Journal of the Scientific Society

EDITORIAL
Year
: 2018  |  Volume : 45  |  Issue : 2  |  Page : 51--52

Present scenario of adult hypertension: Family physician perspective


Jayaprakash Shivalingappa Appajigol 
 Department of Medicine, Jawaharlal Nehru Medical College, KLE University of Higher Education and Research, Belagavi, Karnataka, India

Correspondence Address:
Jayaprakash Shivalingappa Appajigol
Department of Medicine, Jawaharlal Nehru Medical College, KLE University of Higher Education and Research, Belagavi, Karnataka
India




How to cite this article:
Appajigol JS. Present scenario of adult hypertension: Family physician perspective.J Sci Soc 2018;45:51-52


How to cite this URL:
Appajigol JS. Present scenario of adult hypertension: Family physician perspective. J Sci Soc [serial online] 2018 [cited 2019 Jul 17 ];45:51-52
Available from: http://www.jscisociety.com/text.asp?2018/45/2/51/247162


Full Text



Sir,

Cardiovascular diseases (CVDs) are major cause of morbidity and mortality. Hypertension is an important preventable cause of CVD and all-cause mortality worldwide. It is an established fact that proper treatment of hypertension can prevent up to a third of cardiovascular deaths. Apart from smoking cessation, blood pressure control is the most important strategy for reducing CVD mortality.[1]

The prevalence of hypertension in India has increased from 2% to 25% among the urban population and 2% to 15% among the rural population in the last 50–60 years.[2] These studies categorized individuals as hypertensives when their blood pressure was 140/90 mmHg or more. Recent guidelines released by the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend lower thresholds for defining blood pressure. As per the new guidelines, hypertension is defined as a systolic blood pressure (SBP) of 130 mmHg or greater or a diastolic blood pressure (DBP) of 80 mmHg or greater.[3] According to the new guidelines, more people will be classified under the category of hypertension.

Guidelines for the management of hypertension have come a long way. The first report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure was published in 1977. Based on minimum clinical data available at that time, JNC-1 suggested that “virtually all persons with a DBP ≥105 mmHg be treated with antihypertensive drug therapy.”[4] Between 1977 and 2003, the JNC issued seven reports under the direction of the National Institutes of Health (NIH). After that, in spite of 5 years in preparation, the NIH did not publish JNC-8 report and decided to withdraw from publishing guidelines. It transferred the responsibility of issuing hypertension-related guidelines to the AHA and the ACC. Meanwhile, without the approval of the NIH or the AHA/ACC, JNC-8 committee members published their guideline report in 2014 (JNC-8). Finally, AHA/ACC in association with other bodies published its guidelines in 2018.[3] Similarly, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) issued their initial guideline in 2003 and later on revised and new updates were released in 2007, 2009, and 2013.[5] In 2018, the ESH/EHA published its revised guidelines which recommend more stringent blood pressure control.[6] Hypertension guidelines recently released by two important societies, i.e. American societies (ACC/AHA) and European societies (ESH/ESC), have completely changed the management of hypertension. The impact of the new guidelines is expected to be significant.

Conventionally, hypertension is defined as a blood pressure ≥140/90 mmHg and recommended to maintain it <140/90 mmHg. However, the 2017 ACC/AHA guidelines suggested more aggressive management approach.[3] Accordingly, hypertension is defined as SBP ≥130 mmHg or DBP ≥80 mmHg. Medications are indicated in patients with SBP between 130 and 139 mmHg or DBP between 80 and 89 mmHg with clinical CVD or patients who have atherosclerotic CVD risk of 10% or more for 10 years. Medications are also indicated for all patients with SBP 140 mmHg or above or DBP 90 mmHg or above. Blood pressure target of <130/80 mmHg is recommended for all hypertensive patients.

According to the 2018 ESC/ESH guidelines, hypertension is defined as a persistent elevation in office SBP ≥140 and/or DBP ≥90 mmHg.[6] Lifestyle intervention is the initial approach for adults with blood pressure of 140–159/90–99 aged 80 years. If blood pressure goal is not achieved with lifestyle modification alone, they should be started on pharmacotherapy. Initial pharmacotherapy is recommended along with lifestyle interventions for high-risk hypertensives with blood pressure of 140–159/90–99 mmHg or patients with blood pressure of ≥180/≥100 mmHg. It is recommended that all patients should achieve a blood pressure of <140/90 mmHg. Treated blood pressure values should be targeted to 130/80 mmHg, provided patient tolerates the treatment. In patients <65 years receiving BP-lowering drugs, it is recommended that SBP should be lowered to a range of 120–129 mmHg in most patients. In patients aged >65 years, SBP should be targeted to between 130 and 140 mmHg and DBP to <80 mmHg.

Although both the guidelines appear different from each other, they carry some of the important messages. Target blood pressure in previous recommendations was <140/90 mmHg. However, now, both the guidelines agree that this target is not sufficient and recommend the target <130/80 mmHg. The European guidelines go one step ahead and recommend a target of SBP of the range 120–129 mmHg in people aged <65 years. These stricter BP goals recommended are mainly based on the results from Systolic Blood Pressure Intervention Trial.[7] Out-of-office blood pressure monitoring is given extra emphasis. Ambulatory blood pressure monitoring or home blood pressure monitoring is advised for accurate diagnosis of hypertension. Lifestyle modifications are the initial therapy followed by pharmacological treatment.

Worldwide data suggest that blood pressure is not appropriately controlled, especially in middle- and low-income countries. The present guidelines, being more stringent, further increase the burden of hypertension. On the other hand, these recommendations of more aggressive BP control strategies might lead to better cardiovascular outcomes. It is the responsibility of every clinician to correctly diagnose and treat hypertension to appropriate targets based on the best available evidence. Family physicians and primary care physicians, who come in contact with the community, play a tremendous role in detecting, treating, and thereby contributing to cardiovascular risk reduction.

References

1Sacco RL, Roth GA, Reddy KS, Arnett DK, Bonita R, Gaziano TA, et al. The heart of 25 by 25: Achieving the goal of reducing global and regional premature deaths from cardiovascular diseases and stroke: A modeling study from the American Heart Association and World Heart Federation. Circulation 2016;133:e674-90.
2Chellamma P, Nair JC, Kottarath AT, Saleem A, Jaya AT, Thaj A. Risk factors associated with hypertension among adults residing in an urban area of Kerala – A cross-sectional study. J Evol Med Dent Sci 2017;6:6316-21.
3Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/AphA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-248.
4Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. A cooperative study. JAMA 1977;237:255-61.
5Kotchen TA. Developing hypertension guidelines: An evolving process. Am J Hypertens 2014;27:765-72.
6Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-104.
7SPRINT Research Group, Wright JT Jr., Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. Arandomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16.