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AFRICA
BP and off-target side effects of antihypertensive treatment.
These were dizziness, falls, syncope, electrolyte abnormalities,
bradycardia (ACCORD only) and acute kidney injury. However,
there were no injurious falls and no excess of patients requiring
acute or chronic dialysis for end-stage chronic kidney disease in
the intensively treated group.
Are the AHA/ACC high blood pressure guide-
lines fit for global purpose?
In a major commentary written in
Hypertension
, Poulter
et
al.
, on behalf of the International Society of Hypertension,
questioned the relevance of these guidelines from a global
perspective, especially in low- and middle-income countries.
19
This is particularly pertinent to South Africa, and SAHS is in
broad agreement with this document.
In South Africa, more than 90% of hypertensives are not
controlled because of lack of awareness, failure to access
treatment due to failure to screen, screened but not diagnosed,
diagnosed but untreated and treated but not controlled.
20
By
redefining hypertension to a level of 130/80 mmHg, this will
significantly increase the prevalence of hypertension. In the USA
it is estimated that the number of hypertensives will increase by
43% or 31.1 million people.
21
The prevalence of hypertension in
South Africa is 35.1% and this means it is likely to rise to 50.2%
(presuming a similar increase as reported in the USA) if the new
definition is applied.
Similarly, the new targets will necessitate greater use of health
services for increased health visits to monitor patients, greater use
of antihypertensives to achieve the lower target, and increased
use of laboratory services to monitor for adverse effects. In both
the ACCORD and SPRINT trials, there was increased incidence
of acute kidney injury and electrolyte abnormalities that will
require extra monitoring.
As most hypertensives in the public sector are managed by
nurse practitioners with the assistance of medical practitioners,
there would be, by necessity, a major retraining of all health
workers. The net result will be increased demands on health
services that are already overburdened by demand and under-
resourced in terms of health worker and financial constraints.
This is in the setting of conflicting evidence for long-term clinical
benefit, especially in low-risk groups.
Conclusion
The AHA/ACC hypertension guideline is a major departure from
previous definitions of hypertension and target BP. Although a
target BP
<
130/80 mmHg may be acceptable in certain high-risk
patients, the SAHS does not recommend the adoption of the
new definitions and targets in South Africa.
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