'daskedmetoguessbefore,Iwouldhavesaidtheassociationwithsystolicwouldbemuchstrongerthanwithdiastolic.
Notleastbecauseofthewaydiastolicvarieswithageinmostcountries,goingdownasyougetolder,overtheageofabout55or60.
Sothat'sarealsurprisetous,andwe'regoingtobeworkingonthat.
We'velookedattheliterature,wecan'treallyexplainit,butit'ssomethingwe'regoingtolookatanditwillbeinterestingtoseethe2019data,ifitreaffirmsthat.
32ASIMPLEMEASURETOSAVELIVES#checkyourpressureMMMPUBLICATIONSGlobalMMM17http://www.
thelancet.
com/journals/langlo/article/PIIS2214-109X(18)30259-6/fulltextGlobalMMM18https://academic.
oup.
com/eurheartj/article/40/25/2006/5481538MMM17Supplement:39nationalpapersfromthetopMMMcountrieshttps://academic.
oup.
com/eurheartjsupp/issue/21/Supplement_D[Neil]Okay,sothat'sagreatsummaryfromTomonwhatwedidin2018andtheresultsyoucollected.
Justtobringyouuptospeedonthepublications.
Goingbacktoourfirstmajorpublicationoftheresults,wasinTheLancetGlobalHealth,whichyou'llappreciateisahighimpactjournal.
Weweredelightedtogetourselvespublishedthere.
Beforethestudybegan,wehadacoupleofpublications,oneintheJournalofHypertension,oneinTheLancet,sortofannouncingtheprojectcomingthrough.
ButthatwasthefirstresultspaperinTheLancetGlobalHealth.
TheequivalentpaperforMMM18appeared,IthinkonMay1st,intheEuropeanHeartJournalthisyear.
Anditalsowasfeaturedonthecoveroftheprintedjournal,andweweredelightedthatthatwentaround.
Italsogotaneditorialwithsomeinterestingcommentsabouttheproject.
Goingbackto2017,thetop40countrieswereinvitedtojoinin-thosethathadscreenedatleasttwoandahalfthousandpatientswereaskedtojoinin-thesupplementsizebeingthedeterminantofthat.
And39ofthose40countriesagreedtoproduceanationalpaper.
ThatappearedintheEuropeanHeartJournalSupplement,andthatcameoutthisyear,onceagain,thisyear.
Yeah,beginningofthisyear.
Justtoletyouknowforthefuture,we'relookingforwardtodoingthesamethingfortheMMM18supplement.
That'sgoingto,onthenextslide,Ithinkwesee…33ASIMPLEMEASURETOSAVELIVES#checkyourpressureNEXTTARGETSFORMMM:MMM18NationalPapersSupplementMMM17,MMM18,MMM19combinedglobal/nationalpaper(s)Othersub-groupanalysesContinuetoincreaseawarenesswithMMM20UseMMMdatatocreateaguidancedocumentforpolicyinfluencewhereitismostneeded[Neil]TheMMM18NationalPapersSupplement,thoseanalysesareinprogress.
We'reindiscussionwiththeEuropeanHeartJournalSupplementsagain.
They'reverykeentohousethesedata,sothat'swhatwe'redoing,andonceagain,Ithinkwe'regoingtogoforthecountriesthathavescreenedatleasttwoandahalfthousand.
Atthatlevel,Ithinkthere'sabitmorerobustnessabouttheanalyses.
We'realsoconsciousofthefactthatyoumayhavetakenpartinMMM17,and18,and19,andeachyearfallenbelowthetwoandahalfthousandmark,butcombiningthosedatawouldgiveyouprobablygiveyouahugenumbercomparedwithanythingelsethat'sarisenfromyourcountry.
Sowe'retalkingaboutifyouoranybodyelseinyourcountryfeelsthattheywouldliketodoacombinedpaper,wherewegetreasonablenumberstogetherbycombiningyears–'17and'18,or'17,'18and'19,oracombination–thenthosepublicationsareagoodideaandwewouldbekeentofostersupportforthoseintermsofprovidingthetemplateandreviewingthemthroughtheInternationalSocietyofHypertension.
Atthemomentwe'vegotseveralsubgroupanalysesgoingonbasedonthedatabasefrom'17and'18.
We'relookingatthosewho'vehadmyocardialinfarction,secondlythosewho'vehadstrokes.
We'relookingattheassociationbetweenstrokemortalityinthecountriesinvolved,andsomeoftheMMMdatatoseeiftheycorrelatewhichofcourse,iftheydo,addsgreatstrengthtoour…Well,itfendsoffsomeofthecriticism,whichhasallbeenperfectlyreasonable,thatthesearenotnecessarilyrepresentativesamples.
Bydesign,theywerenotsupposedtoberepresentativesamples.
Butifweseeanassociationbetweenstrokemortalityandsomeofthedatawe'repickingupinMMM,thenthat'sveryimportantbitsofinformationandwillhelpustousethedatatoinfluencepolicy.
Sointhemeantime,wewanttocontinuetoincreaseawarenesswithanothersurvey,anMMM20.
Andfromourpointofview,wewantthistocarryonaslongaswecangetsupporttodoso.
Andthenobviouslykeyinthis,asyouwillhaveseenfromoneofourearlierslides,theultimateaimistousethesedatatochangepolicyandwehopeverymuchtoraisemoneytogetmeetingstogethertobeabletoproducedocumentstohelpsitesandcountriesinfluencethepolicywithintheircountriestogetbetterscreening,bettermanagementofbloodpressure.
34ASIMPLEMEASURETOSAVELIVES#checkyourpressureASIMPLEMEASURETOSAVELIVES#checkyourpressureTHANKYOUForfurtherinformationvisitwww.
maymeasure.
comorcontactmanager@maymeasure.
com[Neil]Sothatbringsustotheend,andI'dliketojuststartbysayingabigthankyoutoallofyou,again.
Justwithoutyourhugeefforts,volunteersfromallovertheworld,noneofthiscouldhappen.
AlittlebitofalocalspecialthankyoutothewholeMMMteam,andtoTomandhisteamofstatisticians,volunteerstatisticians-therearefourorfivewhosupportTomandpullallthistogether.
Ithinkifyoulookbackover2017,aquarterofamillionpeopleweredetectedeitheruntreatedhypertensiveorinadequatelytreatedhypertensive.
2018,onethirdofamillionwereeitheruntreatedorinadequatelytreatedhypertension,thatwefound.
Soover580,000peoplehavebeendetected,inadequatelytreatedoruntreatedinhypertension,andwedon'tknowyetournumbersfor2019.
We'reprettyclosetogettingallthedatain,andwe'llknowwithinafewweeks.
Sothisisahugeachievement.
IfyoulookedattheBMJrecently,itshowedinarelativelysmallnumberinChina,thatjusttellingpeopletogoandgettheirbloodpressuressortedoutsomewhereelse,andgivethemsomeadviceofnon-pharmacologicalmeasure,thatmadeabigdifferencetobloodpressures-aboutsixmillimetres,abigdifference.
Andthat'swhatwe'redoingallaroundtheworld,hitherto'17and'18,on580,000people.
SoIthinkthere'sarealneedtokeepthisgoing,ifforlotsofotherreasons,whichwecouldgointo.
SoIhopeyouwilltakepartin2020.
Whatwe'dliketohearfromyouishowwemightdoitbetter.
ArethereanyspecialquestionsweshouldaddBearinmindthedatabasehasgottobekeptsmall,wecan'texpandit.
Allyouinvestigatorsfedthatbacktousthatwehavetotryandkeepthequestionsthatweasklimited.
Soifyou'regoingtoaddaquestion,suggestonethatyouthinkwemightdrop.
Howmightwedothiswholethingbetterin2020andsubsequentyearsWellobviously,ifwecouldgetmoremoneytosupportyou,tosupportyourvolunteers,toprovidesomeinfrastructurelocallyandwe'retryingveryhardtodothat.
Onethingyoumightwanttoaskusis,oftheanalyseswe'vedone,arethereanynewonesthatyoucanthinkofthatweshouldbedoingGiveusyourthoughtsonthat,ifyou'vegotany.
Andindeed,anyotherconcernsthatyou'vegotaboutwhatwe'vedonesofar,orhowwe'redoingit,wewouldliketohearbackfromyou.
Obviously,itwouldbegreattobeface-to-face.
Wecan'tdothat,becauseoffunding.
Ifwegetthatfunding,wewilldothat.
Finally,IshouldmentionthattheBritishHeartFoundationputoutacallcalledtheBigBeatChallenge,andyouhadtoputinanapplicationbymid-Junethisyear.
We'vedonethatonbehalfofMayMeasurementMonth,andit'sa30-million-poundgrantfromtheBHF.
We'vegoneinforthat.
Wewillhearwhetherwe'reshortlistedattheendoftheyear.
Myguessisthatwemaynotbe.
Therearelotsofcompetition.
Butifweareshortlisted,thenwe'vegotsixmonthstotakethingsontothenewerlevelandthatwillgeneratelotsoffundingtomakesureeachannualsurveyisproperlyfunded.
Andweappreciatethatitisn'tatthemoment.
Sothatjustbringsmebacktosaying,onceagain,thankyou.
Thankyouforyourhugeefforts.
It'sbeenanincrediblyexcitingjourneystartingthisthingoffinOctober2016towherewearenow.
Thankyoutoeverybody,andIhopethishasbeenausefulsessionbringingyouuptodatewithMMM.
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