Hypertension epidemiology and primary care indicators in Portugal: a contemporary nationwide analysis

BACKGROUND: Hypertension remains a leading contributor to cardiovascular mortality worldwide. However, integrated surveillance frameworks linking epidemiological burden, healthcare performance, and clinical outcomes remain limited. This study aimed to characterize hypertension epidemiology and management in Portuguese primary health care using real-world evidence from publicly-available indicators. METHODS: A retrospective ecological (aggregated group-level) study was conducted, using the five Portuguese mainland administrative health regions and the country as the units of analysis, with data obtained from Portuguese primary health care information systems from 2021-2025. Temporal and regional trends in hypertension prevalence and incidence, blood pressure (BP) monitoring and control, cardiovascular risk assessment, therapeutic review, prescribing patterns, and composite management indicators were assessed across the five mainland Portuguese administrative health regions. A multidisciplinary expert panel provided structured clinical appraisal of indicator relevance and interpretability. RESULTS: Hypertension prevalence and incidence increased nationally over time, with persistent regional heterogeneity. The Norte region showed consistently higher performance across monitoring and control indicators, whereas Algarve and Alentejo exhibited generally poorer results. BP monitoring and control improved across all regions, with the proportion of hypertensive adults aged 18-64 years, with BP <140/90 mmHg increasing from 29.3% in 2021 to 65.0% in 2025. Composite management indicators improved, but the degree of improvement varied between different index versions. Medication costs generally increased up to 2024 but decreased afterwards, while prescription indicators remained stable, despite heterogeneous regional patterns. CONCLUSION: Hypertension management indicators in Portuguese primary care improved substantially between 2021 and 2025; however, regional disparities and methodological limitations remain. Current monitoring frameworks provide valuable real-world insights but incompletely capture clinically meaningful outcomes, supporting the need for more outcome-directed systems.