Is it time to reframe the way we think about hypertension?
A staff editorial published in the latest, hypertension-centric issue of The Lancet suggests physicians might make quicker progress toward reducing global levels of uncontrolled hypertension if they reframe the condition as part of a patient’s whole health profile, rather than as an isolated disease.
The editorial emphasizes a fact that’s been broadcast time and again—that all countries in the world, regardless of their economic status or scientific impact, are struggling to control high blood pressure among their populations. A recent report in the Journal of the American Medical Association revealed that while deaths due to heart disease in the U.S. have been rising for about a decade now, hypertension diagnoses have increased the most—especially among young people.
Fresh research from the NCD Risk Factor Collaboration also underlines the tenuous state of hypertension management in developed nations, considering 12 high-income countries over four decades and finding a “disappointing plateau” in BP management over the past decade. The proportion of patients who did manage to achieve BP control didn’t exceed 70% even in the best-performing countries, the authors said.
“Clearly, even in countries with well-functioning health systems, uncontrolled high blood pressure remains an important risk factor for substantial morbidity and mortality,” the Lancet editorialists wrote.
But while high-income countries are struggling, the reality is that the situation is worse in low- and middle-income countries (LMICs). An increasing burden of non-communicable diseases, conflict, poverty and inequity all contribute to weakened healthcare systems, and in a cross-sectional study of more than 1.1 million adults in 44 LMICs, Pascal Geldsetzer and his colleagues found that fewer than 40% of people with high blood pressure had actually been diagnosed. Just 30% of hypertensives had received treatment for the condition; only 10% achieved BP control.
The editorialists said differences between clinical guidelines in the U.S. and Europe are detracting from the true aim of hypertension management, which is to reduce target organ damage in patients.
“Is the concept of hypertension as a disease with defined, albeit changing, thresholds actually unhelpful?” they questioned. “Should any given blood pressure be seen in the much wider context of overall cardiovascular and other disease risk, much in the same way as we regard blood cholesterol or body mass index as conferring specific risks?”
The team cited a paper by Emily Herrett and colleagues in which the researchers retrospectively studied more than 1.2 million patients in the U.K., testing the efficacy of four different strategies to reduce cardiovascular risk. Of the approaches—which included one strategy to reduce risk based on BP alone, two to reduce risk based on a combined BP threshold and risk score and one based solely on risk score—the best-performing strategy was the one based on risk score alone.
In New Zealand, the editorialists wrote, society guidelines for hypertension don’t really exist, and the government bases its national recommendations squarely on cardiovascular risk scores.
“The outstanding question is, will increased blood pressure without any additional cardiovascular risk factors still damage organs in the long-term?” they wrote. “Further research is needed to understand this association. In the meantime, primary prevention, treatment decisions and further research on optimum blood pressures should stop seeing blood pressure in isolation and take a whole-person risk reduction view.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.