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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
AFRICA
265
Africa, the number of people with hypertension increased from
54.6 million in 1990 to 92.3 million in 2000, and 130.2 million
in 2010. Under prevailing circumstances, this could increase to
216.8 million by 2030.
6
Gap in the care versus opportunity to control
hypertension
The PASCAR task force recommends key steps for appropriate
office measurement (Fig. 1). BP-lowering strategies that have
shown their efficacy in HIC are likely to succeed in Africa. In
Table 2, a synopsis is provided of currently published treatment
guidelines differing regarding treatment thresholds.
A simple and practical treatment algorithm using these
thresholds is recommended (Fig. 2). Our schedule should
consider patient costs (including transport and loss of wages
because of time off to attend clinic visits), which affect treatment
adherence and burden to the healthcare system.
Because of the asymptomatic nature of hypertension, long-
term medication adherence is poor. Patients and healthcare
practitioners must be educated on non-pharmacological BP
control methods (see Fig. 2). We encourage patient education
using text messages, e-mails or social media (WhatsApp
or Facebook), all of which are progressively available and
affordable in Africa. We also encourage face-to-face education
by traditional and religious leaders.
Table 2. Blood pressure guidelines
WHO PEN
1
NICE 2011
2
ESH/ESC 2013
3
ASH/ISH
2014
4
AHA/ACC/
CDC 2013
5
US JNC 8
2014
6
South Africa
2015
7
Egypt 2013
8
Definition of
hypertension
(mmHg)
≥ 140/90
≥ 140/90 and
daytime ABPM
(or home BP)
≥ 135/85
≥ 140/90
≥ 140/90
≥ 140/90 Not addressed ≥ 140/90
≥ 140/90 (high risk) –
150/95 (low risk) and
daytime ABPM (or
home BP) ≥ 135/85
Drug therapy in
low-risk patients
after non-pharma-
cological treatment
(mmHg)
> 160/100
≥ 160/100 or
daytime ABPM
≥ 150/95
≥ 140/90
≥ 140/90
≥ 140/90 < 60 years, ≥
140/90;
≥ 60 years, ≥
150/90
≥140/90
≥ 140/90 for high risk
and ≥ 160/100 for low
risk
First-line therapy < 55 years, low-
dose thiazide
diuretic and/or
ACE inhibitor;
≥ 55 years, CCB
and/or low-dose
thiazide diuretic
< 55 years,
ACE inhibitor
or ARB; ≥ 55
years or African
ancestry, CCB
ACE inhibitor or
ARB; beta-blocker;
CCB; diuretic
Low-dose
diuretic
ACE inhibi-
tor or ARB;
CCB; diuretic
CCB/diuretic
in people
of African
ancestry
ACE inhibi-
tor or ARB;
CCB; diuretic
CCB/diuretic
in people
of African
ancestry
Any of diuretics, beta-
blockers, CCB, ACEIs
or ARBs. preferably
a thiazide diuretic. In
elderly (> 65 years) or
in blacks, start with
diuretic or CCB.
Beta-blockers as
first-line drug
No
No (step 4)
Yes (in specific
subgroups)
No (step 4)
No (step 3)
No (step 4)
No (step 4)
Yes, in specific e.g.
young, particularly
those with tachycardia
Diuretic
Thiazides,
Chlortalidone,
indapamide
Thiazides, chlortali-
done, indapamide
Thiazides,
chlortalidone,
indapamide
Thiazides
Thiazides,
chlortalidone,
indapamide
Thiazide or
thiazide-like
(indapamide)
Thiazides, chlortha-
lidone, amiloride or
spironolactone
Initiate drug
therapy with two
drugs (mmHg)
Not mentioned Not mentioned In patients with
markedly elevated
BP or patients with
high overall CV risk
≥ 160/100
≥ 160/100
≥ 160/100
≥ 160/100 Diuretic + beta-block-
ers/CCB/ACEIs/ARBs
if BP > 170/105
Blood pressure
target (mmHg)
< 140/90
< 140/90;
≥ 80 years,
< 150/90
< 140/90; elderly
< 80 years, SBP
140–150, SBP < 140
in fit patients;
elderly ≥ 80 years,
SBP 140–150
< 140/90;
≥ 80 years, <
150/90
< 140/90;
lower targets
may be
appropriate in
some patients,
including the
elderly
< 60 years, <
140/90;
≥ 60 years <
150/90
< 140/90
< 150/95 in low-risk
patients and in elderly
(> 65 years).
< 140/90: ≥ 2 risk
factors, CKD, TOD
< 130/80: HF or CKD
when associated with
proteinuria > 1 g/24
hours.
Blood pressure
target in patients
with diabetes
mellitus (mmHg)
< 130/80
Not addressed
< 140/85
< 140/90
< 140/90;
lower targets
may be
considered
< 60 years,
< 140/90;
≥ 60 years, <
150/90
< 140/90 < 140/90 mmHg or <
130/80 if associated
with proteinuria >
1 g/24 hours
ABPM, ambulatory blood pressure monitoring; ACC, American College of Cardiology; ACE inhibitor, angiotensin converting enzyme inhibitor; AHA, American
Heart Association; ARB, angiotensin receptor blocker; ASH, American Society of Hypertension; BP, blood pressure; CCB, calcium channel blocker; CDC, Centers for
Disease Control and Prevention; CKD, chronic kidney disease; CV, cardiovascular; ESC, European Society of Cardiology; ESH, European Society of Hypertension;
ISH, International Society of Hypertension; NICE, National Institute for Health and Care Excellence; SBP, systolic blood pressure; TOD, target-organ damage; US
JNC 8, Eighth US Joint National Committee; WHO PEN, World Health Organisation Package of Essential Non-communicable disease interventions.
1
World Health Organisation. Implementation tools: package of essential non-communicable (PEN) disease interventions for primary healthcare in low-resource settings.
Available at:
http://apps.who.int/iris/bitstream/10665/133525/1/9789241506557_eng.pdf.Accessed April 8, 2015.
2
National Institute for Health and Care Excellence. NICE guidelines [CG127]. Hypertension: clinical management of primary hypertension in adults. Available at: www.
nice.org.uk/guidance/cg127/chapter/guidance.Accessed April 8, 2015.
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et al
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