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How to deal with the mass killer, hypertension
High blood pressure is the single biggest contributor to the
global burden of disease, with hypertension leading to 10.7
million deaths every year.
1
Most worrying is a recent global
study showing that on average, more than half of those
affected don’t know they have it.
2
Because cardiovascular
disease affects a third of adults in the world, it is the largest
epidemic ever known to mankind.
3
With mortalities increasing year on year, awareness, and
therefore treatment and control rates, have been shown to
worsen as the economic status of populations drop.
2
Prof
Neil Poulter, immediate past president of the International
Society of Hypertension (ISH), says that between the highest-
income countries and the lowest, there was an 8.2% drop in
awareness, a 15% drop in treatment rates and a 6.3% drop in
control. This prompted the ISH to mount an unprecedented
global blood pressure (BP) awareness campaign during May
last year.
4
Speaking at the 34th World Congress of Internal Medicine
(WCIM) that was held in Cape Town in October, Prof
Poulter said an earlier studyshowed that just 46.5% of 57 840
hypertensive people canvassed knew they had hypertension,
followed by a dramatic drop off between those treated
(40.6%) and those controlled (13.2%). In the subsequent
global ISH screening and awareness initiative, dubbed ‘May
Measurement Month’ (MMM, 2017), volunteers screened
over 1.2 million people in 80 countries. They uncovered over
150 000 people with untreated raised BP (17.3% of those
untreated) and over 100 000 with treated but uncontrolled
BP (46.3% of those treated). The ISH went one better this
year, screening over 1.5 million people in 89 countries and
detecting over 220 000 with untreated raised BP (18.4%
of those untreated) and over 110 000 with treated but
uncontrolled BP (just 40.4% of those treated).
He described the MMM campaigns as a major success
and a ‘heart-warming, fantastic volunteer effort.’
Take-home lessons
‘So, we need to put screening in place and provide
suitable drugs – most people are not getting enough drug
combinations. You need two or more drugs to manage
hypertension properly,’ said Prof Poulter.
Drug guidelines are confusing, differing in the European
Union, America andBritain, withdifferent drug combinations
recommended for different race groups. Prof Poulter favours
the British combination-drug guidelines.
‘Our problem is that world-wide we don’t know what
the best combinations are. We know that patients need at
least two drugs, sometimes three, ideally in a single pill, for
the best outcomes. A single (combination-drug) pill gives
more effective and rapid BP control than monotherapy
and two ‘free’ drugs. You get reduced side effects, enhanced
adherence, improved cardiovascular protection and they’re
more cost-effective,’ said Prof Poulter.
Prof Poulter has just completed a major trial of three
different two-drug combinations for lowering BP in black
Africans in six sub-Saharan countries (the CREOLE study),
with definitive but yet-to-be-released results. He said he
hopes to present them ‘somewhere prestigious’ early next
year.
‘We now know what works for black Africans. Our
primary end-point was to lower ambulatory systolic BP after
six months,’ he revealed, while keeping tight-lipped about the
much-anticipated findings.
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.
continued on page 32…