Hypertension Care-Cascade Gaps and Stroke Burden From High Systolic Blood Pressure

AIMS: Stroke remains a major global health challenge, with high systolic blood pressure (HSBP) a leading modifiable contributor. The hypertension care-cascade gap most strongly associated with HSBP-attributable stroke burden across countries remains unclear. METHODS: This country-level ecological study used NCD Risk Factor Collaboration hypertension care-cascade estimates, Global Burden of Disease 2023 HSBP-attributable stroke estimates, and Socio-demographic Index (SDI) data, 1990-2019, including 199 countries/territories and 5970 country-years. Indicators were diagnosis, treatment, blood pressure control, and cumulative gaps; outcomes were HSBP-attributable stroke disability-adjusted life-year (DALY) and stroke death rates. Analyses included correlations, country-year models, sex-age-stratified models, exploratory 10-year age-shifted models, and 2019 country typology. RESULTS: By 2019, 80.2% of people with hypertension lacked blood pressure control. The blood pressure control gap aligned most clearly with HSBP-attributable stroke burden; each 10-percentage-point higher gap was associated with a 49.1% higher stroke DALY rate (95% CI 38.5-60.5) and a 47.7% higher stroke death rate (37.9-58.2), exceeding other gaps. Associations were consistent across sex-age strata. Priority analyses identified low-SDI older men as high-gap/high-burden strata, while exploratory age-shifted analyses showed the strongest aggregate associations in men aged 30-44 years and women aged 35-44 years at the index year. CONCLUSION: The control gap showed the strongest country-level alignment with HSBP-attributable stroke burden, with high-gap/high-burden patterns concentrated among older men in low-SDI settings. Exploratory age-shifted patterns in younger adults warrant further study. These findings highlight the potential value of the control gap for population-level surveillance and comparative assessment.