Still on the Road to Worldwide Hypertension Control
2016; Lippincott Williams & Wilkins; Volume: 134; Issue: 6 Linguagem: Inglês
10.1161/circulationaha.116.023960
ISSN1524-4539
Autores Tópico(s)Climate Change and Health Impacts
ResumoHomeCirculationVol. 134, No. 6Still on the Road to Worldwide Hypertension Control Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBStill on the Road to Worldwide Hypertension Control Andrew E. Moran, MD, MPH Andrew E. MoranAndrew E. Moran From Division of General Medicine, Department of Medicine, Columbia University Medical Center, New York, NY. Originally published9 Aug 2016https://doi.org/10.1161/CIRCULATIONAHA.116.023960Circulation. 2016;134:451–454Article, see p 441Raised blood pressure (BP) is the leading preventable risk factor responsible for disease burden in high-, middle-, and low-income countries and was responsible for ≈9 to 12 million deaths worldwide in 2013.1 However, raised BP is chronic and almost always asymptomatic, thereby making it low priority for health systems, providers, and patients. Estimates of global and regional mean BP benchmark temporal trends in raised BP-related risks and demonstrate the potential public health benefit of shifting populations to healthier BP distributions.2 However, these estimates are not immediately relevant to current clinical practice, which is focused on eliminating above-threshold raised BP, that is, hypertension. Antihypertensive medication treatment lowers stroke risk by 35% to 40% and coronary heart disease and heart failure by 20% to 25% among hypertensive patients, so the case for identifying, treating, and controlling hypertension is founded on strong evidence and should be a top public health priority.3,4 In this issue of Circulation, Mills et al5 use data from 135 population-based studies representing 90 countries to estimate the global, regional, and country-level epidemiology of hypertension and hypertension awareness, treatment, and control.Measuring BP to detect hypertension, and then treating it, seems simple to us and in fact has been the bread and butter of routine medical practice for generations of healthcare providers. It is therefore sobering to learn that in low- and middle-income countries (LMICs), the epidemic of hypertension appears to be growing (7.7% increase in age-standardized adult prevalence to 31.5%, 2000–2010). Among LMIC adults with hypertension, only about a third of were aware of their diagnosis, one quarter were treated, and <10% were controlled to <140/90 mm Hg. There were minimal improvements in these benchmarks in LMICs from 2000 to 2010. In contrast, the authors found a slight hypertension prevalence decrease in high-income regions (to 28.5% in 2010, a −2.6% change from 2000) and incremental improvements in high-income country awareness (to more than two-thirds of hypertensive patients), treatment (to more than one-half), and control (to more than one-quarter). Mills et al included studies that used standard BP measurement methods and defined hypertension as self-reported use of antihypertensive medications or mean BP ≥140 mm Hg systolic or 90 mm Hg diastolic. Readers should interpret their country-level hypertension epidemiology estimates with a grain of salt. For many countries, no data were available, and estimates were derived by imputation based on age, sex, geographic proximity, and country income. Imputation of the component of prevalence based on the diagnostic criterion of self-reported treatment may be particularly problematic because awareness and subsequent treatment depend on health system access and quality, which vary even among countries at the same national income level.Action to Improve Hypertension Control WorldwideHow do we reduce the burden of hypertension worldwide? The World Heart Federation has set a goal of reducing premature deaths from cardiovascular disease by at least 25% globally by the year 2025, in line with the World Health Organization's 25×25 goal for reducing deaths from noncommunicable diseases. To reach this goal, the World Heart Federation provides "road maps" advising health system policies and clinical practices. The road map for hypertension control advises practical implementation steps toward a 25% improvement in hypertension control.6AwarenessHypertension awareness is low in LMICs because opportunistic screening is simply less available. Basic but validated and calibrated BP measurement and trained personnel should be mandated for primary healthcare facilities worldwide. In the meantime, if access to primary ambulatory medical care facilities is limited, pharmacies, work sites, houses of worship, or mobile vans equipped with standard equipment and trained observers may serve as initial screening sites. While acknowledging that taking multiple measures on different days reduces misclassification of hypertension status, the World Heart Federation road map takes a pragmatic approach to screening, allowing diagnosis based on a minimum of 2 BP readings on a single occasion and diagnostic thresholds of 140 mm Hg systolic and 90 mm Hg diastolic. We should not expand hypertension screening programs until we can ensure the opportunity for follow-up treatment and control for every newly diagnosed patient.Treatment and ControlThe World Heart Federation global hypertension road map sets a minimum standard of pharmacological treatment of hypertension for patients with severe hypertension (≥160/100 mm Hg) or those with moderate hypertension (140–159/90–99 mm Hg) accompanied by high cardiovascular disease risk (Table). Access to affordable medications is a key component to improving treatment and control in LMICs. For many LMIC patients, high out-of-pocket medication costs limit medication initiation and adherence. Introduction of robust universal health insurance (including access to primary health care and affordable medications) improves hypertension control.7,8 Control can also be improved with use of fixed-dose combination pills, more frequent contact with providers (including cost-effective providers such as nurses, community health workers, or pharmacists), or decision support tools.9–11 These approaches and their combinations have rarely been directly compared, so for now, hypertension control programs should be planned on the basis of local strengths and obstacles. Even when mass screening and program costs are added, hypertension control programs likely remain cost-effective in LMICs.12–14Table. Recommend Most Basic Treatment Thresholds From the World Heart Federation Raised BP Road MapRecommended BP Treatment Thresholds: The World Heart Federation Raised BP Road MapBPCardiovascular Disease Risk CategoryAction RequiredSBP ≥160 mm Hg or DBP ≥100 mm Hg…Initiate drug treatmentSBP 140–159 mm Hg or DBP 90–99 mm HgHigh risk (as per local guidelines)Initiate drug treatmentSBP 140–159 mm Hg or DBP 90–99 mm HgLow riskEmphasize diet and lifestyle changes with regular (eg, 6 mo) rescreeningBP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.Adapted from Adler et al.6 Copyright © 2015, Elsevier, Inc. Authorization for this adaptation has been obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.Measuring SuccessWhat is the best benchmark for success in controlling hypertension worldwide? There are many paths to achieving the goal of 25% improvement in hypertension control, but it is clear that the health gain from achieving systolic BP <140 mm Hg is less in patients starting at a mean of 145 mm Hg than in those starting at a mean of 170 mm Hg. We should therefore consider measuring success in terms of not only percent controlled but also mean change per treated patient, which would place more weight on BP lowering in patients with more severe hypertension who will experience more BP reduction with treatment. Such a benchmark would make it easier for providers caring for populations with a greater proportion of severe hypertensive patients to succeed. More data are also needed on tradeoffs between feasibility and accuracy in measurement in LMIC settings so that frequency of BP screening is based not only on immediate feasibility but also on the consequences of missed or delayed diagnosis (false negatives) and treating misdiagnosed patients (false positives). Finally, more population BP data are needed so that no country-level hypertension estimates reported on the world map are imputed, but all are based on original measurements. As electronic health data collection improves in LMICs, it may be that future surveillance will gather data not from dedicated health surveys but from local clinics and pharmacies.Policies and PatientsThe means for detecting, treating, and controlling hypertension worldwide are at hand. What is needed now is the will to apply them more effectively. It is critical to raise interest in hypertension outside of the public health and medical communities. Even systematic universal screening and treatment programs will not control hypertension if patients' daily behavior is not motivated by understanding of its long-term consequences. Although the enormous health impact of hypertension is undeniable, it remains an asymptomatic risk and will never motivate public action as much as an immediately lethal and contagious disease. Health professionals alone cannot spur public interest in hypertension. It will take experts in communications, celebrity advocates, and local community champions to bring home the dangers of hypertension to the public. Only then will public interest in and action against hypertension match the magnitude of the problem.FootnotesCirculation is available at http://circ.ahajournals.org.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Andrew E. Moran, MD, MPH, Columbia University Medical Center, Department of Medicine, Division of General Medicine, 622 W 168th St, New York, NY 10032. E-mail [email protected]References1. 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