Key result
Hypertension phenotypes shift by age, with ISH dominating above 65 and IDH below 40.
Why the study?
Large-scale global data comparing the distribution of hypertension phenotypes across different regions, sexes, and age strata were limited.
Cross-Sectional (n=246,401)
Yes
This large global cross-sectional analysis demonstrates that isolated systolic hypertension is the dominant phenotype in both sexes above age 65, whereas isolated diastolic hypertension predominates below age 40 (especially in females), with substantial regional variation across 84 countries.
Answers are grounded in this paper and cite their sources.
Substantial ISH prevalence in untreated hypertension should not yet change practice; leaves open prospective studies on phenotype-specific outcomes.
Background Isolated systolic hypertension (ISH), usually characterized by increased arterial stiffness and accelerated vascular aging, is more common in older people whilst younger adults are more likely to present with isolated diastolic hypertension (IDH). However, large-scale global data comparing the distribution of hypertension phenotypes by region, sex and age strata are limited. Methods This cross-sectional study utilized data on untreated hypertensive adults (aged ≥18 years) from 84 countries collected in the May Measurement Month (MMM) 2021–2023 campaigns. Based on the average of the second and third seated blood pressure (BP) readings, participants were categorized into three phenotypes: ISH (SBP ≥140mmHg and DBP <90mmHg), combined systolic-diastolic hypertension (SDH, SBP ≥140 mmHg and DBP ≥90 mmHg), and IDH (SBP <140 mmHg and DBP ≥90 mmHg). Factors associated with these phenotypes were identified using multilevel multinomial logistic regression. Results Among 246,401 untreated hypertensive adults, crude percentages (n) of ISH, SDH and IDH were 28.7% (70,634), 38.9% (95,884) and 32.4% (79,883), respectively. ISH increased sharply with age, reaching 55.7% and 48.5% among hypertensive females and males aged ≥70, whereas IDH predominated in younger participants (49.3% in females and 40.6% in males aged 18–29) and SDH peaked in middle-aged groups. After age-standardization, proportions of ISH, SDH, and IDH were similar across sexes (26.8%, 34.5%, and 38.7% in females, compared to 26.8%, 37.6%, and 35.6% in males). Large regional differences in these phenotypes were apparent: the percentage of ISH ranged from 18.5% in East Asia to 41.0% in Northern Africa and Middle East, and IDH from 28.9% in Northern Africa and Middle East to 42.3% in East Asia. Multivariate analysis identified several independent factors positively associated with all three hypertension phenotypes relative to participants with normotension, including older age, male sex, daily alcohol consumption, elevated weight, and a higher resting pulse rate. Notably, resting pulse rate >80bpm (versus ≤80bpm) showed a stronger association with IDH (OR=1.80) and SDH (OR=1.72) than with ISH (OR=1.08). After full adjustment, a significant interaction between sex and age (P<0.001) (Figure) was identified. The proportion of ISH was higher in males than in females below age 40, but in both sexes, increased with age from around 45 years. In contrast, the proportion of IDH was higher in females than males below age 40 and decreased with age in both sexes thereafter. Conclusions After full adjustment, ISH is the dominant phenotype in both sexes above age 65, whereas below age 40, IDH predominates in both sexes but more so in females. These findings require further investigation to understand the aetiology and pathophysiology of BP phenotype distributions across age, sex and regions, with potential implications for different prevention strategies by population.Fully adjusted proportion
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Wang et al. (2026) conducted a cross-sectional in Untreated hypertension (n=246,401). Age, sex, and geographic region vs. Normotension or reference demographic strata was evaluated on Distribution of hypertension phenotypes: isolated systolic hypertension (ISH), combined systolic-diastolic hypertension (SDH), and isolated diastolic hypertension (IDH) (p=<0.001). Among 246,401 untreated hypertensives, ISH was 28.7%, SDH 38.9%, and IDH 32.4%, with significant age-sex interaction (P<0.001) as ISH dominated above age 65 and IDH below age 40.
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