Hypertension Journal

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Hypertension: Where we Stand and the Road Ahead
  JOHTN
GUEST EDITORIAL
Hypertension: Where we Stand and the Road Ahead
Satyendra Tewari
Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Address for correspondence: Dr. Satyendra Tewari, Professor, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh, India.
Tel.: 91-522-2494000 Ext. 4229
Phone: +919415012127, Fax: 91-522-2668573/2668013.
E-mail: stewari_sgpgi@yahoo.com
Received: 02-11-2017; Accepted: 12-12-2017
 
ABSTRACT
Hypertension is the most common risk factor for coronary arterydisease, stroke, and chronic kidney disease. Hypertension isresponsible for at least 45% of deaths due to heart disease and 51%of deaths due to stroke.[1] According to the WHO, the prevalenceof raised blood pressure (BP) in Indians was 32.5% (33.2% inmen and 31.7% in women). Every third patient is hypertensive.The WHO has proposed a relative reduction in tobacco use by30%, harmful alcohol intake by 10%, salt consumption by 30%,prevalence of hypertension by 25%, control of cardiovasculardisease (CVD) risk factors in at least 50%, and stem the rising tideof obesity and diabetes for decreasing the non-communicabledisease (NCD) burden in world.[2] The UN has also adoptedthe aims for a 33% reduction in NCD mortality by 2030.[3] Toachieve these targets, substantial reductions in CVD (accountsfor over half of all NCD-related deaths) are mandatory. The mostimportant strategy for reducing CVD mortality is BP controland tobacco smoking cessation. In 25 years period from 1990to 2015, the prevalence of systolic BP levels of at least 110-115mmHg rose from 73,000 to 81,000/100,000 population whilethe prevalence of systolic BP ≥140 mmHg rose from 17,000 to21,000/100,000. Hypertension led to 4.9 million deaths due toischemic heart disease, 2.0 million due to hemorrhagic stroke,and 1.5 million due to ischemic stroke in 2015.[4] Dementia isa common problem in elderly estimated the cumulative risk ofdementia at 33% for men and 45% for women from age 65 toage 100 years. One of the suspected risk factors for dementiaand Alzheimer's disease is hypertension. In mid-adulthood,hypertension was associated with increased risk of dementia.[5,6]
How to cite this article: Tewari S. Hypertension: Where westand and the road ahead. Hypertens 2018;4(1): 1-4.
Source of support: Nil
Conflict of interest: None
 
 

Hypertension is the most common risk factor for coronary arterydisease, stroke, and chronic kidney disease. Hypertension isresponsible for at least 45% of deaths due to heart disease and 51%of deaths due to stroke.[1] According to the WHO, the prevalenceof raised blood pressure (BP) in Indians was 32.5% (33.2% inmen and 31.7% in women). Every third patient is hypertensive.The WHO has proposed a relative reduction in tobacco use by30%, harmful alcohol intake by 10%, salt consumption by 30%,prevalence of hypertension by 25%, control of cardiovasculardisease (CVD) risk factors in at least 50%, and stem the rising tideof obesity and diabetes for decreasing the non-communicabledisease (NCD) burden in world.[2] The UN has also adoptedthe aims for a 33% reduction in NCD mortality by 2030.[3] Toachieve these targets, substantial reductions in CVD (accountsfor over half of all NCD-related deaths) are mandatory. The mostimportant strategy for reducing CVD mortality is BP controland tobacco smoking cessation. In 25 years period from 1990to 2015, the prevalence of systolic BP levels of at least 110-115mmHg rose from 73,000 to 81,000/100,000 population whilethe prevalence of systolic BP ≥140 mmHg rose from 17,000 to21,000/100,000. Hypertension led to 4.9 million deaths due toischemic heart disease, 2.0 million due to hemorrhagic stroke,and 1.5 million due to ischemic stroke in 2015.[4] Dementia isa common problem in elderly estimated the cumulative risk ofdementia at 33% for men and 45% for women from age 65 toage 100 years. One of the suspected risk factors for dementiaand Alzheimer's disease is hypertension. In mid-adulthood,hypertension was associated with increased risk of dementia.[5,6]

Unfortunately, the implementation of knowledge ofhypertension and its treatment and consequences into clinicalpractice is poor and disappointing. About 50% of population isunaware of their hypertension status. Even in highly developedand affluent countries, satisfactory control of BP amounts to nomore than approximately 30% of the diagnosed hypertensivepatients, and in other countries, it is even less. In India, awarenessof BP in rural and urban India was found to be 25.1% and 41.9%, respectively, while percentage of hypertensive patients havingtheir BP under control in rural and urban India was only 10.7and 20.2, respectively.[7]

 
For many decades, observational studies have documentedlower risks for cardiovascular outcomes in individuals with lowerBP. The prospective studies collaboration reported a continuousand graded relation of systolic and diastolic BP to mortalityfrom coronary heart disease and stroke.[8] Observational data donot always predict the effects of clinical intervention and goodrandomized trials are required to assess the effect of treatmentof hypertension on risk and outcomes for cardiovascular disease.SPRINT trial was a landmark trial that demonstrated clear benefitsof the intensive BP lowering strategy.[9] Extrapolated to thegeneral population, it is clear that large numbers of hypertensiveindividuals could benefit from more aggressive BP lowering.

The dietary approaches to stop hypertension (DASH)eating plan, as studied in the landmark clinical trial, emphasizedincreased consumption of fruit, vegetables, whole grains, nuts,and low-fat dairy products.[10] The DASH diet has higher protein,fiber, and potassium content, but lower fats and carbohydrates.DASH diet was found to lower systolic and diastolic BP by 5.5and 3.0 mmHg, respectively.

Despite proven benefits, DASH diet is grossly underutilized.Public health interventions and educational programs can helppatients to learn about healthy eating habits that fit withintheir budgets. The prescription for lifestyle intervention in themanagement of elevated BP should be emphasized. Effective,individualized nutrition counseling is complicated and timeconsuming. Therefore, utilizing the services of other professionalssuch as counselors and dieticians for patients with hypertensioncan be a good step forward. It is a collective responsibilityof health professionals to emphasize healthy lifestyle habitsincluding the DASH eating plan, physical exercise, weight loss,tobacco cessation to our colleagues, and patients.

The increasing prevalence of obesity in children will leadto a tide of young adults with hypertension, diabetes, and dyslipidemia who with time will become middle-aged adultsat increased risk for cardiovascular disease. This highlightsthe importance of effective prevention programs to tackle theepidemic of childhood obesity. The consequences of increasedbody mass index are astounding. It accounted for 4 milliondeaths worldwide and more than two-thirds of these deaths weredue to cardiovascular causes.[11] The widespread applicationof genome-wide association studies has identified hundreds ofgenetic variants associated with each of the CVD risk factorsand with the occurrence of coronary heart disease.[12] Weightloss in overweight and obese individual should be considered anessential approach to the primary prevention of hypertension,diabetes mellitus, and coronary heart disease and an integralpart of treatment for patients with hypertension and othercardiovascular disease risks. Given the ongoing worldwideobesity epidemic, strategies to prevent weight gain throughoutthe life course must be promoted as a powerful public healthapproach for the prevention of hypertension, diabetes, and thedownstream occurrence of cardiovascular disease.

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Tewari

Relation between sodium intake and BP has been a subjectof debate for decades. One of the most convincing trials to date,the DASH diet study, tested sodium restriction on a controldiet versus a diet rich in vegetables, fruits, and low-fat dairyproducts. In the DASH study, sodium restriction from high tointermediate levels reduced systolic BP (SBP) by 2.1 mmHg,while sodium restriction from intermediate to low levels loweredSBP by 4.6 mmHg. The combined effects of the DASH diet andsodium restriction were considerable and resembled those ofsingle-agent drug treatment for hypertension. In participantswith hypertension at baseline, the combination of the DASHdiet with low sodium levels resulted in 11.5 mmHg lower SBP.[13]Thus, the public health consequences of sodium restriction maybe great. In addition to modest antihypertensive effects, sodiumrestriction favorably impacts the cardiovascular system. Inthe hypertension genetic epidemiology network study, highersodium intake (>3.7 g per day) was found to be associated withincreased the left atrial and left ventricular dimensions, as wellas with two different indices of the left ventricular strain andimpaired left ventricular diastolic filling.[14]

In end of 2017, the new antihypertension guidelines werereleased by ACC/AHA.[15] These have generated considerabledebate. These guidelines closely follow the result of SPRINTtrial. The most noteworthy feature of the 2017 guidelinesis the new classification scheme for elevated BP [Table 1]:Whereas an SBP of 120-139 mmHg or a diastolic pressureof 80-89 was previously classified as prehypertension, theselevels of BP are now classified as Stage 1 hypertension. Thelowering of the threshold defining hypertension will result inan increase in the proportion of adults with hypertension in theUnited States from 32% to 46%. Meta-analyses have revealedthat CVD risk begins at the SBP threshold of 130 mmHg andthe diastolic BP threshold of 80 mmHg.[8,16] The medicosocialimplications of restaging hypertension are vast. By applyingthe new classification, the global prevalence of hypertensionin the age group of 20-55 years will instantly escalate by an additional 14% and in the age group of 55-74 years by nearly10%. The guidelines committee has taken a bold step aimedat decreasing the global burden of CVD by targeting lowerBP threshold realizing the fact that even modest elevations insystemic BP >120 mmHg contribute to CVD burden (clinicalor subclinical). Another new element introduced into the 2017guidelines is the incorporation of formal CVD risk assessmentinto the decision process regarding the level of BP that shouldtrigger pharmacologic intervention. When the 10-year predictedrisk of CVD exceeds 10%, initiation of pharmacologic treatmentis now recommended for adults with Stage 1 hypertension.[17]As a result, only few elderly patients with Stage 1 hypertensionwill be untreated due to more aggressive treatment of systolichypertension in older patients in whom a majority have isolatedsystolic hypertension. Another feature is the promotion ofthe use of home-based BP measurement and ambulatoryBP measurement and less reliance on office readings. This isimportant when seen with perspectives of diagnosing white coathypertension and masked hypertension as well as when labelinga person as hypertensive for the 1st time.

 
Table 1: Classification of hypertension according to 2017 ACC/AHA guidelines
Hypertension: Where we Stand and the Road Ahead
DBP: Diastolic blood pressure, SBP: Systolic blood pressure, BP: Bloodpressure

The SPRINT results clearly showed that aggressive loweringof BP is beneficial in all age groups >50 years. However, there iscontroversy regarding method of BP measurement in the study.The methodology used (automated BP measurement in quietroom without any observer) is impractical in daily practice. Toreconcile a SPRINT equivalent office, BP reading is a challenge.It has been postulated that SPRINT BP of < 120 mmHg is almostsimilar to office BP of about 10-15 mmHg higher (130-135mmHg). Therefore, it can be said that the new guidelines merely"tighten" the prevailing objective for BP goals in the community.The current goals of hypertensive treatment are shown inTable 2. Currently, angiotensin-converting enzyme inhibitors,angiotensin receptor blockers, calcium channel blockers, anddiuretics are the leading groups of antihypertensive medications.Beta-blockers for control of hypertension have fallen below.Alpha-blockers and agonists like clonidine are to be given onindividual need. Specific targets can be achieved by effectivemonotherapy or sequential combination drug therapy. Patientswho were previously treated to goal may now require to add ondrugs to their previous therapy to meet new targets, therebyputting some extra burden on patient or health provider'sexchequer. The key question is not whether more patients will betreated as a result of widespread adoption of the new guidelines.

 
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Hypertension road ahead Tewari

Table 2: Current goals of hypertension treatment
Hypertension: Where we Stand and the Road Ahead
DBP: Diastolic blood pressure, SBP: Systolic blood pressure, BP: Blood pressure, CVD: Cardiovascular disease, ASCVD: Atherosclerotic cardiovasculardisease

Table 3: Classification of hypertension in children
Hypertension: Where we Stand and the Road Ahead

Rather, the important point is whether the right patients arebeing treated. The adoption of new guidelines will reduce therisk of stroke and heart attack for individual high-risk patientswhile lowering the population burden of CVD, thus proving tobe cost-effective in long run by virtue of decreasing long-termmorbidity and mortality.

Adult hypertension is a much talked about subject, but thesame cannot be said for hypertension in children. Defininghypertension in children and adolescents is a difficult task,much unlike the approach used to define it in adults, in whomextensive population-based data establish levels of BP abovewhich risk increases for hypertension-related CVD events. Theclassification for hypertension in children is given in Table 3.[18]

To conclude, the prevention and patient education are asimportant as the diagnosis and treatment. Future programs toincrease health literacy and hypertension control can use uniqueand novel ideas like are likely to use of smartphones, internetlinked BP devices, smart pillboxes, and apps to track BP, dailymedication use, and encourage adherence with prescribedtherapy. Better use of such support systems can make our jobsas health-care providers little easier and our patients more wellinformed. It is ultimately the population that should benefit fromimproved BP control.
 
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