The SA Journal Diabetes & Vascular Disease Vol 15 No 2 (November 2018)

VOLUME 15 NUMBER 2 • NOVEMBER 2018

PASCAR ROADMAP

SA JOURNAL OF DIABETES & VASCULAR DISEASE

importance of reaching minimum standards (Table 3) for the health

systems of countries to achieve the 25% hypertension control

target. Implementation of these solutions and suggestions on

customising the overall strategy at a country level are discussed.

The WHF roadmap provides a general framework that could

be useful for LMICs, however, to be implemented it should

be customised according to the local context. With PASCAR’s

leadership and the contribution of other professional organisations,

this approach seems to be at the right time to turn the many

hypertension challenges in Africa into immense opportunities.

Although population-based strategies for lowering BP may be cost-

effective, they are not the focus of this roadmap, but we recognise

these would be beneficial.

Methods

In January 2014, panel members who were appointed to develop

the PASCAR roadmap were invited to join the PASCAR task

force on hypertension. Based on their expertise and leadership

in hypertension, 41 nominees from 21 countries received

invitations, with 95% responding positively. These experts included

cardiologists, nephrologists, public health physicians, researchers

(including clinical trialists), nurses, pharmacologists, evidence-based

medicine specialists and guideline developers.

During the first face-to-face meeting held in Nairobi on 27

October 2014,

the group acknowledged the lack of a continental

strategy to address the hypertension crisis. A decision was taken

to develop a roadmap for the prevention and management of

hypertension in Africa as a matter of urgency under the auspices

of the WHF.

To customise the WHF BP roadmap for Africa, the core group

performed a comprehensive literature search and communicated

with the WHF from November 2014 to July 2015 via teleconference

and e-mail. After receiving and comprehending the WHF roadmap

document, task force members held a second face-to-face meeting

in London on 30 August 2015, to make suggestions on its relevance

and customisation. A detailed presentation of this roadmap

was reviewed and discussed by PASCAR task force members,

hypertension experts and leaders of hypertension societies via

e-mail, with WHF feedback.

Development of a warehouse for African guidelines and clinical

trials on hypertension was also reviewed. Finally, the steps in

developing the African roadmap for reducing CVD mortality rates

through BP control was planned.

The first draft of the PASCAR roadmap for hypertension

management and control was presented in Mauritius on 4 October

2015. Attendees were 13 presidents of national cardiac societies

or representatives, the president of the International Forum for

HypertensionControl andCardiovascularDiseasePrevention inAfrica

and representative of the International Society of Hypertension,

a representative of the African Heart Network, members of the

PASCAR task force on hypertension, and scientists from the WHF.

The draft was reviewed and oral and e-mail comments were received

from participants. The WHO PEN programme

was compared with

the PASCAR hypertension roadmap to ensure complementarity

between the two documents.

The second version of the roadmap draft was submitted to a

core group for internal review from October to December 2015.

In March 2016, a selected group of hypertension experts from 12

French-speaking countries met in Yaoundé to discuss the algorithm

Table 3.

Minimum care for hypertension management at each healthcare

level in Africa

Level of care

Primary

Secondary

Tertiary

Basic staff, equipment,

Trained health Medical

test and medication

worker or nurse Practitioner Specialist

Basic equipment

Automated blood pressure

+++

devices, or calibrated

sphygmomanometer, either

mercury or oscillometric

plus appropriate cuffs

Home blood pressure

+++

devices

Ambulatory blood

+/–

+++

pressure devices

Tape measure for waist

+++

circumference

Scale for weight

+++

Stadiometer for height

+++

Standard 12-lead ECG

+++

Glucometer

+++

Funduscope

+++

Stethoscope

+++

Basic tests

Urine dipsticks for

+++

protein, blood and glucose

Standard 12-lead ECG

+++

recording

Glucometer strips for

testing glucose + +++ +++

Na+, K+ and creatinine

+++

with calculation of eGFR

Cholesterol

+++

Glycated haemoglobin

+++

(HbA

)

Chest radiograph

+/–

+++

Basic medication classes with examples*

Thiazide or thiazide-like

+++

diuretic (hydrochlorothiazide,

indapamide,

chlorthalidone)

Calcium channel blockers

+++

(amlodipine, nicardipine,

long-acting nifedipine)

Angiotensin converting

+++

enzyme inhibitor

(enalapril, lisinopril,

perindopril, ramipril)

Angiotensin receptor

+++

blockers (candesartan,

valsartan, losartan)

Vasodilating beta-blockers

+++

(nebivolol, bisoprolol,

carvedilol)

Spironolactone

+++

Long-acting

-blocker

(doxazocin)

Combinations of blood

+++

pressure-lowering

medications

+++: strongly recommended; ++ moderately recommended, +:

recommended; –: not done; +/–: done if facilities are available.

*Availability of drugs at each level of care has been indicated and

recommended here for initiation only, all drugs can be used once initiated by

a medical practitioner.

A trained healthcare worker may initiate and follow up some medication.