02 Oct 2024
Why hypertension is a major unresolved problem
Hypertension: A major global health challenge
Explore the global challenge of hypertension, affecting one in three adults, and the strategies for screening, diagnosis, and management, including lifestyle modifications, pharmacotherapy, and device-based treatments, as outlined by Sofie Brouwers.
Hypertension remains one of today’s major global health challenges despite the existence of adequate tools for screening, diagnosis, treatment, and ongoing advances in public health initiatives. Affecting about one in three adults worldwide, its prevalence varies across regions, with higher rates observed in low- and middle-income countries1. Specifically, Sub-Saharan Africa, South Asia, and parts of Latin America face a disproportionate burden due to genetic predisposition, dietary patterns, and socioeconomic factors.
Hypertension significantly contributes to cardiovascular morbidity and mortality, despite the theoretical possibility of prevention1,2. This report highlights the main persisting problems in screening, diagnosing, and hypertension management.
Challenges in screening and diagnosis
First, the lack of awareness and screening of hypertension results in high undiagnosed rates. Globally, 41% of women and 51% of men with hypertension are undiagnosed3. The rates of undiagnosed hypertension vary among regions (from 23-69%) due to differences in health coverage and primary care3. One of the main challenges in diagnosing hypertension is its asymptomatic nature in the early stages. Patients often remain unaware of their condition due to the lack of noticeable symptoms, leading to delayed diagnosis and treatment initiation. Additionally, the variability in blood pressure readings complicates accurate diagnosis. To address this, out-of-office (home and/or ambulatory) blood pressure measurements have been recommended for decades (ESC/ESH arterial hypertension guidelines since 2003), yet they remain underused.
Challenges in the management of hypertension
Therapeutic inertia and treatment adherence
Once hypertension is diagnosed, also managing it remains a significant public health challenge despite the availability of effective lifestyle interventions, pharmacotherapy, and advanced treatments like renal denervation (the 3 cornerstones).
The high occurrence of (i) therapeutic inertia and (ii) lack of treatment adherence contribute to high levels of uncontrolled hypertension4:
- Therapeutic inertia is the failure of healthcare providers to initiate or intensify therapy when indicated. This inertia can stem from multiple sources, including a lack of familiarity with current guidelines, concerns about potential side effects, and miscommunication between patients and providers. Additionally, healthcare providers may underestimate the severity of hypertension or overestimate the level of control achieved with current treatment plans.
- Treatment adherence refers to the degree to which patients correctly follow medical advice. Although adherence usually pertains to medication, it also includes adherence to healthy lifestyle measures, especially considering cardiovascular risk factors. Factors influencing lack of adherence include psychological factors such as stress and mental health conditions, and socioeconomic factors such as the cost of medications and access to healthcare services.
Three cornerstones of hypertension therapy
1 - Lifestyle modification
The first cornerstone of therapy involves modifying lifestyle through dietary changes, increased physical activity, and weight loss. Bringing healthy lifestyle measures into practice can lower blood pressure significantly and comparable to approximately 1 pharmacological agent. For example, a 5 kilogram weight reduction correlates to a blood pressure reduction of +- 4-5/3-4 mmHg and regular aerobic exercise can lower blood pressure by +- 7-8/4-5 mmHg5,6. However, long-term adherence to these modifications is challenging, with patients often struggling to maintain healthy diet and exercise routines.
2 - Pharmacotherapy
Pharmacotherapy is the second cornerstone of hypertension management, with a wide range of effective antihypertensive medications available, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB), diuretics, and beta-blockers. These major drug classes display a more or less similar blood pressure reduction (approximately - 9/5 mmHg) and a blood pressure-mediated reduction in cardiovascular events. Combining these drug classes can lower blood pressure up to +- 20/11 mmHg7. Despite this, many patients fail to achieve target blood pressure levels due to non-adherence to medication regimens8. Studies have shown that up to 50% of patients with hypertension do not take their medications as prescribed9. This non-adherence can be attributed to patient beliefs, misconceptions about hypertension and its treatment, the complexity of treatment regimens, side effects, and the lack of immediate symptoms.
3. Device-based treatment
Device-based treatment is the third cornerstone and is independent of patient adherence. Renal denervation is currently the only approved and proven therapy in this category. Renal denervation, which modulates the overactive sympathetic renal nerves, has proven effective and safe in multiple RCTs and registries10. However, its widespread implementation in clinical practice is still limited. As an invasive procedure, it is less accessible and more costly, but it offers a once-in-a-lifetime treatment option, making it attractive for patients.
Conclusion
In conclusion, despite hypertension being a largely controllable condition, awareness, treatment, and control remain low. Addressing the multifaceted aspects of hypertension requires integrated healthcare systems that prioritize early detection, personalized treatment regimens, patient and provider education, and effective policy initiatives advocating for healthy lifestyle programs.
References:
- WHO Global report on hypertension: the race against a silent killer, 19 September 2023
- Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1923-1994
- Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet 2021;398(10304):957-980
- Arterial hypertension. Lancet 2021;398(10296):249-261
- Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2003;42(5):878-84
- Personalized exercise prescription in the prevention and treatment of arterial hypertension: a Consensus Document from the European Association of Preventive Cardiology (EAPC) and the ESC Council on Hypertension. Eur J Prev Cardiol 2022;29(1):205-215
- Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ 2003;326(7404):1427
- Resistant hypertension? Assessment of adherence by toxicological urine analysis. J Hypertens 2013;31(4):766-74
- Medication adherence in hypertension. J Hypertens 2020;38(4):579-587
- Renal denervation in the management of hypertension in adults. A clinical consensus statement of the ESC Council on Hypertension and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2023;44(15):1313-1330
