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WHO simplifies treatment guidelines for hypertension

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CONTEXT

The World Health Organization recently came out with guidelines for pharmacological treatment of hypertension. Hypertension is the leading cause of death in India and around the world. It is often associated with lifestyle related disease. 

What Data Suggests

  • High blood pressure is a leading cause of disease, disability and death in all regions of the world, affecting an estimated 1.4 billion persons across the world.
  • But still only 14% have it under control. This is because of three gaps in health system performance.
  • Many who have hypertension are not aware, several of those who are diagnosed  are not taking adequate treatment and only half of those who are treated are effectively controlled on their prescribed treatment.
  • If health systems do not improve their ability to detect and effectively treat hypertension, serious diseases of heart, brain, kidneys and blood vessels will rise.

Adopting Healthy Habits and Medications

  • People having blood pressure will need to adopt healthy living habits: reduced salt intake; consumption of more fruit and vegetables; avoidance or limited intake of alcohol; regular physical activity; maintenance of a healthy body weight; adequate water consumption, good sleep and stress reduction.
  • In addition, several will need drugs for adequate control of blood pressure. The recent WHO guidelines is explicitly dealing with this issue. 
  • Apart from assessing the strength of published scientific research, we also drew on the perspectives of policy makers, health system managers, healthcare providers, patients and communities.
  • While several international guidelines on management of hypertension do exist, many of them reflect the tertiary care perspective of high-income countries.
  • Effective hypertension control must pivot on competent and continuous primary care, for both early detection and long-term management.
  • Guidelines have also been segregated over whether hypertension treatment should be initiated solely on the basis of blood pressure values or on a comprehensive risk assessment which takes age, gender, smoking status, body mass, prior cardiovascular disease, diabetes and blood cholesterol profile besides blood pressure values into consideration.

Suggested thresholds

  • Initiation was recommended for all adults whose blood pressure readings, reliably measured, exceed 140 mm of mercury for the upper level (systolic) or above 90 mm for the lower level (diastolic). 
  • However, for persons with a prior history of cardiovascular disease, diabetes or chronic kidney disease, treatment should be initiated if the systolic pressure exceeds 130 mm.
  • The same threshold is advised for persons with a high future risk of developing cardiovascular disease, based on clinical and laboratory assessment.
  • Laboratory tests should be performed at the time of diagnosis of hypertension. However, if testing facilities are not readily available and tests are likely to be delayed, treatment may be initiated with a single relatively safe drug amlodipine (a long acting calcium channel blocker) and tests may then be ordered. 
  • When test results are available, they will help with choice of further treatments and in comprehensive risk assessment.

What drugs can be prescribed

  • When tests confirm that there are no contraindications to certain drugs, three classes of drugs are offered to the prescribing physician on the strength of evidence.
  • Those are, thiazide diuretics and thiazide-like agents; angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (both of which act at different levels of the renin–angiotensin system) and calcium channel blockers.
  • Better clinical outcomes are achieved in most persons when drugs from any two of these categories are initially used in combination, in moderate doses, rather than using a single drug in a high dose.
  • This provides the advantage of combining two different but complementary modes of action and avoids the side-effects that accompany a high dose of any single drug.

Conclusion

  • These guidelines are positioned within a strong scientific frame of evidence, while accommodating the practical aspects of implementation across diverse health systems.
  • Low- and middle-income countries, which have the highest health burdens resulting from uncontrolled hypertension, should find it easier to implement these guidelines rather than those tailor-made for high-income countries.

Source: The Hindu.

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