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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 6, November/December 2020
AFRICA
327
those with the presence of frailty, the cut-off value is < 140/90
mmHg. This recommendation is particularly applicable to
SSA. However, in our view, the 20/10-mmHg reduction needs
further comment. Although it is well recognised that this
reduction in BP will substantially reduce cardiovascular events,
it needs a degree of context. For example, if the initial BP is
as high as 190/110 mmHg, a 20/10-mmHg reduction only to
170/100 mmHg would not be appropriate.
Clinical evaluation and diagnostic tests
The ISH guidelines recommend a full medical history addressing
previous BP levels, risk factors, co-morbidities, and symptoms
of secondary causes, together with a physical examination with
a focus on the circulation, heart and signs of secondary causes.
Laboratory investigations include Na
+
, K
+
, creatinine, estimated
glomerular filtration rate (eGFR), dipstick urine, lipids and
fasting glucose. A 12-lead ECG should be performed to detect
left ventricular hypertrophy, atrial fibrillation and ischaemic
heart disease. In PASCAR’s opinion these basic tests represent
an optimal situation to assess hypertension-mediated organ
damage (HMOD) and secondary causes at the primary-care
level. While these tests are ideal, ECG machine availability
and the skills to interpret are lacking in many SSA countries,
especially in rural areas.
CV risk stratification
More than 50% of hypertensive patients have additional CV risk
factors such as diabetes, the metabolic syndrome, dyslipidaemia
and smoking. CV risk assessment is important and should be
assessed in all hypertensive patients, and it relies on levels of
BP, risk factors, and presence and/or absence of HMOD. The
rationale is that patients at highest risk will achieve the greatest
absolute reduction in adverse events and allow scarce resources
to be optimally used. A simple risk chart is provided and is
applicable to SSA. Alongside the chart is QRISK2, an online
risk calculator that may be pertinent to SSA due to adjustment
for black African race.
Non-pharmacological treatment of hypertension
Non-pharmacological treatment is a fundamental part of the
management of hypertension. Healthy lifestyle choices can
prevent or delay the onset of high BP and can reduce CV risk,
are often the first line of antihypertensive treatment, and enhance
the effects of antihypertensive treatment. The recommended
changes are provided in Table 2. Briefly, the lifestyle changes
include a combination of optimising diet, exercise, weight,
alcohol consumption and avoiding precipitants and smoking.
There is no differentiation in the recommendations between
optimal and essential. Most of these recommendations are
only implementable in HICs due to a variety of reasons. In the
poorer communities of SSA, choice of food is determined by
affordability and ability to store. Lack of electricity means that
cooking and heating is done on open fires in crowded townships
and rural villages, causing pollution, and exercise opportunities
are limited due to safety concerns and lack of leisure time.
More pragmatic essential recommendations need to be
considered for SSA. However, salt and sugar intake can be
reduced and should be encouraged as salt is considered a major
contributor to poor BP control in SSA. Legislative control of
sodium content in processed foods is a feasible means to reduce
salt intake at a population level.
18
Further engagement with
policy makers needs to address access to freshly grown produce.
Initiation and drug treatment of hypertension
ISH guidelines recommend drug treatment for all patients with
established hypertension with BP ≥ 160/100 mmHg, which is
certainly in line with PASCAR’s viewpoint. However, for patients
with stage 1 hypertension, there is differentiation between
optimal and essential. Patients at high risk, with HMOD or
established CV or renal disease, should receive drug treatment,
but those with low to moderate risk without these complications
should receive drug treatment under optimal management.
Under essential treatment, if there is limited drug availability,
then treatment should be considered for older people, 50–80 years
old. In SSA this recommendation is not realistic as the majority
of the population is below 50 years of age and hypertension
presents at a younger age and is often more progressive (see
below). PASCAR recommends treating all patients diagnosed
with hypertension, including those with stage 1 hypertension
who have not responded to lifestyle modifications.
The ISH guidelines recommend initiation of two drugs,
preferably in a single-pill combination (SPC) in the majority of
patients. The initial combination is an angiotensin converting
enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
in combination with a calcium channel blocker (CCB). According
to the ISH guidelines, in African patients an ARB is preferred
over an ACE inhibitor due to risk of angioedema, despite the
CREOLE study showing a low risk of non-severe angioedema.
19
ACE inhibitors are generally less costly than ARBs and can
be used unless there is a contra-indication. Furthermore, in
African patients an initial combination of CCB plus thiazide/
thiazide-like diuretic is recommended. In the CREOLE study
Table 2. Recommended lifestyle changes
Recommended to increase
Recommended to avoid
Salt
Reduce salt in food preparation and at the table
High-salt foods (fast foods, processed foods, cereals)
Diet
Eat whole grains, nuts, seeds, legumes, tofu, fruit, vegetables (leafy vegetables, beetroot,
avocados), polyunsaturated fats
High-sugar food, saturated and trans fats
Drinks
Coffee, green and black tea, hibiscus tea, pomegranate juice, beetroot juice, cocoa
Excessive (> 2/day) alcohol or binge drinking
Smoking
Smoking
Physical activity
Aerobic and resistance exercise 30 minutes/ day 5–7 days a week, strength training
Stress
Transcendental meditation/ mindfulness
Chronic stress
Alternative therapies
Complementary, alternative or traditional medicines
Environment
Air pollution and cold temperature