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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 2, March/April 2015
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AFRICA
and assess the impact of risk factors in an African population,
will address these challenges and provide risk factors to be
included in a tailored CVR algorithm. However this may not
help for the urgent up-coming guideline process.
In recent studies, Gaziano and co-authors
12
documented how
we can address the lack of cholesterol levels in the Framingham
score algorithm. Beyond this CVR profiling challenges, the
presenter documented the role of affordability of medicines
in African settings (Peer and others 2014), and within the
medicines cost scope, the quality of hypertension drugs was also
discussed.
13,14
Finally, the crucial question to be addressed by the
hypertension management guideline is to establish what the
management strategy could be for hypertension in African
settings within the context of limited resources, to reduce
stroke, and heart and renal complications. Here the task-shifting
process and the contribution of trained non-physician healthcare
workers was identified as one approach among others to reliably
and effectively assess cardiovascular risk in primary care settings
(where there are no attending physicians) and detect subjects to
be referred to qualified health facilities.
14
Prof Alta Schutte (South Africa) presented the American
Society of Hypertension (ASH)/International Society of
Hypertension (ISH) clinical practice guidelines for management
of high BP, a 12-page document published in 2014 with an easy-
to-follow algorithm. She made mention of the fact that these
guidelines specifically consider hypertension in black patients
to be common, to occur at a younger age, to tend to cause
more severe complications such as stroke and renal disease,
and to respond well to calcium channel blockers (CCBs) and
diuretics, and that blacks have a tendency to be salt sensitive. It
was however noticeable that the ASH/ISH recommendations for
black patients conflicted with those from JNC 8.
Prof Albertino Damasceno (Mozambique) suggested ways to
formulate recommendations in an actionable way in Africa. The
best ways would include primary prevention, with integrated care
for chronic diseases from primary healthcare with task shifting,
use of the global risk strategy (move the curve left, reduce
mortality), use of therapies that are available, cheap and effective
(diuretics and CCBs), and a long-term monitoring strategy
aimed at improving long-term compliance of the patients.
Prof Basden Onwubere (IFHA, Nigeria) called the attention
of the group to how to resist the temptation of writing a
textbook. Desirable attributes of a guideline would be validity,
reproducibility, clarity, clinical applicability and flexibility.
Meticulous documentation of evidence is a key step. Guidelines
should be clearly written and concise enough, without losing
important evidence-based messages. Proper scoping ensures
that target professional groups are guided by guidelines when
developed, and not controlled or confused. Regular reviews of
guidelines should be scheduled.
Prof Neil Poulter reviewed the methodology for
guideline development, the act of translating evidence into
recommendations, and defining the strength of recommendation.
Consideration needs to be given to the approach to be used;
‘systematic’ or ‘comprehensive’. The systematic approach is
complex, time and resource consuming, and possibly duplicates
what has already been done. Recommendations are then graded
as high, moderate and low according to the level of evidence. It
is remarkable that only two HT guidelines have really followed
a systematic review process, the NICE in 2011, and the JNC 8
in 2013. A pragmatic guideline addresses the majority, if not all
clinical questions relevant to the topic. The pragmatic approach
refers to substantial bodies of work and reflects on those areas of
perceived difference (due to difference in target audience or more
recent evidence). Consensus (expert opinion) is a substantial and
crucial aspect that is well accepted in this methodology. A good
option for PASCAR might be in between the two approaches,
and to contextualise the WHF hypertension roadmap.
Overall discussion and ways forwards
The group recognised the urgent need to develop a hypertension
roadmap for Africa that will help improve BP control and
reduce renal disease, heart disease and stroke in the region. A
consensus was achieved on the practicability of the WHF global
hypertension roadmap, which could be a reference guide for the
PASCAR group. It was observed that due to lack of evidence,
there was controversy on whether and how patients with grade
1 hypertension (systolic of 140–159 and/or diastolic of 90–99
mmHg) should be managed.
A consensus was reached on PASCAR’s commitment to
design and conduct clinical trials that would answer these
questions in the future, as the research element of the roadmap
process. The group felt that for the urgent step of developing
an African guideline for the management of hypertension, it
was appropriate to focus additional effort on locally available
national/international African guidelines or data rather than
redoing international work (such as comprehensive guidelines)
.
Questions to be addressed in the African guidelines for the
management of raised blood pressure would include: (1) in
African adults with hypertension, does initiating antihypertensive
pharmacological therapy at specific BP thresholds improve
health outcomes? (2) In African adults with hypertension, does
treatment with antihypertensive pharmacological therapy to a
specified BP goal lead to improvements in health outcomes? (3)
In African adults with hypertension, do various antihypertensive
drugs or drug classes differ in comparative benefits and harms on
specific health outcomes? (4) In African adults with hypertension,
what is the best cost-effective antihypertensive drug in the
primary care setting?
The guidelines will be a single document with a summary,
targeting adult hypertension and written for primary care level of
practice. The document will be valid, reproducible, clear, simple
and concise enough to be easily adopted by various African
countries and implemented and monitored regularly. Algorithms
for primary healthcare workers will be developed and different
formats of the documents are desirable in accordance with each
healthcare level.
The following key stakeholders will be included in the
development process: PASCAR, IFHA, AFRAN, national
professional societies (HT and cardiac), WHF, WHO-AFRO
(chronic disease branch), WHO-EMRO, Africa Union (social
cluster of the AU), all policy makers, International Society of
Hypertension in Blacks (ISHIB), World Hypertension League
(WHL), ISH (low- and middle-income countries), and ESH
(low- and middle-income countries). Finally, the group adopted
a timeline, activities and deliverables in the development of the
roadmap with guidelines that are relevant to Africa over an
18-month period.