According to the WHO global burden of disease, high blood pressure (HBP) is the leading cause of morbidity, mortality and disability worldwide resulting in 9.4 million deaths and 162 million years of productive life lost.(1) More than two thirds of individuals with hypertension live in low and middle-income countries (LMICs).
Untreated hypertension can have devastating consequences, increasing the risk of complications such as stroke, cardiovascular disease and chronic kidney diseases. Unlike in high income countries (HICs), the majority of hypertension related deaths in LMICs occur at younger ages, with consequent adverse health, economic and societal implications.
A large proportion of individuals with hypertension are not aware of their disease. Of those aware, half do not receive any treatment, and of those treated, half are not controlled. In many parts of the world the awareness, treatment and control is even lower, with less than 10% of individuals with hypertension controlling their condition.
Inadequate access to health services and simple evidence-based medications, delays in diagnosis, limited opportunistic or targeted screening programmes, poor adherence to prescribed pharmacological and non-pharmacological therapies, and complexities associated with taking multiple medications are some of the reasons for inadequate control and failure to attain treatment targets. The capacity of health systems to identify those with hypertension, provide evidence-based interventions and ensure compliance to these interventions is severely limited by the lack of trained healthcare workforces and the high costs of medical treatment in many parts of the world.
Effectively addressing hypertension worldwide requires a multi-pronged strategy comprising population-based risk reduction strategies and improvements to health systems. Several innovations are available and have been evaluated in LMICs. These include task shifting with the involvement of non-physician healthcare providers, empowered by electronic clinical decision support systems (DSS). Such an intervention, evaluated by the SimCard Trial in India and China, demonstrated a 25% increase in the proportion of patient-reported anti-hypertensive medication use in community settings.(2) The mPower Heart Project in India, a nurse-facilitated, DSS-enabled intervention for hypertension care delivery in primary care, demonstrated 50% higher detection during opportunistic screening, as well as large and sustained reductions in blood pressure (BP) among hypertension patients at 18 months of follow-up (unpublished data; personal communication Prabhakaran D).
Other innovations include fixed-dose combinations to improve control and adherence, reminders through text messaging, innovative approaches for health promotion using social media, evaluation of salt substitutes, using traditional approaches such as yoga to promote a healthy lifestyle, simplifying BP measurement by miniaturizing BP monitors and connecting them to smartphones. Many of these innovations are being evaluated and in the next few years we will witness several revolutionary changes in the detection and management of hypertension.
- World Hypertension League and the International Society of Hypertension. High Blood Pressure: Why Prevention and Control are Urgent and Important. A 2014 Fact Sheet. 2014; Available at: http://ish-world.com/news/a/WHL-and-ISH-Hypertension-Fact-Sheet/ accessed on 14/05/2016
- Tian M, Ajay VS, Dunzhu D, Hameed S, Li X, Liu Z, Li C, Chen H, Cho K, Li R, Zhao X, Jindal D, Rawal I, Ali MK, Peterson ED, Ji J, Amarchand R, Krishnan A, Tandon N, Xu LQ, Wu Y, Prabhakaran D, Yan L. A Cluster-Randomized Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India. Circulation. 2015 Jul 17. pii: CIRCULATIONAHA.115.015373.