Is hypertension an ignored orphan?
Hypertension or high blood pressure is considered a disease of three paradoxes. It is easy to detect, but diagnosis rates are dismal. It is easy to treat, but treatment rates are disappointing.
While several potent drugs are available, control rates are abysmal. While high-income countries are observing a decline in hypertension burden, India is witnessing a rise in the burden of hypertension and its consequences such as stroke and heart attacks. A 20-mm Hg increase in systolic BP (SBP) is associated with a 35% greater risk for stroke and a 29% greater risk for heart attack. A 20/10-mm Hg elevation from 120/80 mm Hg increases the risk of developing end-stage kidney disease 2.6-fold, and mid-life hypertension is associated with a 41% increased risk of incident dementia during older ages. Yet, in India, only 1 in 3 are aware of their hypertension status, and in the worst-case scenario of remote and underserved areas, only 8% have their blood pressure controlled. This rising burden in hypertension contributes to massive economic hardships of patients and carers and increases costs to the health system in the face of low physician-to-patient ratios, misinformation and lack of access to medicines. Indeed, we have come a long way from masterly inactivity as proposed by the physician of Franklin D. Roosevelt to the current aggressive management of hypertension. However, the WhatsApp university continues to propagate the myth that there is no reason to manage high blood pressure with drugs and that it is a conspiracy of the nexus of doctors and pharma industry.
The control of BP on a large scale, vests on three principles: addressing established risk factors such as unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity through policy measures, paying attention to emerging risk factors that include pollution (air, water, noise, and light), urbanization, and a loss of green space and finally the universal provision of simple and inexpensive drugs to manage hypertension. These include the creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. New emergent risk factors require novel solutions. For example, it is estimated that if we bring down the ambient air pollution levels in Delhi from the current average of 125 μg/m3 to the national standard of <40 μg/m3, the prevalence of hypertension among adults can reduce by 15% from the current adult prevalence of 40%.
There have been several advancements in the control of hypertension through drugs. These advancements are not related to new or costly drugs but to some paradigm shifts in the way we manage hypertension. We now know that a half dose combination of drugs is very effective with few side effects, unlike the previous recommendation of full dose single drugs. Second, we need innovative strategies to improve compliance to drug therapy by patients and reduce physician inertia in aggressively controlling the blood pressure to the recommended levels. Several approaches such as single dose combinations, poly pills, electronic decision support systems are under evaluation. In addition, telemedicine appears promising as they save time for the patient, particularly if they need refills. Finally, we, in India, need clinical trials to identify the right anti-hypertensive drug. It would surprise many that no such trial has been conducted so far in India despite anti-hypertensive medications being available for over 50 years.
As Ibn Sena famously said, “there are no incurable illnesses; it’s only a lack of will”. It will be to our peril if we continue to ignore hypertension.
The article has been authored by Dorairaj Prabhakaran, Vice President (Research and Policy)