Cardiovascular Journal of Africa: Vol 28 No 4 (July/August 2017)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017

268

AFRICA

civil society, on controlling hypertension to reduce premature

mortality from CVD. To guide the action of stakeholders, we

also highlight the importance of reaching minimum standards

(Table 3) for the health systems of countries to achieve the 25%

hypertension control target. Implementation of these solutions

and suggestions on customising the overall strategy at a country

level are discussed.

The WHF roadmap provides a general framework that

could be useful for LMICs, however, to be implemented it

should be customised according to the local context. With

PASCAR’s leadership and the contribution of other professional

organisations, this approach seems to be at the right time to

turn the many hypertension challenges in Africa into immense

opportunities

Although population-based strategies for lowering

BP may be cost-effective, they are not the focus of this roadmap,

but we recognise these would be beneficial.

Methods

In January 2014, panel members who were appointed to develop

the PASCAR roadmap were invited to join the PASCAR task

force on hypertension. Based on their expertise and leadership

in hypertension, 41 nominees from 21 countries received

invitations, with 95% responding positively. These experts

included cardiologists, nephrologists, public health physicians,

researchers (including clinical trialists), nurses, pharmacologists,

evidence-based medicine specialists and guideline developers.

During the first face-to-face meeting held in Nairobi on 27

October 2014,

the group acknowledged the lack of a continental

strategy to address the hypertension crisis. A decision was taken

to develop a roadmap for the prevention and management of

hypertension in Africa as a matter of urgency under the auspices

of the WHF.

To customise the WHF BP roadmap for Africa, the core

group performed a comprehensive literature search and

communicated with the WHF from November 2014 to July 2015

via teleconference and e-mail. After receiving and comprehending

the WHF roadmap document, task force members held a second

face-to-face meeting in London on 30 August 2015, to make

suggestions on its relevance and customisation. A detailed

presentation of this roadmap was reviewed and discussed by

PASCAR task force members, hypertension experts and leaders

of hypertension societies via e-mail, with WHF feedback.

Development of a warehouse for African guidelines and

clinical trials on hypertension was also reviewed. Finally, the

steps in developing the African roadmap for reducing CVD

mortality rates through BP control was planned.

The first draft of the PASCAR roadmap for hypertension

management and control was presented in Mauritius on 4

October 2015. Attendees were 13 presidents of national cardiac

societies or representatives, the president of the International

Forum for Hypertension Control and Cardiovascular Disease

Prevention in Africa and representative of the International

Society of Hypertension, a representative of the African Heart

Network, members of the PASCAR task force on hypertension,

and scientists from the WHF. The draft was reviewed and oral

and e-mail comments were received from participants. The

WHO PEN programme

was compared with the PASCAR

hypertension roadmap to ensure complementarity between the

two documents.

Table 3. Minimum care for hypertension management

at each healthcare level in Africa

Basic staff, equipment, test

and medication

Level of care

Primary

Secondary Tertiary

Trained health

worker or nurse

Medical

Practitioner Specialist

Basic equipment

Automated blood pressure

devices, or calibrated

sphygmomanometer, either

mercury or oscillometric

plus appropriate cuffs

+++

+++ +++

Home blood pressure

devices

+++

Ambulatory blood

pressure devices

+/–

+++

Tape measure for waist

circumference

+++

+++ +++

Scale for weight

+++

+++ +++

Stadiometer for height

+++

+++ +++

Standard 12-lead ECG

+++

Glucometer

+++ +++

Funduscope

+++

Stethoscope

+++

+++ +++

Basic tests

Urine dipsticks for

protein, blood and glucose

+++

+++ +++

Standard 12-lead ECG

recording

+++

Glucometer strips for

testing glucose

+++ +++

, K

and creatinine

with calculation of eGFR

+++

Cholesterol

+++

Glycated haemoglobin

(HbA

)

+++

Chest radiograph

+/–

+++

Basic medication classes with examples*

Thiazide or thiazide-like

diuretic (hydrochloro-

thiazide, indapamide,

chlorthalidone)

+++

+++ +++

Calcium channel blockers

(amlodipine, nicardipine,

long-acting nifedipine)

+++

+++ +++

Angiotensin converting

enzyme inhibitor

(enalapril, lisinopril,

perindopril, ramipril)

+++ +++

Angiotensin receptor

blockers (candesartan,

valsartan, losartan)

+++ +++

Vasodilating beta-blockers

(nebivolol, bisoprolol,

carvedilol)

+++ +++

Spironolactone

+++ +++

Long-acting

-blocker

(doxazocin)

Combinations of blood

pressure-lowering

medications

+++ +++

+++: strongly recommended; ++ moderately recommended, +:

recommended; –: not done; +/–: done if facilities are available.

*Availability of drugs at each level of care has been indicated and

recommended here for initiation only, all drugs can be used once

initiated by a medical practitioner.

A trained healthcare worker may initiate and follow up some medication.