CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
172
AFRICA
Editorial
Dismal management of hypertension at primary level:
does it reflect a failure of patients, a failure of the
system or a failure of doctors?
NBA NTUSI
‘My great concern is not whether you have
failed, but whether you are content with your
failure.’
Abraham Lincoln
Hypertension is a major but modifiable risk factor for cardio-
vascular disease (CVD). About 25% of adults in the world have
hypertension and this is expected to increase in the coming
years.
1
In sub-Saharan Africa (SSA), the number of hypertensive
adults is projected to rise from 80 million in 2000 to 150 million
by 2025.
2
In SSA, not only is hypertension common, but it is frequent-
ly misdiagnosed. This is of great economic relevance as it
commonly affects the young, and causes serious complica-
tions.
3,4
Persistently elevated blood pressure is associated with
poor outcomes, including left ventricular hypertrophy, heart
failure, stroke, premature coronary artery disease, chronic
kidney disease, intra-cerebral haemorrhage, retinopathy, vascular
dementia and acute life-threatening emergencies. Moreover, the
management of hypertension remains sub-optimal worldwide.
Data from the National Health and Nutrition Examination
Survey (NHANES) and the United States Census Bureau from
1999 to 2000 revealed that only 29 to 31% of adult hyperten-
sives were controlled, with the prevalence of poor control being
higher in older people and blacks.
5
Multiple patient-, system- and
physician-related factors contribute to the poor management of
hypertension, despite the publication of best-practice guidelines
for management of high blood pressure by different professional
societies.
In this issue of the journal, Parker and colleagues report on
a study conducted in Cape Town, South Africa, showing that
these doctors’ knowledge on the management of hypertension
and of the South African hypertension guidelines was poor, with
62.5% of the doctors surveyed attempting to treat hypertension
to target, and only 50% recommending lifestyle modifications
to their patients.
6
Furthermore, physician inertia was rife, as the
participating doctors estimated that about 35% of their hyperten-
sive patients were controlled on the treatment prescribed, and yet
therapy was not routinely up-titrated for the majority of patients.
Factors identified by these doctors as impacting on optimal
management of hypertension at primary level included poor
patient adherence to prescribed treatment, communication diffi-
culties (as the doctors did not always speak the language of
the patients), heavy patient workloads and staff shortages, and
patient loss to follow up.
Hypertension in South Africa
Hypertension in South Africa was responsible for 46 888 deaths
(9% of all deaths) and 2.4% of disability-adjusted life years
in 2000.
7
Risk factors for high blood pressure in South Africa
include low educational attainment, older age, increased weight,
excess use of alcohol and a family history of hypertension or
stroke.
8
Hypertension in black South Africans differs in its clini-
cal presentation, epidemiology and complications from that of
white South Africans and hypertensive patients from developed
countries. Black South Africans, particularly the young, typi-
cally have malignant hypertension complicated by hypertensive
nephrosclerosis, stroke, hypertensive heart disease, heart failure
more commonly, and coronary artery disease less frequently.
8,9
Furthermore, the mortality from stroke is twice as high among
blacks compared to other race groups.
10
Poor control of hypertension at primary level
in South Africa
Poor management of hypertension by despondent primary
healthcare workers in South Africa has previously been docu-
mented.
11,12
Rayner
et al.
13
and Steyn
et al.
14
have reported that
only 39.8 and 42.1%, respectively, of South African primary
healthcare hypertensive patients were adequately controlled.
Furthermore, Schoeman and Rayner, from a cross-sectional
analysis of South African hypertensive patients in general prac-
tice have demonstrated that physician inertia is common, with
30.7% of hypertensive patients on monotherapy, 42.8% on two
drugs and only 26.5% receiving more than two agents.
15
Risk factors for hypertension
Essential (primary) hypertension is responsible for the majority
of cases of elevated blood pressure, where it is found to be more
severe and more common in blacks, older people and obese
women. High salt intake, excessive alcohol use, physical inactiv-
ity and dyslipidaemia remain important additional risk factors.
Several other factors are risk factors/causes of secondary hyper-
tension (as summarised in Table 1).
Refractory hypertension
Multiple factors contribute to poor control of hypertension.
Refractory hypertension is an indication for referral of hyper-
tensive patients from primary-care centres to a higher level of
