Catherine O. Johnson’s research while affiliated with Institute for Health Metrics and Evaluation and other places

Background Pulmonary arterial hypertension (PAH) is a vascular disease characterised by restricted flow and high pressure through the pulmonary arteries, leading to progressive right heart failure and death. This study reports the global burden of PAH, leveraging all available data and using methodology of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to understand the epidemiology of this under-researched and morbid disease. Methods Prior to the current effort, the burden of PAH was included in GBD as a non-specific contributor to “other cardiovascular and circulatory disease” burden. In this study, PAH was distinguished as its own cause of death and disability in GBD, producing comparable and consistent estimates of PAH burden. We used epidemiological and vital registry data to estimate the non-fatal and fatal burden of PAH in 204 countries and territories from 1990 to 2021 using standard GBD modelling approaches. We specifically focused on PAH (group 1 pulmonary hypertension), and did not include pulmonary hypertension groups 2–5. Findings In 2021, there were an estimated 192 000 (95% uncertainty interval [UI] 155 000–236 000) prevalent cases of PAH globally. Of these, 119 000 (95 900–146 000) were in females (62%) and 73 100 (58 900–89 600) in males (38%). The age-standardised prevalence was 2·28 cases per 100 000 population (95% UI 1·85–2·80). Prevalence increased with age such that the highest prevalence was among individuals aged 75–79 years. In 2021, there were 22 000 deaths (18 200–25 400) attributed to PAH globally, with an age-standardised mortality rate of 0·27 deaths from PAH per 100 000 population (0·23–0·32). The burden of disease appears to be improving over time (38·2% improvement in age-standardised years of life lost [YLLs] in 2021 relative to 1990). YLLs attributed to PAH were similar to estimates for conditions such as chronic myeloid leukaemia, multiple sclerosis, and Crohn's disease. Interpretation PAH is a rare but fatal disease that accounts for a considerable health-associated burden worldwide. PAH is disproportionally diagnosed among females and older adults.

Introduction: Heart failure (HF) mortality rates in the US appear to have increased in the past decade. It is unknown how these have changed in recent years by racial and ethnic groups within states. Research Question: To understand disparities in HF mortality patterns between 1990 and 2020 Aim: To estimate the change in HF mortality rates between 1990 and 2020 for Hispanic, non-Hispanic Black, and non-Hispanic White males and females in each US state Methods: We used multiple cause of death records from the National Vital Statistics System and population data from the National Center for Health Statistics to estimate HF mortality from 1990 to 2020 by state, age group, sex, and racial and ethnic group. A binomial model was fit to the data using RegMod, a Bayesian extension of a generalized linear model which incorporated priors from a hierarchy and modeled year as a spline. Results: In 2020, we estimated 566230 (95% UI 566160 to 569740) deaths due to HF. Between 1990 and 2010, HF rates declined in general for all racial and ethnic groups across the US, but not consistently for all states (Figure). From 2010 to 2020, this trend reversed, with age-standardized mortality from HF increasing over this time period, but again this change was not consistent across states. Among the Hispanic population, mortality increased for all states except for Maine, with the largest change for both sexes in Oklahoma. For the non-Hispanic, Black group, mortality increased among all states, with the largest change for both sexes in Oklahoma and South Dakota. Among the non-Hispanic, White populations, mortality decreased for both sexes in District of Columbia, while the largest increases were in Oklahoma. Conclusion: Heart failure mortality increased in the past decade, with striking increases in specific locations by race and ethnic group. Identifying etiologies and drivers of increased HF deaths, including the role of new therapies for subsets of systolic function, could help target novel therapies to subpopulations at highest risk. Differences in trends by state and race and ethnicity groups provides important information for clinicians and policymakers interested in reducing mortality rates.

Up-to-date estimates of stroke burden and attributable risks and their trends at global, regional, and national levels are essential for evidence-based health care, prevention, and resource allocation planning. We aimed to provide such estimates for the period 1990–2021. We estimated incidence, prevalence, death, and disability-adjusted life-year (DALY) counts and age-standardised rates per 100 000 people per year for overall stroke, ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage, for 204 countries and territories from 1990 to 2021. We also calculated burden of stroke attributable to 23 risk factors and six risk clusters (air pollution, tobacco smoking, behavioural, dietary, environmental, and metabolic risks) at the global and regional levels (21 GBD regions and Socio-demographic Index [SDI] quintiles), using the standard GBD methodology. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. In 2021, stroke was the third most common GBD level 3 cause of death (7·3 million [95% UI 6·6–7·8] deaths; 10·7% [9·8–11·3] of all deaths) after ischaemic heart disease and COVID-19, and the fourth most common cause of DALYs (160·5 million [147·8–171·6] DALYs; 5·6% [5·0–6·1] of all DALYs). In 2021, there were 93·8 million (89·0–99·3) prevalent and 11·9 million (10·7–13·2) incident strokes. We found disparities in stroke burden and risk factors by GBD region, country or territory, and SDI, as well as a stagnation in the reduction of incidence from 2015 onwards, and even some increases in the stroke incidence, death, prevalence, and DALY rates in southeast Asia, east Asia, and Oceania, countries with lower SDI, and people younger than 70 years. Globally, ischaemic stroke constituted 65·3% (62·4–67·7), intracerebral haemorrhage constituted 28·8% (28·3–28·8), and subarachnoid haemorrhage constituted 5·8% (5·7–6·0) of incident strokes. There were substantial increases in DALYs attributable to high BMI (88·2% [53·4–117·7]), high ambient temperature (72·4% [51·1 to 179·5]), high fasting plasma glucose (32·1% [26·7–38·1]), diet high in sugar-sweetened beverages (23·4% [12·7–35·7]), low physical activity (11·3% [1·8–34·9]), high systolic blood pressure (6·7% [2·5–11·6]), lead exposure (6·5% [4·5–11·2]), and diet low in omega-6 polyunsaturated fatty acids (5·3% [0·5–10·5]). Stroke burden has increased from 1990 to 2021, and the contribution of several risk factors has also increased. Effective, accessible, and affordable measures to improve stroke surveillance, prevention (with the emphasis on blood pressure, lifestyle, and environmental factors), acute care, and rehabilitation need to be urgently implemented across all countries to reduce stroke burden.

Background: Up-to-date estimates of stroke burden and attributable risks and their trends at global, regional, and national levels are essential for evidence-based health care, prevention, and resource allocation planning. We aimed to provide such estimates for the period 1990–2021. Methods: We estimated incidence, prevalence, death, and disability-adjusted life-year (DALY) counts and age-standardised rates per 100 000 people per year for overall stroke, ischaemic stroke, intracerebral haemorrhage, andsubarachnoid haemorrhage, for 204 countries and territories from 1990 to 2021. We also calculated burden of stroke attributable to 23 risk factors and six risk clusters (air pollution, tobacco smoking, behavioural, dietary, environmental, and metabolic risks) at the global and regional levels (21 GBD regions and Socio-demographic Index [SDI] quintiles), using the standard GBD methodology. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. Findings: In 2021, stroke was the third most common GBD level 3 cause of death (7 ·3 million [95% UI 6·6–7·8]deaths; 10·7% [9·8–11·3] of all deaths) after ischaemic heart disease and COVID-19, and the fourth most common cause of DALYs (160·5 million [147·8–171·6] DALYs; 5·6% [5·0–6·1] of all DALYs). In 2021, there were 93·8 million(89·0–99·3) prevalent and 11·9 million (10·7–13·2) incident strokes. We found disparities in stroke burden and riskfactors by GBD region, country or territory, and SDI, as well as a stagnation in the reduction of incidence from 2015onwards, and even some increases in the stroke incidence, death, prevalence, and DALY rates in southeast Asia, eastAsia, and Oceania, countries with lower SDI, and people younger than 70 years. Globally, ischaemic stroke constituted65·3% (62·4–67·7), intracerebral haemorrhage constituted 28 ·8% (28·3–28·8), and subarachnoid haemorrhage constituted 5·8% (5·7–6·0) of incident strokes. There were substantial increases in DALYs attributable to high BMI(88·2% [53·4–117·7]), high ambient temperature (72·4% [51 ·1 to 179·5]), high fasting plasma glucose (32 ·1%[26·7–38·1]), diet high in sugar-sweetened beverages (23 ·4% [12·7–35·7]), low physical activity (11 ·3% [1·8–34·9]), high systolic blood pressure (6·7% [2·5–11·6]), lead exposure (6·5% [4·5–11·2]), and diet low in omega-6polyunsaturated fatty acids (5·3% [0·5–10·5]). Interpretation: Stroke burden has increased from 1990 to 2021, and the contribution of several risk factors has also increased. Effective, accessible, and affordable measures to improve stroke surveillance, prevention (with the emphasis on blood pressure, lifestyle, and environmental factors), acute care, and rehabilitation need to be urgently implemented across all countries to reduce stroke burden.

High systolic blood pressure (SBP) is the leading preventable global health risk. As part of the Global Burden of Disease Study 2021, we quantify the SBP-associated burden (relative to a theoretical risk exposure level of 105-115 mmHg) among adults over 25, by age and sex, for 204 countries from 1990 to 2021. Standard GBD Bayesian methods were used to estimate SBP mean, standard deviation and corresponding distribution from 1,116 studies. Meta-analyses of 70 randomized controlled trials and cohorts were used to estimate the relative risks for seven outcomes: ischemic heart disease (IHD), stroke, chronic kidney disease (CKD), atrial fibrillation, aortic aneurysm, peripheral arterial disease (PAD) and hypertensive heart disease. Then, the population attributable fraction and SBP attributable burden were computed with 95% uncertainty intervals (UI). In 2021, 10.9 million deaths (9.2-12.5 million) and 225 million (190 - 259 million) disability-adjusted life years (DALYs) were attributable to elevated SBP worldwide, a decrease, since 1990, of 32% and 30% in age-standardized rates, respectively. In 2021, high SBP accounted for 7.8% of total DALYs; 49.9% (40.6 - 58.2%) of DALYs due to IHD; 57.3% (42.7-68.4%) due to stroke; 24.8% (13.0-36.1%) due to CKD; 30.1% (10.7-47.6%) due to atrial fibrillation; 17.1% (12.9-21.4%) due to aortic aneurysm; 13.0% (2.7-23.8%) due to PAD and 100% of the DALYs due to hypertensive heart disease. Globally, the burden attributable to SBP was higher in men than in women (3,162.9 [2,654.8-3,666.4] vs 2,167.3 [1857.4 -2510.9] age-standardized DALYs per 100,000). Age-standardized DALYs attributable to high SBP were highest in Central Asia and Eastern Europe, rates above six thousand per 100,000. The lowest levels were observed in high-income Asia Pacific, Australasia and Western Europe with less than 1000 DALYs per 100,000. Despite a decrease in age-standardized rates since 1990, high SBP remains a major global health risk with considerable regional variations. Targeted interventions are crucial to address these disparities and reduce SBP-related health impacts.

Background and Objective Hypertension frequently coexists with other chronic conditions and cardiometabolic risk factors. The identification of comorbidities is key in the management of hypertensive patients. May Measurement Month (MMM) is a global initiative aimed at enhancing the detection and awareness of hypertension. This study analyzes data from MMM collected between 2017 and 2019 to evaluate hypertension control among adults aged 18 years and the frequency of comorbidities. Methods Three sitting blood pressure (BP) readings, anthropometric measurements, and self-reported history of diabetes, myocardial infarction and stroke were collected. Missing BP readings were inputted using multiple imputation based on available BP measurements and sociodemographic variables. Hypertension was defined as an average systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or taking antihypertensive medication. Hypertension treatment was defined as current medication use; control was defined as BP <140/90 mmHg. Results Among 2,907,848 participants from 95 countries, 34.2% had hypertension, and 12.1% had a history of at least one other chronic condition. Specifically, 8.3% self-reported type 2 diabetes, 4.5% had experienced myocardial infarction, and 2.9% had a history of stroke. Some individuals had multiple comorbidities at the time of the screening: 6% had both myocardial infarction and type 2 diabetes, 8% had myocardial infarction and stroke, 2% had stroke and type 2 diabetes, and 8% had all three comorbidities. Among those with hypertension, 58.9% were on medication and 24.0% had at least one additional comorbidity, specifically, 15.8% reported type 2 diabetes, 8.8% had experienced myocardial infarction, and 5.5% had a history of stroke. Of those with hypertension on medication, 43.1% were controlled. Among treated individuals, hypertension control rates were higher in individuals with comorbidities (50% vs 30%). Conversely, individuals without comorbidities had poorer hypertension control. Conclusions The data suggest a high prevalence of comorbidities within the screened population and among individuals diagnosed with hypertension. Additionally, individuals without comorbidities exhibited suboptimal hypertension management.

Background Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions. Funding Bill & Melinda Gates Foundation.

Objective To evaluate adult (>18 years) hypertension awareness, treatment, control, and comorbidities using three years of May Measurement Month (MMM) data (2017-2019). Design and method Up to three sitting blood pressure (BP) readings as well as lifestyle and comorbidity data (self-reported diabetes, myocardial infarction, stroke and overweight/obesity) were collected from participants. Missing BP readings were imputed through multiple imputation, leveraging available BP measurements and sociodemographic variables. Hypertension was defined using the average of the second and third BP readings (systolic BP >140 mmHg and/or diastolic BP >90 mmHg or taking antihypertensive medication). For those with hypertension, hypertension awareness was defined as self-report of previous diagnosis or current medication use, while control was defined as BP <140/90 mmHg among people on medication. Logistic regression models were used to analyze lifestyle factors and main comorbidities associated with hypertension awareness, treatment and control. Results Among 2,907,848 participants from 95 countries, 34.2% had hypertension. Among those with hypertension, 60.1% were aware, 57.0% were medicated, 32.0% were controlled and 22.8% had at least one additional chronic condition. Of those with hypertension who were on medication, 57.0% were controlled. Europe had the highest proportion of individuals with hypertension while Sub-Saharan Africa had the lowest awareness, treatment and control rates (Figure 1). Hypertension treatment and control were higher in individuals with comorbidities (Figure 2-3). Adjusting for age, sex and survey year, those with comorbidities were more likely to be aware of their hypertension while participants from low-income countries and smokers were less likely to be aware. Individuals from low-income countries and smokers were less likely to receive treatment, while those with comorbidities were more likely to get treated. Middle-income individuals were more likely to receive treatment but less likely to be controlled than high-income individuals (Figure 3). Conclusions MMM provides a means of measuring hypertension, awareness, treatment, and control rates, particularly in resource-limited countries. Data suggests heterogeneity in awareness, treatment and control and poorer hypertension management in individuals without comorbidities, informing global strategies for improved hypertension prevention, detection and management.