Recent Guidelines for Hypertension
2019; Lippincott Williams & Wilkins; Volume: 124; Issue: 7 Linguagem: Inglês
10.1161/circresaha.119.314789
ISSN1524-4571
AutoresH K Chopra, C. Venkata S. Ram,
Tópico(s)Renal function and acid-base balance
ResumoHomeCirculation ResearchVol. 124, No. 7Recent Guidelines for Hypertension Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBRecent Guidelines for HypertensionA Clarion Call for Blood Pressure Control in India H.K. Chopra and C. Venkata S. Ram H.K. ChopraH.K. Chopra From the Department of Cardiology, Moolchand Hospital, New Delhi, India (H.K.C.) and C. Venkata S. RamC. Venkata S. Ram Correspondence to C. Venkata S. Ram, MD, MACP, World Hypertension League/South Asia Office, Apollo Hospitals, and Apollo Medical College, Hyderabad, India. Email E-mail Address: [email protected] World Hypertension League/South Asia Office, Apollo Hospitals, and Apollo Medical College, Hyderabad, India (C.V.S.R.) Texas Blood Pressure Institute, University of Texas Southwestern Medical School, American Society of Hypertension, Dallas (C.V.S.R.) Faculty of Medicine and Health Sciences, Macquarie University, Medical School Sydney, Australia (C.V.S.R.). Originally published28 Mar 2019https://doi.org/10.1161/CIRCRESAHA.119.314789Circulation Research. 2019;124:984–986Systemic hypertension is the leading cause of global cardiovascular mortality and morbidity. Yet, it is a condition which can be diagnosed easily and without much costs. Uncontrolled hypertension promotes target organ damage and significant disease burden on the community. Therefore, aggressive control of hypertension is mandatory to preserve and protect public health in India.Cardiovascular disease (CVD) causes nearly 18 million deaths annually. Despite the phenomenal progress in disease management, 30% of global deaths are attributable to CVD.1 A number of genetic and acquired risk factors for the development of CVD are identified. Amongst the CVD risk factors, systemic hypertension remains as the leading root cause of excessive premature mortality and morbidity.2 The consequences of any level of elevated blood pressure (BP) are of momentous impact on the public health. Since hypertension is a common disorder in the community, guidelines on its management are issued periodically by the experts in the field and advocacy professional organizations. It is estimated that nearly 1.5 billion adults in the world will have hypertension in the decade ahead. If this trend is not reversed, the ramifications do not bode well for the pandemic of CVD. It has thus become a transcendental priority to lower the prevailing BP levels across the world.The latest European guidelines3 retain the previous definition of hypertension (ie, BP >140/90 mm Hg) whereas the American guidelines4 lowered the threshold to define hypertension to <130/80 mm Hg (Tables 1 and 2). The American guidelines (proposing new definition of hypertension) are driven largely by meta-analyses of important outcome trials including SPRINT (Systolic Blood Pressure Intervention Trial). And the European guidelines are assembled largely on the basis of population attributable risk. Yet, both the sets of guidelines recommend the same therapeutic BP goal of 70 years), the incidence of hypertension is nearly 60%. India is under a long stretch of escalating incidence of hypertension mediated disease which is battering and destroying the health of its citizens (Figure 1B). Unless this incontrovertible track is dismantled, India is marching towards a cardiovascular calamity of startling proportions never witnessed.Table 1. Comparison of the Latest ACC/AHA and ESC/ESH Hypertension GuidelinesParameterACC/AHAESC/ESHDefinition of hypertension, mm Hg>130/80>140/90Grading of normal pressure, mm HgNormal <120/80Optimal <120/80Elevated 120–129/<80Normal 120–129/80–84High normal 130–139/85–89Grading of hypertension, mm HgGrade 1, 130–139/80–89Grade 1 140–159/90–99Grade 2, ≥140/90Grade 2, 160–179/100–109Grade 3, ≥180/110Target blood pressure in various subsets≤65 y, <130/80<65 y, <130/80≥65 y, <130/80≥65 y, <140/80Data derived from Williams et al3 and Whelton et al.4Table 2. Office BP Treatment GoalsAge GroupOffice Systolic Blood Pressure Treatment Target Ranges (mm Hg)Diastolic Treatment Target Range (mm Hg)Hypertension+ Diabetes Mellitus+ CKD+ CAD+ Stroke/TIA18−65 yTarget to 130 or lower if toleratedTarget to 130or lower if toleratedTarget to <140 to 130if toleratedTarget to 130or lower if toleratedTarget to 130or lower if tolerated<80 to 70Not <120Not <120Not <120Not <12065−79 yTarget to <140 to 130if toleratedTarget to <140 to 130 if toleratedTarget to <140 to 130 if toleratedTarget to <140 to 130 if toleratedTarget to <140 to 130 if tolerated<80 to 70≥ 80 yTarget to <140 to 130if toleratedTarget to <140 to 130if toleratedTarget to <140 to 130 if toleratedTarget to <140 to 130 if toleratedTarget to <140 to 130if tolerated<80 to 70Diastolic treatment target range (mmHg)<80 to 70<80 to 70< 80 to 70<80 to 70<80 to 70Data derived from Williams et al.3 BP indicates blood pressure.Download figureDownload PowerPointFigure 1. A, Latest hypertension guidelines 2017/2018. B, Financial burden from CVD-INDIA. CVD indicates cardiovascular disease; and HTN, hypertension. Data derived from Gupta.6India should no longer tolerate the current dismal rates of BP control of <15%!6 This frightful status quo should be renounced in favor of healthy BP levels for the country. There is a seeming argument that the newer (lower) thresholds for goal BP levels are unattainable particularly if the country adopts American definition of hypertension. There is enough evidence to prove that BP levels between 130 to 139/80 to 89 mm Hg in the Indian population cause substantial CVD, stroke, and premature mortality7 (Figure 2). A large number of Indians have prehypertension, which embraces the new stage-I hypertension per American guidelines. Although severe hypertension is identified and managed in a specialist care setting, considerable percentage of Indians have stage-I hypertension by any definition. And if you add to this prodigious number, the previous category of prehypertension, the absolute numbers of people at risk is a mind-boggling figure. Given this fact and confronting the storm of hypertension driven scourge, it is germane for India to endorse the newer (lower) thresholds for target BP levels.8 It is indeed a challenge but to turn deaf ear is not justified. Embracing and acknowledging the need for aggressive BP goals will provide enormous public health benefits paving the way for a healthy India. Of course, the ambitious BP target will invite some dissidence. But the denial of insurmountable documentation will take us nowhere and is a dangerous attitude. Any day, prevention is better than roadside assistance!Download figureDownload PowerPointFigure 2. Deaths from ischemic heart disease and blood pressure levels from Mumbai/India cohort study. SBP indicates systolic blood pressure.The European hypertension guidelines identify South Asians as the highest risk category and most vulnerable to the consequences of elevated BP. Coupled with this blaring sound is the growing incidence of diabetes mellitus and prediabetes mellitus in India which further exasperates the prospect of already worsening chronic disease burden.9 Furthermore, European guidelines have identified high uric acid level as an additional risk factor in patients with hypertension; hyperuricemia is common in Indian patients with hypertension.10 What is the pertinency of new guidelines to control hypertension in India? Because of its vast number of people with hypertension, lower BP thresholds will be difficult to accomplish but of far-reaching beneficial consequence. There is enough affirmation that BP levels between 130 to 139/80 to 89 mm Hg cause substantial CVD complications and hence, we should advocate a goal BP of <130/80 mm Hg for most patients with hypertension.11 It is unwise to question whether India should espouse aggressive BP control targets. Instead, the country should lead the way in advocating healthy BP levels for its citizens. Signing up for the revised goals will face tenacious obstacles. Hypertension awareness in the country is low with urban-rural differences in health care access12 and because of fragmentation of disease prevention pathways. Health systems enhancement and standardized access of medical care and medicines should be developed with some power of enforcement at the local level. Any broad national policy towards noncommunicable disease (NCD) has to percolate to the grassroots.CVD and stroke rates in India have escalated rapidly and upward in the last decade. This direction, if not reversed, will impact the human resource pool in the country and will be an instant setback to the economy and national productivity. NCDs account for more than 54% of total deaths in India, out of which CVDs contribute a share of 25%! A worrisome trend is relentless occurrence of NCDs in the ages <50 years, an alarming situation.13 The loss of productivity (from NCDs) is highest in the age group 35 to 64 years, much higher than comparable countries like China and Brazil. Public education about hypertension and NCDs has to be stepped up by all the available forums.14,15Patient empowerment using information technology (mobile phone apps and understandable educational tools) should be activated to overcome the regional, cultural, economic, and cultural barriers. None of these avenues can be traversed without professional education in the arena of NCD prevention. Over decades, the country has been witnessing a steady rise in BP levels, cholesterol levels, glucose levels, body weight, sedentary life-styles, and unhealthy nutrition which calls for multidimensional comprehensive preventive measures. Lifestyle changes have to be enforced to prevent NCDs. National policies and objectives are often discussed, cited, and promoted but not implemented.Indians develop coronary heart disease at younger age (<40 years) irrespective of their geographic or expatriate status. Ironically, the worst affected are those who cannot afford medical expenses. This situation requires immediate implementation of changes in health care delivery access to the entire population. The Indian hypertension guidelines16 should be revised to advocate more aggressive BP reduction as mandated by the current unfavorable trends in CVD driven by uncontrolled hypertension.6 Massive screening check-ups for hypertension should be undertaken but with a guaranteed follow-up and evaluation. BP measurements (preferably with a Kiosk) should be made available at public places like airports, railway stations, shopping malls, hospital lobbies, bank lobbies, and at the workplace to promote awareness about hypertension and its sequelae.To meet the objective of decreasing the CVD mortality by 25% by 2025, the prevalence of hypertension in India has to be reduced by 25% and secondary prevention by 50%. These ambitious but necessary aims cannot move forward by meaningless arguments, and by measureless silly debates by social engineers, eloquent savants, and self-appointed pontiffs. Lack of urgency is a huge obstacle to prevent NCDs. Chronic disease burden from NCDs does not elicit panic like a flu epidemic or Zika and Ebola infections. For politicians and illiterate arm chair commentators, preventive medicine is distant and only an abstract. Fortunately, in the long road leading to CVD, opportunities exist for prevention at every step. India stands to benefit immensely if it seizes every moment to disarm the onset and progression of hypertension mediated CVD. It is essential for the practitioners to recognize that initiating BP control is only the first step and they should monitor the patients closely to ensure that the recommended therapeutic goals are maintained without interruption. India has vastly succeeded in containing communicable diseases; it can repeat the same logic and magic in curbing NCDs as well!In collective wisdom, India is likely the ultimate receptacle for the challenges, solutions, and benefits from tighter BP goals for its vast population.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to C. Venkata S. Ram, MD, MACP, World Hypertension League/South Asia Office, Apollo Hospitals, and Apollo Medical College, Hyderabad, India. Email [email protected]comReferences1. NCD Risk Factor Collaboration (NCD-RiSC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants.Lancet. 2017; 389:37–55. doi: 10.1016/S0140-6736(16)31919-5CrossrefMedlineGoogle Scholar2. GBD 2016 Risk Factors Collaborators. 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