Table 1
Important lifestyle intervention strategies for the prevention and management of hypertension.
| Approach | Recommendations |
|---|---|
| Weight management | Best goal is ideal body weight. Expect about 1 mmHg for every 1-kg reduction in body weight [131]. |
| DASH Diet | Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Expect up to 11 mmHg reduction in SBP [132, 133]. |
| Reduced intake of dietary sodium | Aim for at least a 1000 mg/d reduction per day. (one fifth teaspoon of salt). Expect up to 5 mmHg reduction in SBP [134, 135]. |
| Enhanced intake of dietary potassium | Aim for 3500–5000 mg/d per day. Preferably by a diet (such as locally available fruits and vegetables) rich in potassium. Replacing high-sodium salt with potassium-rich salt is also recommended. Expect up to 4 mmHg reduction in SBP [136, 137]. |
| Physical activity | Aerobic exercise of 90–150 min/week. Expect up to 5 mmHg reduction in SBP [138]. Dynamic resistance exercise of 90–150 min/week. Expect up to 4 mmHg reduction in SBP [138]. Isometric resistance exercise of three sessions/week. Expect up to 5 mmHg reduction in SBP [139, 140]. Ambulatory physical activity such as step count (8000 to 10,000) per day [141]. |
| Moderation in alcohol intake | Complete abstinence or limit alcohol intake to ≤2 standard drinks per day with 2 days off per week. Expect up to 3–4 mmHg reduction in SBP [142]. |
[i] DASH = The Dietary Approaches to Stop Hypertension, SBP = Systolic Blood Pressure.
Table 2
Recommendations from recent hypertension management guidelines.
| Name | Diagnosis | Target/Threshold | Treatment (Initial) | Treatment (Sequencing) |
|---|---|---|---|---|
| ISH, Unger et al., 2020 [12] | ≥140/90 mm Hg (clinic BP). | Aim for at least a 20/10 mmHg BP reduction, ideally to <140/90 mmHg. Target BP <130/80 mmHg if tolerated and age <65 years (but >120/70 mmHg). | A+C (low dose) | A+C (full dose) A+C+D A+C+D+Spironolactone Treatment. Intensity stratified by CVD risk |
| NICE, 2019 [143] | ≥140/90 mm Hg (clinic BP). | Aim for <135/85 mmHg (aged <80) 145/85 mmHg (aged 80+). Use clinical judgement for people with frailty or multimorbidity | A or C or D | A+C or D A+C+D A+C+D+Spironolactone Treatment. Intensity stratified by CVD risk |
| JSH, Umemura et al., 2019 [53] | ≥140/90 mm Hg (clinic BP). | Aim for <130/80 (<75 years) or <125/75 (high-risk patients). targets for those (aged ≥75 years) are 140/90 and 135/85 mmHg, respectively. | A or C or D as first-line drugs. When a –20/–10 mmHg or greater decrease in BP is targeted, combination therapy should be considered. | Treatment intensity stratified by CVD risk. |
| ESC/ESH Task Force, 2018 [25] | ≥140/90 mm Hg (clinic BP). | Aim for <130/80 mmHg if age <65 years and <140/80 mmHg if age >65 years. | A+C or D (1 pill). Drug treatment may be considered when cardiovascular risk is very high due to established CVD in individuals with BP between 130–139/85–89 mmHg. | A+C+D (1 pill) A+C+D+Spironolactone (2 pills). Treatment intensity stratified by CVD risk |
| AHA/ACC, Whelton et al., 2017 [26] | ≥130/80 mm Hg | Aim for <130/80 mmHg | Single-agent (A or C or D) for BP between 130–140/80–90 mm Hg and high CV risk. Two first line agents (A+ C or D) if BP >140/90 mmHg. | Add more drugs (D or spironolactone as necessary) |
[i] ISH = International Society of Hypertension, NICE = The National Institute for Health and Care Excellence, JSH = Japanese Society of Hypertension, ESC = European Society of Cardiology, ESH = European Society of Hypertension, AHA = American Heart Association, ACC = American College of Cardiology, ABPM = Ambulatory Blood Pressure Monitoring, HBPM = Home Blood Pressure Monitoring, BP = Blood Pressure, A = ACE Inhibitor or angiotensin receptor blockers, C = Calcium Channel Blockers, D = Diuretics. In general, ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) is recommended in ideal settings for diagnosis of hypertension. The ABPM equivalent of clinic blood pressure for diagnosis of hypertension in general is 10 mmHg lower for 24h average or 5 mmHg lower for daytime average or 20 mmHg lower for nighttime average. The HBPM equivalent of clinic blood pressure in general is 5 mmHg lower.
Figure 1
Ten key actions recommended by the Lancet Commission of Hypertension [46]. Reprinted from The Lancet, 388, Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, et al. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension., 2665–712, Copyright (2016), with permission from Elsevier.
Table 3
Roadblocks and solutions.
| Dimension | Barriers | Solutions | |
|---|---|---|---|
| Pre/Diagnosis | Demographic and socio-economic factors (individual level) | Lack of access to testing centres | Facilitate access to health centres where individuals can be diagnosed. |
| Knowledge and beliefs (individual level) | People are not aware that they are at risk of hypertension/have hypertension. Individuals have a poor understanding of the importance of detecting hypertension. | Implement community awareness campaigns. Roll out opportunistic screening (see case study 2). Implement community- and worksite-based screening and education. Identify and engage local/national champions, including community health workers and volunteers and other non-traditional means to raise awareness [144] (e.g., barber shops[145]). Encourage out-of-office BP measurement (see case study 3). Encourage involvement in and expansion of May Measurement Month. | |
| Health systems resources and processes | Lack of health care professionals to screen/prescribe priority interventions and to provide counselling | Promote task sharing/enhanced scope of practice for non-physician health workers for opportunistic screening and early diagnosis of HT (see case study 5). Provide clinical decision support systems and incentives for health care providers. | |
| Social relations, norms, traditions | |||
| Demographic and socio-economic factors (individual level) | Financial constraints Forgetfulness and poor motivation Competing family and work responsibilities | Support universal health care (UHC) for all and ensure hypertension is adequately covered in UHC coverage plans. Facilitate access to health centres where patients can be followed up free of charge. Provide financial and social support for patients (eliminate user fees and out-of-pocket medication costs). Choose low-cost alternatives in settings where there is idiosyncratic pricing. | |
| Start of treatment | Knowledge and beliefs (individual level) | Poor understanding of hypertension Doubt that medicine can alleviate symptoms, fear of taking medication Lack of willingness to seek treatment for an asymptomatic condition | Involve families, social networks, local vendors accounting for the fact that many people self-manage using advice from such sources. Support e-health and education of both health care recipients and carers to enable linkage between diagnosis and treatment. |
| Health systems resources and processes | Health care professionals are not aware of guidelines Health care professionals are aware but do not follow guidelines Lack of understanding of guidelines by healthcare professionals | Educate health care professionals on hypertension risk and guidelines. Implement practical guidelines targeted to LMICs: (ISH guidelines). Promote the HEARTS approach and the ISH 2020 guidelines for use of simple of diagnostic and treatment algorithms (see case study 7). Encourage healthcare workers to share knowledge. Regulate and develop policies to increase the uptake of accuracy validated automated BP devices for routine screening and clinical care (see case study 6). | |
| Lack of linkage between the diagnosis of hypertension and treatment Lack of staff, medication, and equipment, long queues, long distances Priority interventions are not available Priority interventions are not affordable | Include affordable high-quality long-acting evidence-based and preferably single pill combination generic antihypertensive drugs in the national list of essential medicines. Promote task sharing/enhanced scope of practice for non-physician health workers with prescription rights to trained nurses and pharmacists for first line anti-hypertensive drugs. Ensure that priority interventions are available at the community level (including pharmacies) (see case study 9). Promote local quality-controlled manufacturing, bulk purchasing and/or efficient system to streamline medication supply (see case study 9). Ensure the availability of low-price, good-quality, and resistant sphygmomanometers. | ||
| Social relations, norms, traditions | Patient lack of partner and social support Poor relations between health workers and patients Fear of being reprimanded by health workers Poor relationships with family and friends ‘Unhealthy’ social norms and traditions Traditional hierarchical relationships between providers and patients | Involve families, social networks, local vendors. Develop and promote ‘healthy lifestyle’ campaigns (see case study 5). Educate providers and health workers re the need for enhanced communication with patients. | |
| Demographic and socio-economic factors (individual level) | Need to prioritise family, work, domestic commitments | Allow for multi-month medication prescriptions and community medication delivery so that patients with stably controlled BP require less frequent office visits. | |
| Follow-up and retention | Knowledge and beliefs (individual level) | Patients are not aware of the need for long term treatment and do not understand the care pathway Patients do not adhere to treatment Patients have issues with complex medication regimen, polypharmacy, side effects of medications Beliefs that long-term medication can cause damage to the body | Strengthen patient and carer education. Develop a whole-society approach, including families, media personalities and social networks. Deliver people centred care to include community-based hypertension management and easily accessible and affordable primary health care. Deliver education and campaigns for health care recipients to promote understanding of the importance of long-term treatment. Use information and communication technology to remind and reassure patients about recommendations. Use patient-nominated, non-professional treatment supporters (e.g., spouse, friends, family, peer groups). Strengthen the role of community health workers who often operate across sectors locally. Improve patient experience (e.g., foster interaction with HCWs when dealing with long queues). Utilise interventions with active involvement of patients and patient support groups. |
| Health systems resources and processes | Same as for ‘start of treatment/drug therapy’ | ||
| Social relations, norms, traditions | Same as for ‘start of treatment/drug therapy’ |
Figure 2
The ideal patient pathway for hypertension, referred to as the Continuum of Care on Page 9 © World Heart Federation.
Figure 3
Selected roadblocks on the way to the ideal patient journey © World Heart Federation.
Table 4
Commitments/achievements on the supply and the demand side.
| Supply | Demand |
|---|---|
| Governmental and societal willingness to make hypertension control a priority | Individual awareness of own BP |
| Shaping healthy environments to facilitate the choices of individuals towards healthier lifestyles | Individual lifestyle modifications |
| Treatment with cost-effective – and affordable – medications | Adherence to treatment |
| Education of both HCPs and patients to address awareness, facilitate and encourage adherence to treatment and understanding that BP control is a lifelong commitment. |
Figure 4
PASCAR Roadmap on Hypertension with a 10-point action plan. Reprinted from Global Heart, 13(1), Dzudie A, Rayner B, Ojji D, Schutte AE, Twagiramukiza M, Damasceno A et al, Roadmap to Achieve 25% Hypertension Control in Africa by 2025, pp. 45–59, 2018, with permission from Ubiquity Press.
Figure 5
The Call to Action agreed in Kenya, reprinted from ‘Accelerating Cardiovascular Health and Care in Kenya’, available at https://www.world-heart-federation.org/wp-content/uploads/2019/01/WHF-Care-in-Kenya-brochure_WEB.pdf, with permission from WHF.
Table 5
Successful features of HT control programmes.
| Programme | Country | Year started | Key components | Control rate |
|---|---|---|---|---|
| HEARTS Cuba [130] | Cuba | 2016 | Highly organized, comprehensive, accessible primary care system Affordable medications Education and training for the public and patients to improve awareness and self-management Standardized training for healthcare professionals Simple directive diagnosis and treatment algorithm Registry providing performance reports Dedicated funding | From 37.7% to 58% in 1 year (overall population) |
| HOPE 4 [112] | Colombia and Malaysia | 2014 | Community screening Treatment of risk factors by non-physician health workers using management algorithms Counselling programmes Free antihypertensive and statin medications Support from family or friend | 69% (intervention group) 30% (control group) |
| Yaroslavl programme [146] | Russia | 2011 | Specific training for healthcare professionals Public awareness program Patient registry with performance reporting Patient recall system | 17% to 33% in 4 yrs (overall population) |
| Kaiser Permanente Northern California Program [147] | USA | 2004 | Treatment algorithm Regularly updated hypertension guidelines Team-based care, BP measurements by medical assistants Registry with performance reports Single-pill combination therapy Quality performance metrics | From 44% to 90% in 13 yrs (clinical population) |
| Canadian Hypertension Control Program [130, 148] | Canada | Start mid-1990s | Regularly updated management recommendations Standardized education to primary care Education for the public and patients Dedicated leadership position | 13% to 66% in 6 yrs (overall population) |
Figure 6
Hypertension Management Protocol for Primary Health Care Settings, reproduced with permission from Resolve to Save Lives.