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VOLUME 15 NUMBER 2 • NOVEMBER 2018
87
SA JOURNAL OF DIABETES & VASCULAR DISEASE
DIABETES NEWS
How to deal with the mass killer, hypertension
H
igh blood pressure is the single biggest
contributor to the global burden of
disease, with hypertension leading to 10.7
million deaths every year.
1
Most worrying is a
recent global study showing that on average,
more than half of those affected don’t know
they have it.
2
Because cardiovascular disease
affects a third of adults in the world, it is the
largest epidemic ever known to mankind.
3
With mortalities increasing year on year,
awareness, and therefore treatment and
control rates, have been shown to worsen
as the economic status of populations drop.
2
Prof Neil Poulter, immediate past president
of the International Society of Hypertension
(ISH), says that between the highest-
income countries and the lowest, there
was an 8.2% drop in awareness, a 15%
drop in treatment rates and a 6.3% drop in
control. This prompted the ISH to mount an
unprecedented global blood pressure (BP)
awareness campaign during May last year.
4
Speaking at the 34th World Congress of
Internal Medicine (WCIM) that was held in
Cape Town in October, Prof Poulter said an
earlier study showed that just 46.5% of 57
840 hypertensive people canvassed knew
they had hypertension, followed by a dramatic
drop off between those treated (40.6%) and
those controlled (13.2%). In the subsequent
global ISH screening and awareness initiative,
dubbed ‘May Measurement Month’ (MMM,
2017), volunteers screened over 1.2 million
people in 80 countries. They uncovered over
150 000 people with untreated raised BP
(17.3% of those untreated) and over 100
000 with treated but uncontrolled BP (46.3%
of those treated). The ISH went one better
this year, screening over 1.5 million people
in 89 countries and detecting over 220 000
with untreated raised BP (18.4% of those
untreated) and over 110 000 with treated
but uncontrolled BP (just 40.4% of those
treated).
He described the MMM campaigns as
a major success and a ‘heart-warming,
fantastic volunteer effort.’
Take-home lessons
‘So, we need to put screening in place and
provide suitable drugs – most people are
not getting enough drug combinations.
You need two or more drugs to manage
hypertension properly,’ said Prof Poulter.
Drug guidelines are confusing, differing in
theEuropeanUnion, AmericaandBritain,with
different drug combinations recommended
for different race groups. Prof Poulter favours
the British combination-drug guidelines.
‘Our problem is that world-wide we
don’t know what the best combinations
are. We know that patients need at least
two drugs, sometimes three, ideally in a
single pill, for the best outcomes. A single
(combination-drug) pill gives more effective
and rapid BP control than monotherapy
and two ‘free’ drugs. You get reduced side
effects, enhanced adherence, improved
cardiovascular protection and they’re more
cost-effective,’ said Prof Poulter.
Prof Poulter has just completed a major
trial of threedifferent two-drug combinations
for lowering BP in black Africans in six sub-
Saharan countries (the CREOLE study), with
definitive but yet-to-be-released results. He
said he hopes to present them ‘somewhere
prestigious’ early next year.
‘We now know what works for black
Africans. Our primary end-point was to lower
ambulatory systolic BP after six months,’ he
revealed, while keeping tight-lipped about
the much-anticipated findings.
Clearing up muddy treatment waters
In two slightly differing presentations to the
Cape Town WCIM, Prof Poulter reviewed
existing combination-drug trials and decried
the American lower treatment threshold BP
guideline of 130/80 mmHg. He said that
although the SPRINT study, which influenced
this lower threshold, had reported lower rates
of fatal and non-fatal major cardiovascular
events from any cause, at systolic BP targeted
to < 120 mmHg, the Americans measured BP
‘in a way nobody does in this room – they
used a machine with the patient alone in a
back room, which gives lower BPs than those
measured in your clinics.’ He recommends
sticking with the higher 140/90 mmHg
diagnostic threshold for hypertension.
Meanwhile, reports in the prestigious
Lancet
and
British Medical Journal
differ
over the BP targets recommended. What
guidelines in the world tend to agree on,
he said, was that treating with two drugs as
initial therapy was the way to go. Just two
drugs in a single tablet has already improved
compliance by 21%. If a patient was above
a certain level of risk, they should also be on
a statin, regardless of cholesterol levels, until
at least 80 years of age, he added.
Prof Poulter’s conclusions from the ACE
inhibitors vs ARB controversy in managing
hypertension are that individual trial data
and meta-analyses are relatively consistent
in showing the superiority of ACE inhibitors.
ARBs are better tolerated but do not reduce
mortality rate or cardiac events as well as
ACE inhibitors and should be used if patients
cough on ACE inhibitors. Prof Poulter
concluded his presentation with a telling
cartoon of an obese man, with a frothy pint
of beer in one hand and a cigarette butt in
his mouth, sticking his hand through a hole
in a wall, on the other side of which, an
unseeing doctor measures his BP and puts
pills in an outstretched palm.
Session moderator, Prof Sajidah Khan, an
interventional cardiologist at the Gateway
Private Hospital in Umhlanga, said that in
the very country that most funds prevention
(North America), the sale of ultra-processed
foods this year rose by 2.3% compared to a
71% increase in Africa and Eastern countries.
Simultaneously, the revenue growth for the
world’s biggest tobacco retailer, PhilipMorris,
rose by 2.8%. It was therefore unsurprising
that 80% of all cardiovascular disease
occurs in lower- to middle-income countries.
The damaging myths about statins paled by
comparison with this.
Prof Brian Rayner, head of the Division of
Nephrology and Hypertension at the Groote
Schuur Hospital and University of Cape Town,
said a three-pill regimen would address
huge unmet needs in South Africa and the
continent. He said up to 90% of hypertensive
South African patients remain untreated and
agreed with Prof Poulter that the American
guidelines, ‘have set us back and created
confusion in the definition of hypertension –
there’s a big difference between a target and
the definition,’ he added.
References
1.
Poulter NR, Prabhakaran D, Caulfield M,
et al.
Hypertension.
Lancet
2015;
386
(9995): 801–812.
2. Chow CK, Teo KK, Rangarajan S, Islam S,
et al.
Prevalence, awareness, treatment, and control of
hypertension in rural and urban communities in
high-, middle-, and low-income countries.
J Am
Med Assoc
2013;
310
(9): 959–968.
3. Dena Ettehad, Connor A Emdin, Amit Kiran
et
al.
Blood pressure lowering for prevention of
cardiovascular disease and death: a systematic
review and meta-analysis.
Lancet
2016;
387
(10022):
957–967.
4. Beaney T, Schutte AE, Tomaszewski M,
et al.
May
Measurement Month 2017: an analysis of blood
pressure screening results worldwide.
Lancet Glob
Health
2018;
6
(7): e736–743.