A silent killer or an overrated problem? Epidemiological trends in hypertension, including Poland

THE ESSENCE OF HIGH BLOOD PRESSURE

The main reported components of blood pressure are systolic blood pressure (SBP) and diastolic blood pressure (DBP). SBP refers to the peak pressure in the arteries during the contraction of the heart, when blood is ejected into the systemic circulation. DBP, on the other hand, represents the lowest pressure in the arteries during the heart’s relaxation phase, when the ventricles refill with blood [1]. Hypertension, defined as a persistent elevation of SBP (≥ 130 mmHg) and/or DBP (≥ 80 mmHg), is a pathological condition arising from dysregulation of blood pressure control within the cardiovascular system [2]. The pathophysiological mechanisms underlying these elevated pressures include increased systemic vascular resistance, which strains the arterial walls, and maladaptive neurohormonal responses, particularly involving the renin–angiotensin–aldosterone system (RAAS) [3]. Over time, elevated systolic pressure exerts excessive mechanical stress on the vasculature, contributing to arterial stiffness and atherosclerosis, while high DBP can impede coronary artery perfusion, particularly during the diastolic phase. The chronic elevation of both SBP and DBP significantly increases the risk of adverse cardiovascular events, necessitating early detection and tailored interventions to mitigate long-term damage to vital organs [4].
Hypertension is classified into primary (essential) and secondary forms. Primary hypertension, which accounts for 90-95% of cases, has no identifiable cause and is linked to genetic and environmental factors [5]. Secondary hypertension, less common, results from specific conditions such as renal disease or endocrine disorders, and addressing the underlying cause can often lead to improved blood pressure control [6].
Hypertension is one of the most prevalent global health concerns and a leading risk factor for cardiovascular diseases. The prevalence of hypertension varies depending on region and income. It is estimated that over 1.28 billion adults worldwide suffer from hypertension, with the majority residing in low- and middle- income countries where healthcare systems often face challenges in early diagnosis and effective management (Figure 1) [7].
Despite progress in medical understanding and available treatments, many individuals with hypertension remain undiagnosed or do not have their condition adequately managed [8]. This contributes to high rates of complications such as stroke, heart attack, heart failure, and kidney disease [9]. The global impact of hypertension highlights the importance of coordinated public health initiatives, including raising awareness, implementing preventive measures, and enhancing access to treatment, particularly in under-resourced areas.
The primary objective of this study is to demonstrate that arterial hypertension continues to constitute a significant public health challenge in the 21st century. A further aim of this article is to emphasize that blood pressure can be effectively controlled. This work outlines in detail the preventive measures that should be implemented in order to reduce the risk of developing hypertension.

PRECARIOUSNESS OF HYPERTENSION

Hypertension is influenced by a variety of risk factors, many of which are modifiable through lifestyle and behavioral changes. Physical inactivity is one of the most significant contributors to elevated blood pressure, as regular exercise is well documented to improve cardiovascular health and reduce blood pressure levels [10]. In parallel, overweight and obesity are strongly associated with the development of hypertension, and maintaining a body mass index below 25 is widely recommended to mitigate this risk [11]. Dietary habits also play a crucial role; excessive sodium intake has been linked to increased blood pressure, while potassium supplementation has been shown to have a protective effect by counterbalancing sodium’s hypertensive effects [5]. High cholesterol levels, particularly elevated low-density lipoprotein cholesterol, can contribute to athero­scle­rosis, which in turn raises blood pressure by narrowing the arteries [12]. Furthermore, studies suggest that reducing alcohol consumption, particularly in heavy drinkers, is essential for lowering blood pressure, as excessive alcohol intake is a well-established risk factor for hypertension [13]. Smoking cessation is another important preventive measure, as cigarette smoking not only raises blood pressure acutely but also exacerbates long-term cardiovascular risks [14]. Environmental factors, such as exposure to air pollutants, have also been implicated in increasing the risk of hypertension, likely through mechanisms involving oxidative stress and systemic inflammation [15]. Additionally, psychological and social stressors, including chronic stress, shift work, and transitions such as retirement, have been identified as potential contributors to hypertension [16]. Lastly, genetic predispositions are a key factor in determining an individual’s susceptibility to hypertension, with family history often being a significant predictor of the condition. These diverse factors underscore the complexity of hypertension management and highlight the need for multifaceted interventions to prevent and control elevated blood pressure [17].
In addition to the well-established risk factors for hypertension, there are several other contributors that increase the likelihood of developing elevated blood pressure. One significant factor is age, as the risk of hypertension rises with advancing age due to vascular stiffening and decreased arterial elasticity [18]. Gender also plays a role, with men being more prone to hypertension at younger ages, while postmenopausal women face a higher risk as they age, likely due to hormonal changes [19]. Sleep disorders, particularly obstructive sleep apnea, have been increasingly recognized as a risk factor for hypertension, due to intermittent hypoxia and sleep fragmentation leading to sympathetic nervous system overactivity [20].
Additionally, socioeconomic factors, including low income and limited access to healthcare, may exacerbate hypertension risk by influencing dietary choices, stress levels, and access to preventive medical care. Lastly, excessive caffeine intake, though controversial, has been observed in some studies to cause transient increases in blood pressure, particularly in individuals who are sensitive to its effects [21]. These wide-ranging risk factors highlight the complex interplay of genetic, environmental, and lifestyle elements in the development and progression of hypertension.

HYPERTENSION IN POLAND

Among all European countries, Poland ranks 26th in terms of average blood pressure values ​​in women and men, both in SBP and DBP [22]. According to 2022 data, 11 million people were registered with hypertension in Poland. The condition affects 35.2% of adults (appro­ximately 10.9 million individuals) and 0.4% of children (around 30,700 cases). The highest incidence of registered hypertension was observed in the Podlaskie Voivodeship, whereas the lowest was found in the Pomeranian Voivodeship. In terms of prevalence, the Łódź Voivodeship had the highest rates, while the Lesser Poland Voivodeship recorded the lowest. The highest incidence was observed in the age group of men aged 55-59 years and in women aged 50-54 years. The highest prevalence in both sexes was found in the oldest age group, specifically those over 85 years old [23]. Women comprise the majority of patients with hypertension above 75 years old, due to longer life expectancy [7]. Moreover, according to data from the Polish Forum for Prevention Guidelines on Hypertension, it is estimated that nearly 30% of Poles with hypertension are unaware of their condition. Furthermore, only 26% of patients have their blood pressure properly controlled (Figure 2) [24]. In Poland, the initiative “May Measurement Month,” organized by the International Society of Hypertension, is widely recognized for its aim of screening and potentially identifying hypertension early within the population. In May 2017, a total of 5,834 individuals were tested, with 98.9% being of Caucasian descent. The results revealed that 35.3% of the participants had hypertension, including 20.6% who were not taking any antihypertensive medi­cations. Furthermore, among patients who were receiving treatment, a significant 49.1% had poorly controlled blood pressure [25]. The group most frequently found to have undiagnosed hypertension consisted of younger men with higher levels of education, living in urban areas. This trend suggests that younger, educated men in cities may be less likely to undergo regular medical check-ups or screenings, potentially due to busy lifestyles or a perception of being at lower risk for health issues. Despite their higher educational background, which often correlates with better health awareness, these individuals might not prioritize regular blood pressure monitoring. Urban living could also play a role, as the fast-paced lifestyle and stress associated with city environments might contribute to higher blood pressure, which often goes unnoticed [26]. In Poland, women over 35, often single and with secondary or higher education, are the most aware of hypertension prevention through physical activity. This highlights a correlation between education, health awareness, and proactive cardiovascular health measures, potentially influenced by time availability and long-term health investment [27]. During the COVID-19 pandemic, a decrease in the number of registered cases was noted. The reduction in the number of reported cases in 2020 could likely be attributed to the challenges posed by the COVID-19 pandemic, which significantly disrupted healthcare services. During this period, many medical facilities faced resource constraints, including a shortage of healthcare personnel and reduced access to diagnostic procedures, as the focus shifted towards managing the pandemic. As a result, fewer patients were able to receive timely medical evaluations or routine check-ups, leading to a decline in the number of diagnosed and reported cases [23]. The diseases that most often occur in Poles along with hypertension are: disorders of lipoprotein metabolism, type 2 diabetes mellitus, chronic ischemic heart disease, overweight and obesity, heart failure, chronic kidney disease and atherosclerosis [22, 25]. The Polish Society of Hypertension in 2019 identified the following clinical categories based on blood pressure levels. High-normal blood pressure is defined as 130-139 mmHg systolic and 85-89 mmHg diastolic. Stage 1 hypertension is cate­gorized by systolic values of 140-159 mmHg and diastolic values of 90-99 mmHg. Stage 2 hypertension is 160-179 mmHg systolic and 100-109 mmHg diastolic. Stage 3 hypertension is diagnosed when blood pressure levels reach or exceed 180 mmHg systolic or 110 mmHg diastolic [1, 28]. The most recent classification of blood pressure suggested in Europe, including Poland, is based on the 2024 guidelines from the European Society of Cardiology. According to this classification, normal blood pressure is defined as less than 120/70 mmHg during office measurements. Elevated blood pressure falls within the range of 120-139/70-89 mmHg. Hypertension is diagnosed when blood pressure is equal to or greater than 140/90 mmHg [29]. According to current Polish guidelines, five main classes of antihypertensive medications are recommended. These include thiazide diuretics, preferably thiazide-like, beta-blockers that are ideally vasodilatory and highly cardioselective, calcium channel antagonists, specifically dihydropyridine derivatives, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers [28]. Aligned with trends in both Europe and the USA, the preferred pharmacotherapy strategy is the use of a single-pill combination [30]. In Poland, hypertension treatment begins with a two-drug combination: an angiotensin-converting enzyme inhibitor or angiotensin receptor blockers with a thiazide(-like) diuretic or dihydropyridine calcium antagonist. A second-line option includes all three drugs. For resistant cases, spironolactone or another drug is added. Monotherapy is for low-risk stage 1 hypertension (young or elderly patients aged 65-80) and stage 2 hypertension in those over 80. Beta-blockers are first-line treatment for cardiac complications or high heart rates (> 80 bpm), especially in younger patients and women planning pregnancy [28].

INTERVENTIONS

The effectiveness and safety of treating hypertension have been demonstrated by several decades of thorough clinical investigations. Evidence for risk reduction at various blood pressure elevation levels (i.e., stages of hypertension) were examined in a 2016 meta-analysis. In ge­neral, the risk of cardiovascular disease decreased by 20% with each 10-mmHg drop in SBP; however, the reduction was slightly higher in cases of stroke and hypertensive heart failure than in cases of ischemic heart disease, and the reductions tended to be greater in individuals with more severe hypertension [31]. A 2022 modelling study examined the impact of achieving an 80-80-80 hypertension control target: 80% of hypertensive individuals are diagnosed, 80% of them treated, and 80% achieve guideline-recommended blood pressure. Under realistic implementation, most countries could achieve 80-80-80 targets by 2040, reducing all-cause mortality by 4-7% and averting 76-130 million deaths and 110-200 million cardiovascular disease (CVD) cases by 2050 [32]. It is advised that blood pressure be measured during routine visits to primary health care facilities for adults. This includes taking measurements for all adults on their first visit and, if the readings are normal, checking periodically afterward (e.g., once a year). Patients with elevated blood pressure need immediate follow-up for treatment. However, population-wide screening is not recommended as the main approach for detecting and diagnosing hypertension early [33]. A systematic review identified 42 cost-effectiveness analyses conducted in 15 countries. The cost- effectiveness ratios of the studies varied widely, but the majority of them revealed that the treatment of hypertension cost less than $US 1000 per DALY averted [34]. Research using stratified cost-effectiveness ratios based on the baseline cardiovascular risk of individual patients indicated that treatment tends to be more cost-effective in higher-risk categories. Although this idea is not new, selectively treating high-risk hypertension is impractical and poses significant ethical issues [35]. Achieving 50% population blood pressure control by 2050 is comparable to some of the best global health initiatives, such as those addressing the “unfinished agenda” of communicable, perinatal, and nutritional diseases [36]. Overall, the financial benefits of hypertension control of this investment could outweigh these costs by nearly 18 to 1. The World Health Organization (WHO) promotes the HEARTS program to control hypertension efficiently. The HEARTS technical package is aimed at strengthening the clinical management of CVDs and CVD risks in primary health care (PHC). Approximately 50% of CVDs are caused by increased blood pressure; therefore, in many settings, hypertension is the main entry point for CVD prevention [37]. This program is also intended to provide global guidance for PHC CVD risk-reduction programs and acknowledges the requirement to adapt the program for implementation at national and local levels. HEARTS was initially released in 2016 and continues to be updated and expanded [38]. HEARTS acknowledges the crucial role that socioeconomic determinants, health-related factors (such as income and education), and underlying behavioral and environmental risks (such eating poorly and not exercising) play in raising metabolic risks [38, 39]. The HEARTS technical package places a strong emphasis on straightforward methods that are consistently and systematically used in the PHC context to enhance CVD risk reduction. The following modules form the core elements of the HEARTS interventions: evidence-based treatment protocols, access to essential medicines and technology, risk-based CVD management, team-based care, systems for monitoring, and healthy lifestyle [40]. HEARTS promotes very simple directive evidence-based treatment protocols (e.g. defining specific drugs and dosages, mini­mizing titration steps) for the management of hypertension [41]. Access to essential medicines and technology modules provides policymakers with guidance on how to help with the logical selection of medications and equipment. It ensures that the medications and devices chosen are of the highest quality, are available, and are reasonably priced for the public and health care systems [42]. Another HEARTS module includes risk-based charts, which are designed to assess the risk of individuals who do not have a previously diagnosed CVD. The module also provides detailed instructions on how to calculate risk using the charts and provides recommendations on therapies in different risk categories [43]. The team-based care module, in turn, promotes the benefits and highlights the barriers to and need for team-based care. The module discusses the different steps to implementing team-based care, including identifying a leader, determining the professional make-up of the team, engaging the team members, designing work and patient flow, enhancing communication between the team and patients, and specific steps in shifting to team-based care [40]. The systems for moni­toring module describes recommended core indicators and surveillance mechanisms for the HEARTS program, based on the hypertension treatment cascade. Creating clinic registries to track clinic coverage of the hypertensive population and the rate of hypertension control is an essential component. This makes it possible for the program to establish a culture of ongoing quality improvement at all levels [39]. Finally, the healthy lifestyle module provides evidence-based recommendations and tools for the PHC teams to provide lifestyle counselling and self-care advice for patients. The specific interventions include both prevention of tobacco use and how to quit tobacco products, regular physical activity, healthy diet, avoiding alcohol consumption, and maintaining a healthy body weight [38]. There are two policy documents that support a healthy diet: SHAKE and REPLACE (provides guidance for eliminating industrially produced dietary trans fats) [44, 45]. SHAKE outlines the key components of a successful national salt reduction strategy, focusing on the following areas: surveillance (track and monitor salt consumption levels), harness industry (encourage food manufacturers to reformulate products and meals to reduce salt content), adopt standards for labelling and marketing (establish guidelines for clear and accurate food labelling and marketing practices), knowledge (provide education and communication efforts to help individuals reduce their salt intake), environment (create supportive environments that promote healthy eating habits) [44]. Consuming too much sodium (more than 5 g per day) is linked to an increase in SBP as people age, while reducing sodium intake has a blood pressure-lowering effect [46]. However, it is better to introduce changes in the overall dietary pattern. The effects of individual nutrients are challenging to analyze, because people do not consume single foods or their components only [47]. Recent meta-analyses support the evidence that the DASH diet – which stands for the Dietary Approach to Stop Hypertension and includes large amounts of fruit, juices, vegetables, nuts, seeds, and legumes; preference of skimmed milk over full‑fat dairy products; and a smaller amount of meat together with a higher intake of fish – significantly lowers both SBP and DBP [46]. There has also been robust evidence from meta-analyses that vegetarian and vegan diets have significant SBP and DBP lowering effects. It has yet to be fully elucidated which subtype of vegetarian diet (vegan, lacto-vegetarian, lacto-ovo vegetarian, pesco-vegetarian) could have the best BP lowering properties [48]. Long-term alcohol consumption is associated with a high rate of hypertension even when intake is at low to moderate levels [13]. Therefore, in 2018 WHO launched the SAFER initiative. It represents the five most cost-effective strategies to reduce alcohol-related harm. These include strengthening restrictions on alcohol availability, advancing and enforcing drink-driving countermeasures, facilitating access to screening, brief interventions, and treatment, enforcing comprehensive bans or restrictions on alcohol advertising, sponsorship, and promotion, and raising alcohol prices through excise taxes and pricing policies [49]. Quitting tobacco is the most effective lifestyle change for preventing many cardiovascular diseases and offers significant benefits to patients with hypertension [14]. In 2008, the WHO introduced the MPOWER package, a technical framework to help countries implement cost-effective measures to reduce tobacco demand in line with the WHO Framework Convention on Tobacco Control (FCTC). The MPOWER package includes monitoring tobacco use and prevention policies, protecting people from secondhand smoke, offering support to quit smoking, warning about the dangers of tobacco, enforcing bans on tobacco advertising, promotion, and sponsorship, and raising taxes on tobacco products. The worldwide targets for prophylaxis of hypertension, which are recommended by the WHO, should include the following key goals: 20% relative reduction in the harmful use of alcohol by 2030; 30% relative reduction in prevalence of current tobacco use by 2025; 15% relative reduction in prevalence of insufficient physical activity by 2030; and 30% relative reduction in mean population intake of salt/sodium by 2025 [37].

CONCLUSIONS

Hypertension is a critical global health issue, yet it remains underdiagnosed and poorly controlled despite being largely preventable. Effective management of hypertension requires a combination of lifestyle modifications and pharmacological treatments. Non-pharmacological interventions, including increased physical activity, dietary changes (such as sodium reduction and adherence to heart-healthy diets such as DASH), weight control, smoking cessation, and limiting alcohol intake, are crucial in lowering blood pressure and preventing its onset. Public health campaigns should emphasize these lifestyle changes, particularly in populations with limited access to healthcare. Pharmacological treatments, especially single-pill combination therapies, are essential for individuals with established hypertension. Early initiation of treatment, with a focus on combinations of antihypertensive drugs, improves patient adherence and reduces cardiovascular risks. In Poland and globally, many patients remain undiagnosed or poorly treated, highlighting the need for better screening and treatment strategies. Public health initiatives, such as WHO’s HEARTS program and campaigns like “May Measurement Month” in Poland, play a vital role in increasing awareness and early detection. Achieving global targets, including reducing harmful alcohol use, tobacco prevalence, physical inactivity, and sodium intake by 2030, is crucial for decreasing hypertension-related morbidity and mortality. Meeting these goals will help prevent serious complications such as stroke, heart attack, and kidney failure, underscoring the importance of sustained public health efforts and adherence to evidence-based treatments. 

Disclosures

The authors report no conflict of interest.

References