- Current Challenges and Future Directions in the Clinical Management of Hypertension
- Controversies to Consensus in Hypertension Classification and their Impact
- Risk Factors Responsible for Hypertension
- Pathophysiology of Hypertension
- OSA and Hypertension: Present Status and Future Directions
- Obstructive Sleep Apnea and Systemic Hypertension
- Microalbuminuria, Hypertension and Diabetes Mellitus: A Triple Jeopardy
- Hypertension in Elderly Diabetics: Management Strategies
- Hypertension in Young: Management Strategies
- Hypertension in Women: Is it different?
- Hypertension in Elderly in what Way Management is Different
- Stress, Mental Pollution and Hypertension
- Sex and Hypertension: Myth and Facts
- Exercise and Hypertension
- COVID-19 and Systemic Hypertension
- The Role of Autonomic Nervous System in Hypertension
- Vascular Disease and Hypertension
- Air Pollution and Hypertension
- Eye and Hypertension: Changing Perspectives
- Noise Pollution and Hypertension
- Does Hypertension and its Pharmacotherapy Affect the Quality of Sexual Function?
- Reduction of BP Targets to Reduce CVD Events: Status 2020 and Beyond
- Salt Sensitive Hypertension: Emerging Insights in an Old Entity
- White Coat Hypertension: Clinical Outcome
- Critical Appraisal of Essential Hypertension in Young Adults
- Hypertension and Endothelial Dysfunction
- Hypertension and Aortoarteritis
- Hypertension and Left Ventricular Hypertrophy: Clinical Implications
- Hypertension and CKD: A Double Jeopardy
- Hypertension and Conn's Syndrome: Management Strategies
- Renin–Angiotensin–Aldosterone System 2020
- Hypertension and Sildenafil
- Hypertension, Seasonal, Diurnal BP Variability and CVD Risk
- The Management of Hypertension during the Perioperative Period
- Hypertension Preventive Strategies and Campaign in India
- Hypertension with Multiple Comorbidities
- Aortic Dissection in Hypertension: Management Strategies
- Long-term Cardiovascular Sequelae of Uncontrolled Hypertension and their Surgical Management
- Hypertension with Arterial Dissections: A Jeopardy
- Hypertension with Renal Artery Stenosis: Management Strategies
INTRODUCTION
Hypertension is the most prevalence disease in India. It causes significant burden on the health system. According to data from the global burden of disease (GBD) study of 2016, hypertension led to 1.63 million deaths in India in the year 2016 alone.1 A population-based cross sectional study carried between 2012 and 2014 with the sample size of 1.3 million estimates the prevalence and hypertension in India at around 26%.2 GBD data also showed that over half of the deaths due to ischemic heart disease (54.2%), stroke (56.2%) and chronic kidney disease (54.5%) were attributable to high systolic blood pressure (BP).2 The prevalence is expected to much higher as hypertension is a silent disease and the most of the individuals are not even aware of their BP status. Moreover control of hypertension requires strict adhesion to the therapy with regular BP measurements. In a meta-analysis it was found that only 25% of rural and 42% of urban population are aware about BP status3 and even less followed up after elevated BP reading.
| Patients with hypertension should be classified in the following manner: |
Grade 1 hypertension | Systolic 140–159 mm Hg and/or diastolic 90–99 mm Hg |
Grade 2 hypertension | Systolic 160–179 mm Hg and/or diastolic 100–109 mm Hg |
Grade 3 hypertension | Systolic 180 mm Hg or above and/or diastolic 110 mm Hg or above |
Isolated systolic hypertension | Systolic >140 mm Hg but diastolic <90 mm Hg |
| Source: Adapted from the Eighth Joint National Committee, 2014. | |
Two other terminologies frequently used are:
- Hypertensive urgency—severe asymptomatic hypertension (usually systolic >180 mm Hg and diastolic >120 mm Hg)
- Hypertensive emergency—severe hypertension accompanied by cardiac (e.g., acute left ventricular failure), neurological (e.g., hypertensive encephalopathy), or renal dysfunction.
WHAT HAVE WE DONE?
As a response to the low awareness levels, the Government of India launched the universal screening program for hypertension, diabetes mellitus, and three common cancers (breast, cervix, and oral cancer) in 2017 under the National Health Mission (NHM).4 Under the program, the auxiliary nurse midwife (ANM) and accredited social health activist (ASHA) are responsible for organizing screening activities at the villages and other subcenters. All the individuals with the BP > 140/90 mm Hg are referred to a medical officer for conformation and further evaluation. In a similar effort, over the last 2 years, the International Society of Hypertension in conjunction with the World Hypertension League has been implementing the “May Measurement Month”—a global awareness campaign that aims to improve access to screening of BP.5 The theme of 2019 World Hypertension Day was “Know Your Numbers” and focuses on the importance of screening for early detection and treatment of hypertension.6 The main focus of guidelines on hypertension is early detection through screening and a strong public awareness program educating individuals and the harmful effects of this silent disease. A public health 4approach to hypertension in India would involve the five components detailed below. This includes five population level interventions for prevention of hypertension of which reduction of obesity, salt intake, and cessation of tobacco use are the most important; screening of the adult population at five points of care for hypertension by trained staff using standardized BP measurement with validated devices, and management of hypertension with lifestyle modifications combined with therapy using representative drugs from five classes of antihypertensive, which should be made available in the public health system.
UNIVERSAL SCREENING AND CHALLENGES IN ITS IMPLEMENTATION
As Kaplan mentioned in the Joint National Committee in 1998, BP measurement is the “clinical procedure of greatest importance that is performed in the sloppiest manner.”7 The rationale behind the government-led universal screening program has been improving equity and awareness within the underprivileged strata of society by giving them access to quality health care also raising awareness against the risk factor commonly associated with hypertension. Also the benefit of screening outweighs its harm as recommended by US Preventive Services Task Force recommendation statement. Screening is the most powerful and effective method in combating hypertension. The operational guidelines state that screening is to be conducted at the community level so that no individual has to travel for more than half an hour in order to be screened8 leading to important reduction in peak work output. According to the NHM document, the program also aims to improve overall awareness regarding noncommunicable diseases and risk factors through increased information, education, and communication activities.8 All adults above the age of 18 years should undergo opportunistic screening by healthcare providers at all points of care in India, either during the course of their visits to the health facilities, or separately as a screening examination if requested by the person. Targeted screening at the community level of high-risk groups like the elderly (>60 years), obese, current smokers, those with diabetes, those with existing cardiovascular disease, and those with a strong family history of heart disease or stroke can be undertaken by trained nonphysician staff. This screening will also enable people with high BP to be identified, so that they can be prevented from developing hypertension by use of appropriate lifestyle modifications. High-risk individuals including people with age >50 years, those who are obese, diabetic, current smokers, those who have history of any cardiovascular disease (coronary artery diseases, stroke, etc.), or a history of hypertension or premature cardiovascular disease in the family can be recognized and managed accordingly.
But screening such a last populations requires enormous amount of manpower, training, and resources and already the government-run program is behind its target for 2018–19.9 So the question is—“Is screening the most beneficial method for resource-limited setting in India? Moreover ASHA/ANM workers have other responsibilities in addition to this and doing this on an annual basic requires a lot more work. Improper BP measurement can lead to higher BP measurement and overestimation of individual true BP and lead to inaccurate classification. This in turn increases the burden on the healthcare system. In a study done by Jose AP et al. on 678,490 individuals, the impact of repeated BP measurements on BP categorization was done and it was observed that there was 63% higher prevalence of hypertension when only first BP measurements were considered for diagnosis compared to mean of second and third reading.10 Healthcare professionals (HCPs) are yet to master the technique that was invented 100 years ago. This means that a significant population is being wrongly diagnosed and is subjected to unnecessary treatment. On the other hand, underestimation of BP can be missed opportunity for starting lifestyle changes and pharmacotherapy and also carries ethical implications. Aware of the outcomes of ill-advised screening method, guarantee that the preparation of ASHAs, ANMs, and clinical officials is completed with tirelessness and caught up with fresh training at regular interval.
Table 1 lists the sources of errors produce a false BP measurement.
USE OF DIGITAL (OSCILLOMETRIC) DEVICES
In evidence-based systematic review, oscillometric devices were considered appropriate for use in adults (Level A recommendation) including for those with trauma and shock, and were given a Level B recommendation for use in adults with hypertension, because of discrepancies accruing from increased arterial stiffness. However, other studies have cited concerns about their accuracy.11 In a study of validated digital devices in practice settings, 88% of digital devices had measurement within 3 mm Hg of the reference standard compared to 95% of mercury sphygmomanometers, suggesting that digital devices can have accuracy equivalent to mercury sphygmomanometers.12 The World Health Organization (WHO) recommends the use of electronic devices, which are affordable and reliable and which have the capacity for manual settings.13 Although the cost of digital devices might be more than the manual devices but using digital device can also decrease the need of trained staff in an already resource-limited country thereby cutting cost.
ROLE OF AYUSH DOCTORS
As per WHO in 2016 there were 1,225,381 health workers in urban areas and 844,159 in rural areas, an urban–rural ratio was 1.45. Of all health workers, 59.2% were in urban areas, where 27.8% of the population resides, and 40.8% were in rural areas, where 72.2% of the population resides. The ratio of urban density to rural density for doctors was 3.8 (Fig. 1).
AYUSH is an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy and are the six Indian systems of medicine prevalent and practiced in India and some of the neighboring Asian countries with very few exceptions in some of the developed countries. National Rural Health Mission came into play in 2005 but implemented at ground level in 2006 and introduced the concept of “mainstreaming of AYUSH and revitalization of local health traditions” to strengthen public health services.7,14 This concept helped in utilizing the untapped AYUSH workforce, therapeutics, and the principles for the management of community health problems at different levels. This convergence has been envisaged with the following objectives:
- Choice of the treatment system to the patients
- Strengthen facility functionally
Lately, the government has been actively promoting AYUSH and one of the main functions of AYSUH is to help with National Health Policy. India's allopathic doctor–patient ratio is at 1:1445, lower than the WHO's norm of 1 doctor per 1,000 people, and with this vast deficit we need health workers for such mass screening programs.
Various hindrances exist at different degrees of the healthcare cascade that account for the low rates of BP control in India. At the health system level, a low political priority is given to hypertension. At a hospital level, poor healthcare provider education in hypertension management, the lack of a systematic approach and inadequate access to drugs serve to undermine BP control.
Fig. 1: Health workers by category: absolute number.Source: Adapted from the Health Workforce In India. WHO; 2016.
6At a community or individual level, lack of awareness of hypertension, limited capacity to bear out of pocket costs, and competing life priorities make control of BP challenging.11
There are certain essential steps that are needs to be taken for control hypertension. A model system that is universal in all of India needs to be setup that includes:
- Measuring BP in hospitals in systematic standardized methods at every hospital visit while educating all concerned healthcare workers in its correct measurement.
- Informing each patient of its BP goals, current BP, and reminding him the importance of taking prescribed drug for the same.
- Including the nonphysician healthcare staff in managing HCP and educating people against diagnosis and follow up.
- A closed pharmacy system that provides hypertension drugs at below typical market prices through bulk purchases.
REFERENCES
- Gakidou E, Afshin A, Abajobir AA, Abate KH, Abbafati C, Abbas KM, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease study 2016. Lancet. 2017;390:1345–422.
- Geldsetzer P, Manne-Goehler J, Theilmann M, Davies JI, Awasthi A, Vollmer S, et al. Diabetes and hypertension in India: a nationally representative study of 1.3 million adults. JAMA Intern Med. 2018;178:363–72.
- Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Angelantonio DE, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. 2014;32(6):1170–7.
- Shri JP (2017). Nadda inaugurates National Training for Universal Screening and Control of Common NCDs. [online] Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=161821 [Last accessed October, 2020].
- May Measurement Month. [online] Available from: http://maymeasure.com/ [Last accessed October, 2020].
- International Society of Hypertension. May Measurement Month & WHD. [online] Available from: http://ish-world.com/public/world-hypertension-day.htm [Last accessed October, 2020].
- New Delhi: Government of India; 2005. Ministry of Health and Family Welfare. National Rural Health Mission (2005–2012), Mission document.
- National Health Mission, Ministry of Health & Family Welfare, Government of India. Operational Guidelines-Prevention, screening and control of common non-communicable diseases: Hypertension, diabetes and common cancers (oral, breast, cervix). [online] Available from: http://nicpr.res.in/images/PDF/guidelines_for_population_level_screening_of_common_NCDs.pdf [Last accessed October, 2020].
- 2.3 crore screened for BP, cancers in 1 year under Modicare. [online] Available from: https://timesofindia.indiatimes.com/india/over-1-3-crore-screened-for-bp-cancers-in-1-year-undermodicare/articleshow.
- Jose AP, Awasthi A, Kondal D, Kapoor M, Roy A, Prabhakaran D. Review Impact of repeated blood pressure measurement on blood pressure categorization in a population-based study from India. J Hum Hypertens. 2019;33(8):594–601.
- Skirton H, Chamberlain W, Lawson C, Ryan H, Young E. A systematic review of variability and reliability of manual and automated blood pressure readings. J Clin Nurs. 2011;20(5-6):602–14.
- A'Court C, Stevens R, Sanders S, Ward A, McManus R, Heneghan C. Type and accuracy of sphygmomanometers in primary care: a cross-sectional observational study. Br J Gen Pract. 2011;61(590):e598–603.
- Parati G, Mendis S, Abegunde D, Asmar R, Mieke S, Murray A, et al. Recommendations for blood pressure measuring devices for office/clinic use in low resource settings. Blood Press Monit. 2005;10(1):3–10.
- New Delhi: Ministry of Health and Family Welfare, Government of India; 2005. National Rural Health Mission. Framework of Implementation; 2005–2012.
- New Delhi: Ministry of Health and Family Welfare, Government of India; 2011. National Health System Resource Center. National Rural Health Mission, Mainstreaming of AYUSH and Revitalization of Local Health Traditions under NRHM, An Appraisal of the Annual State Programme Implementation Plans 2007–2010 and Mapping of Technical Assistance Needs.