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Table of Contents
EDITORIAL
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 57-59

Hypertension: Changing trends and targets … and guidelines galore!


1 Adjunct Professor, JSS Academy Higher Education and Research, Mysuru; Namana Medical Centre, Bengaluru, Karnataka, India
2 Namana Medical Centre, Bengaluru, Karnataka, India

Date of Submission04-Mar-2022
Date of Acceptance05-Mar-2021
Date of Web Publication05-Apr-2022

Correspondence Address:
Prof. Nagaraj Desai
Namana Medical Centre, Bengaluru - 560 094, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_32_22

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How to cite this article:
Desai N, Koregol P. Hypertension: Changing trends and targets … and guidelines galore!. APIK J Int Med 2022;10:57-9

How to cite this URL:
Desai N, Koregol P. Hypertension: Changing trends and targets … and guidelines galore!. APIK J Int Med [serial online] 2022 [cited 2022 Dec 2];10:57-9. Available from: https://www.ajim.in/text.asp?2022/10/2/57/342537



“To wrest from Nature the secrets which have perplexed philosophers in all ages, to track to their sources the causes of disease, to correlate the vast stores of knowledge, that they may be quickly available for the prevention and cure of disease–these are our ambitions.”

-William Osler (1849–1919)

It is a cliché to state that the study of a disease involves understanding of its etiology, pathophysiology, methods of clinical diagnosis, therapeutics, and the strategies of their implementation in clinical practice to improve the outcomes, benefitting without any harm, not only an individual but also the society at large.

In this framework of model, the evaluation of our approach to the diagnosis and management are important as they influence the control of hypertension not only at the level of an individual but also at the level of community. In this regard, clinical guidelines on hypertension have played a very important Role. However, one desires more given the published reports of their implementation in clinical practice. Clinical guidelines on hypertension for the first time appeared as a report in the year 1977. This was sponsored by the National Heart Lung Blood Institute (then, National Institute of Health-NIH) of the USA.[1]

Recalling the first-ever report of the publication of clinical guidelines on hypertension jogs back my (first author) memory as a postgraduate student in medicine, to a lecture by the then chairman of the Joint National Committee (JNC) I committee Dr. Iqbal Kishan of Mayo clinic, USA, when he visited PGIMER, Chandigarh. At that time, the emphasis was more on diastolic blood pressure (BP), and the document, a short one of just six pages considering the present voluminous ones, exhorted the physicians to care for the control of “mild” degrees of hypertension as much as severer degrees of hypertension.

Since then, as many as seven reports of JNC have been published, and after considerable delay, the panel of experts who were part of JNC published in 2014 what is considered as “not an official JNC VIII report” as NIH of USA was not part of it.[2]

Now, for some years, quite a few clinical societies, including American, European, Canadian, Indian, and several others, have published their own guidelines with periodic revisions. Importantly, many of these guidelines have been efforts of collaboration with other clinical societies either coauthoring or endorsing them. The Indian guidelines, its fourth, have also been published.[3]

One can observe some differences and approaches employed in these clinical guidelines. However, they all have a common goal of reducing hypertension and its complications in the communities, through optimum management of hypertensive patients in clinical practice. Typically, the scientific evidence is evaluated by a group of invited experts. Mitigating or removing the potential conflicts of interest of an author in such a document is a necessary obligation. A recent study evaluated the variations in guidelines on hypertension. The authors identified and analyzed 48 clinical guidelines published over a 10-year period (2010–2020). The economic status of the country of origin of guidelines was also an important consideration. This study found that clinical practice guidelines remained largely consistent in the definition, staging, and target BP recommendations for hypertension. Extensive variation was observed in treatment recommendations, particularly for second-line therapy. Variation existed between income settings; the low-income countries prescribed cheaper drugs, offered clinicians less choice in medications, and initiated dual therapy at later stages than higher-income countries.[4]

The guidelines, especially newer ones, generally dwell upon opportunistic screening to diagnose abnormal blood pressure in a person, accurate measurement of BP, evaluating the cardiovascular risks, detecting comorbidities which may influence one's approach, targets BP to be achieved, selection of treatments including classes of drugs and combination therapies, and usage of fixed dose combination (FDC) in a single pill. Importantly, guidelines emphasize enrolling the patients actively to better manage them by adequately educating and counseling them. Some guidelines also exhort the clinician to make appropriate choices keeping the costs of therapies in mind. Many experts argue that there should be country-specific guidelines if possible, given the realities and several challenges including availability, cost, and several other issues.

Lowering the threshold for the diagnosis and actions to be taken requires enormous resources, not just fiscal! This is well discussed.[5]

For India, the implication including economics of diagnosing and treating hypertension in the light of recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines is a humongous task and well brought out by Chopra and Venkat S. Ram.[6] Yet, another recent Indian clinical study underscores the implication of repositioning the goal post for the diagnosis of hypertension. The authors undertook a cross-sectional survey method to evaluate. An estimate suggested that 3 of 5 adult Indians would be hypertensive if one applies ACC/AHA guidelines.[7]

It is very clear then that we have decades of hard work ahead to reduce the burden of hypertension and cardiovascular diseases. One can summarize by stating that as a physician, consciously, one has to carefully tread and choose the strategies to treat, to enable patients to enjoy the benefits of real advancements in science and clinical evidence. Unwittingly, we have come to depend on these guidelines as clinicians, “to feel up to date.” It is then prudent to give adequate weightage be given to our Indian guidelines too.

Dictionary meaning of the word “adherence” is “the fact of behaving according to a particular rule, etc., or of following a particular set of beliefs, or a fixed way of doing something.” The clinical guidelines are just guidelines helping the clinician; they are not rules. Yet, they help us quickly in reviewing the current thoughts and the basis thereof. The awareness among physicians regarding the clinical guidelines in all details and its study in the real-world practice is needed but is not widely published. It may lead to a better planning of health-care delivery including retraining physicians themselves, use of modern technology for timely reminders, and creating opportunities for self-improvement. The real-world experience of practical challenges by a practitioner may have to be dovetailed into guidelines and it is important creating a space for an additional voice.[8]

This begs yet another important question – the enrolment of the physician himself in treating the patient “adhering” to the clinical guidelines in choosing medications. A group of young authors comprising a group of medical students guided by Prof. Pratibha Nadig publish their observations regarding the physicians' adherence to the JNC and ACC/AHA guidelines, in an inhospital setting collecting the data on patients admitted to several clinical services.[9] They conclude that the adherence is modest. A more detailed information regarding the admission BP and the treatment the patients were receiving could have also been useful. A study designed to answer the issues of physicians' adherence may have several confounders and inherent limitations. For a chronic disease like hypertension, research in outpatient-based evaluation, review of prescription received in the pharmacy, the extent of changes in prescriptions made according to the target BP, associated risk factors, and comorbid conditions are clinically important. Furthermore, I would have liked to see the extent of agreement with the Indian guidelines. Nevertheless, this present data, collected by them, should enthuse the young to work further and extend their work into the outpatient and chronic setting. Such an effort could also be dovetailed with continuing education programs to assess the changes in the physicians' adherence.

Although we have been using office BP readings to treat our patients, its limitations are well known. It is useful to note that substantial and appropriate emphasis has been given to the strategies necessary for accurate measurement of BP in any setting where valid BP measurements are desired. Diagnosis of white coat hypertension or masked hypertension needs to be considered in the management of hypertension. It is too obvious that we require to have reliable data of out-of-office BP to make such diagnoses. Home BP monitoring and ambulatory 24 h monitoring are being increasingly advocated by various guidelines. In this issue of the Journal, Dr. Hegde and his colleagues published a large data of nearly 1000 patients collected from their outpatient clinic practices on ambulatory BP monitoring in clinical practice. They conclude that analysis of ambulatory BP monitoring (ABPM) parameters helps to identify the patients with BP variability (BPV) which has important implications for the prevention of transit-oriented development (TOD). They also suggest the use of ABPM in all individuals with cardiometabolic risk profiles or with established TOD even with normal office BP readings.[10] Some important and critical caveats to incorporate such a technology routinely and adlib include costs, inconveniences, and availability of technology in clinical practice. Hence, it will have to be individualized although we recognize its utility in managing our patients. Home BP monitoring may help to some extent, but to diagnose early morning surge, nocturnal dip, and variability, 24 h, one cannot depend upon it, underscoring the importance of ambulatory 24 h data in clinical practice. With the wider use in clinical practice and availability of newer technologies such as cuffless devices, its use should only increase, which may even bring down the costs! Recently, we published our data using such a technology.[11]

Treatment of hypertension should be initiated with two drugs having complementary mechanisms of action when BP is >20/10 mmHg above the goal. It is indeed, satisfying to note that several guidelines including American, European, International society of hypertension, Indian, and others, as if in one voice, talk of judicious use of combination therapy with even a fixed-dose pill to reduce pill burden and improve compliance, and to reach the target goal efficiently in a given patient. Prudence to start with half dose fixed-dose combination (FDC) pill to be escalated to full dose FDC is suggested by the International Society of Hypertension. Option of starting with a single drug therapy should always be exercised when target goals are lesser and in the absence of comorbid conditions. One cannot overemphasize the role of, often neglected, lifestyle modification.

Physicians and all medical service personnel should arm themselves with scientific advancements and use them with clinical wisdom. Detection, treatment, and prevention of complications of hypertension by strategizing, keeping the economics of care in mind, should remain the guiding principles to reach the goals of therapy.

Inviting to participate in his own care by counseling the patient in decision-making adds tremendous value. This could work at the patient as well as his family level. Going ahead, creating awareness regarding BP and its deleterious effects, when not normal, under the umbrella of overarching health education of public, starting at school may make a positive impact on the generations next. It is known that for the primary prevention programs, it takes a few generations to work at the community levels. It must be pointed out that governmental as well as nongovernmental agencies play a very pivotal and important role in managing hypertension and cardiovascular disorders, in general, especially at the societal level. They should pick up the gauntlet to deliver the results! for instance, community-level interventions like reducing sodium content in the common salt we use in cooking, and popularizing it among the public. A recent and large Chinese study demonstrated its clinical importance in reducing cardiovascular events in controlled clinical studies.[12]

In India, only in recent decades, a semblance of greater enthusiasm is being shown by the governments, nongovernmental agencies, and societies to control noncommunicable cardiovascular diseases such as hypertension and others. Results of these important efforts require to be shared widely and “create a movement among the physician, nonphysician health-care colleagues, and public.”

Let's hope, the tide results in intended outcomes… rather than just rhetoric of creating slogans for the day.



 
  References Top

1.
Report of the joint national committee on detection, evaluation, and treatment of high blood pressure. A cooperative study. JAMA 1977;237:255-61.  Back to cited text no. 1
    
2.
James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507-20.  Back to cited text no. 2
    
3.
Shah SN, Munjal YP, Kamath SA, Wander GS, Mehta N, Mukherjee S, et al. Indian Guidelines on hypertension-IV (2019). J Hum Hyperten 2020;34:745-58.  Back to cited text no. 3
    
4.
Philip R, Beaney T, Appelbaum N, Gonzalvez CR, Koldeweij C, Golestaneh AK, et al. Variation in hypertension clinical practice guidelines: A global comparison. BMC Med 2021;19:117.  Back to cited text no. 4
    
5.
Messerli FH, Rimoldi SF, Bangalore S. Changing definition of hypertension in guidelines: How innocent a number game? Eur Heart J 2018;39:2241-2.  Back to cited text no. 5
    
6.
Chopra HK, Ram VS. A clarion call for blood pressure control in India. Circ Res 2019;124:984-6.  Back to cited text no. 6
    
7.
Gupta K, Ramakrishnan S, Zachariah G, Rao JS, Mohanan PP, Venugopal K, et al. Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey. Int J Cardiol Hypertens 2020;7:100055.  Back to cited text no. 7
    
8.
Burnier M; 1999 World Health Organization/International Society of Hypertension Guidelines. Blood pressure control and the implementation of guidelines in clinical practice: Can we fill the gap? J Hypertens 2002;20:1251-3.  Back to cited text no. 8
    
9.
Bhaskara NV, Andra RK, Bhat M, Mithun Reddy KK, Shankar R, Diwakar A, et al. A study on physicians' adherence to joint national committee guidelines for hypertension. APIK J Int Med 2022;10:73-7. Available from: https://www.ajim.in/preprintarticle.asp?id=338896. [Last accessed on 2022 Mar 04].  Back to cited text no. 9
    
10.
Hegde SB, Aroor S, Anupama YJ, Hegde SN. Ambulatory blood pressure monitoring and its utility in management of hypertension in a clinic setting in South India. APIK J Int Med 2022;10:111-7. Available from: https://www.ajim.in/preprintarticle.asp?id=338903. [Last accessed on 2022 Mar 04].  Back to cited text no. 10
    
11.
Ram CV, Muppalla SB, Sarvepalli VJ, Gajjela PK, Ray S, Jadhav U, et al. Achieving the latest American Heart Association and American College of Cardiology therapeutic goals for hypertension with combination therapy and its effects on blood pressure and central hemodynamic parameters. Am J Cardiol 2022;168:78-82.  Back to cited text no. 11
    
12.
Neal B, Wu Y, Feng X, Zhang R, Zhang Y, Shi J, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med 2021;385:1067-77.  Back to cited text no. 12
    




 

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