Cardiovascular Journal of Africa: Vol 31 No 6 (November/December 2020)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 6, November/December 2020 AFRICA 325
Commentary
PASCAR commentary on the International Society of
Hypertension global guidelines 2020: relevance to
sub-Saharan Africa
ESW Jones, Albertino Damasceno, Elijah N Ogola, Dike B Ojji, Anastase Dzudie, BL Rayner
Abstract
Hypertension guidelines have been based on country-specific
data until the publication of the International Society of
Hypertension (ISH) global guidelines. The major differences
between the ISH global guidelines and other international
guidelines are the stratified recommendations to accom-
modate differences in available resources between countries
and within countries. This is a key and novel proposal in the
new ISH guidelines. There is the separation of optimal versus
essential criteria for diagnosis and treatment according to
availability of resources. This guideline includes recommen-
dations for sub-Saharan Africa. The Pan-African Society of
Cardiology (PASCAR) continues to promote awareness and
recommendations on hypertension in Africa. This commen-
tary provides a summary and discussion of the global guide-
lines in order to clarify the position of PASCAR.
DOI: 10.5830/CVJA-2020-055
Most authoritative hypertension guidelines for the diagnosis and
management of elevated blood pressure have been developed for
specific regions or countries.1-4 These guidelines have been based
on studies that were predominantly performed in high-income
countries (HICs), with the vast majority of participants being of
non-sub-Saharan African (non-SSA) origin.2,5,6 No hypertension
cardiovascular (CV) outcome study has been performed in SSA.
Despite this, these international guidelines have been used to
develop management protocols for SSA.
Until 2017, guidelines were unanimous that the cut-off
point to diagnose hypertension was 140/90 mmHg, except
in the elderly where the systolic blood pressure (SBP) was
increased to 150 mmHg.7-9 Based on this definition, the World
Health Organisation (WHO) estimated that Africa had the
highest prevalence of hypertension.10 The Pan-African Society
of Cardiology (PASCAR) hypertension roadmap11 similarly
used this diagnostic threshold. However, in 2017, the American
College of Cardiology (ACC)/American Heart Association
(AHA) revised their hypertension guidelines with radical changes,
including lower cut-off points for the diagnosis of hypertension
(BP ≥ 130/80 mmHg).
Implications of these changes include an additional 31 million
US individuals considered to have hypertension, just because of
this change in threshold.1 The lowering of the threshold of
hypertension diagnosis was not replicated in the 2018 guidelines
from the European Society of Hypertension (ESH)/European
Society of Cardiology (ESC), which maintained the previously
set 140/90 mmHg.2
In 2018, the International Society of Hypertension (ISH)
questioned whether the ACC/AHA high blood pressure
guidelines were fit for global purpose, especially in low- and
middle-income countries (LMICs).12 In 2020, the ISH published
global hypertension practice guidelines, which have great
relevance to SSA. Specific detail for the manner to achieve
hypertension control is based on the needs, available resources
and practice behaviours of a given population. This commentary
aims to clarify the position of PASCAR on these global practice
guidelines and their relevance to SSA.
Why do we have guidelines?
Before commenting on the ISH hypertension guidelines, it is
important to consider why we need guidelines. The principles
were particularly well summarised by Go et al.13 Briefly, they
are required to identify people eligible for management; for
monitoring at practice and population level; for increasing
patient and provider awareness; providing an effective diagnosis
and treatment plan; systematic follow up for initiation and
Division of Nephrology and Hypertension, Groote Schuur
Hospital; Kidney and Hypertension Research Unit,
University of Cape Town, Cape Town, South Africa
ESW Jones,MB BCh, FCP (SA), Cert Nephrol, PhD,
BL Rayner, MB ChB, FCP, MMed, PhD
Faculty of Medicine, Eduardo Mondlane University;
Research Unit, Department of Medicine, Maputo Central
Hospital, Maputo, Mozambique
Albertino Damasceno, MD
College of Health Sciences, University of Nairobi, Kenya
Elijah N Ogola,MD
Cardiology Unit, Department of Internal Medicine,
University of Abuja and University of Abuja Teaching
Hospital, Gwagwalada, Abuja, Nigeria
Dike B Ojji, MD
Cardiology and Cardiac Pacing Unit, Service of Internal
Medicine, Douala General Hospital, Douala, Cameroon
Anastase Dzudie,MD