Cardiovascular Journal of Africa: Vol 30 No 3 (May/June 2019)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 3, May/June 2019 AFRICA 187
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Clearing up muddy treatment waters
In two slightly differing presentations to the Cape Town
WCIM, Prof Poulter reviewed existing combination-drug
trials and decried the American lower treatment threshold
BP guideline of 130/80 mmHg. He said that although
the SPRINT study, which influenced this lower threshold,
had reported lower rates of fatal and non-fatal major
cardiovascular events from any cause, at systolic BP targeted
to < 120 mmHg, the Americans measured BP ‘in a way
nobody does in this room – they used a machine with the
patient alone in a back room, which gives lower BPs than
those measured in your clinics.’ He recommends sticking
with the higher 140/90 mmHg diagnostic threshold for
hypertension.
Meanwhile, reports in the prestigious Lancet and British
Medical Journal differ over the BP targets recommended.
What guidelines in the world tend to agree on, he said, was
that treating with two drugs as initial therapy was the way
to go. Just two drugs in a single tablet has already improved
compliance by 21%. If a patient was above a certain level of
risk, they should also be on a statin, regardless of cholesterol
levels, until at least 80 years of age, he added.
Prof Poulter’s conclusions fromtheACE inhibitors vsARB
controversy in managing hypertension are that individual
trial data and meta-analyses are relatively consistent in
showing the superiority of ACE inhibitors. ARBs are better
tolerated but do not reduce mortality rate or cardiac events as
well as ACE inhibitors and should be used if patients cough
on ACE inhibitors. Prof Poulter concluded his presentation
with a telling cartoon of an obese man, with a frothy pint of
beer in one hand and a cigarette butt in his mouth, sticking
his hand through a hole in a wall, on the other side of which,
an unseeing doctor measures his BP and puts pills in an
outstretched palm.
Session moderator, Prof Sajidah Khan, an interventional
cardiologist at the Gateway Private Hospital in Umhlanga,
said that in the very country that most funds prevention
(North America), the sale of ultra-processed foods this year
rose by 2.3% compared to a 71% increase in Africa and
Eastern countries. Simultaneously, the revenue growth for the
world’s biggest tobacco retailer, Philip Morris, rose by 2.8%.
It was therefore unsurprising that 80% of all cardiovascular
disease occurs in lower- to middle-income countries. The
damaging myths about statins paled by comparison with this.
Prof Brian Rayner, head of the Division of Nephrology
and Hypertension at the Groote Schuur Hospital and
University of Cape Town, said a three-pill regimen would
address huge unmet needs in South Africa and the continent.
He said up to 90% of hypertensive South African patients
remain untreated and agreed with Prof Poulter that the
American guidelines, ‘have set us back and created confusion
in the definition of hypertension – there’s a big difference
between a target and the definition,’ he added.
References
1. Poulter NR, Prabhakaran D, Caulfield M, et al. Hypertension.
Lancet 2015; 386(9995): 801–812.
2. Chow CK, Teo KK, Rangarajan S, Islam S, et al. Prevalence, aware-
ness, treatment, and control of hypertension in rural and urban
communities in high-, middle-, and low-income countries. J Am
Med Assoc 2013; 310(9): 959–968.
3. Dena Ettehad, Connor A Emdin, Amit Kiran et al. Blood pres-
sure lowering for prevention of cardiovascular disease and death:
a systematic review and meta-analysis. Lancet 2016; 387(10022):
957–967.
4. Beaney T, Schutte AE, Tomaszewski M, et al. May Measurement
Month 2017: an analysis of blood pressure screening results world-
wide. Lancet Glob Health 2018; 6(7): e736–743.