20 Aug Controversies in hypertension
Norman M Kaplan, Lionel H Opie
Hypertension remains the most common risk factor for cardiovascular morbidity and mortality. Its incidence is rising in both ageing and obese populations, but its control remains inadequate worldwide. We address several persisting controversies that may interfere with appropriate management of hypertension. They include: the reasons behind the increasing incidence of hypertension and the possible ways to slow the process, especially by lifestyle changes; the need for overall cardiovascular risk assessment; the major issues in the decision to institute drug therapy and the choice of drugs; and the importance of screening for various identifiable causes. We provide the background for these controversies, followed by some opinions on how to guide practitioners to offer more effective management of hypertension.
Hypertension remains the most common risk factor for cardiovascular morbidity and mortality (figure 1).1 Despite massive and costly efforts to identify and treat hypertension, less than a third of individuals with a usual blood pressure exceeding 140/90 mm Hg are adequately treated.2,3 Even in individuals whose hypertension is thereby presumed to be well controlled, less than a third are protected from subsequent strokes and heart attacks.4,5 The inadequacy of current practice is obvious: too few individuals at risk, because of raised blood pressure, are being diagnosed and treated effectively.
Another reason is the complexity of the origin of hypertension, a multifactorial disease (figure 2).6 Therefore, much improved population-wide and individual approaches to the prevention and control of hypertension are needed. Here, we address selected controversies of hypertension, along with some of our views on how doctors should provide the best management. Developing countries and increasing incidence of hypertension “More than a quarter of the world adult population is already hypertensive and this number is projected to increase to 29%, 1•56 billion, by 2025.”7 Almost threequarters of the worldwide population with hypertension will be in developing countries, with this occurrence fuelled by urbanisation.
Thus, global-health inequalities will be further increased. Therefore, attention should be directed at possible ways to slow this occurrence through population-wide manoeuvres, including the avoidance of obesity, increased exercise, and reduction of dietary sodium.8 But how can any of these become a national priority in developing countries when other diseases such as HIV/AIDS must take priority for restricted health budgets, along with the ravages of persistent infectious diseases, famine, drought, and civil strife?
These factors will dominate over apparently non-urgent health priorities such as hypertension, at least in sub- Saharan Africa. Thus global approaches need to focus on lifestyle changes that can be widely initiated as preventive measures, whereas approaches for individuals should be associated with antihypertensive drug therapy. How can these aims be best achieved?