Scaling up effective treatment of hypertension-A pathfinder for universal health coverage

HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control

PURPOSE OF REVIEW

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

RECENT FINDINGS

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

[HEARTS in the Americas: targeting health system change to improve population hypertension controlHEARTS nas Américas: impulsionar mudanças no sistema de saúde para melhorar o controle da hipertensão arterial na população]

Purpose of review

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

Recent findings

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation.

Summary

Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

Disruption of diabetes and hypertension care during the COVID-19 pandemic and recovery approaches in the Latin America and Caribbean region: a scoping review protocol

INTRODUCTION

The COVID-19 pandemic significantly disrupted primary healthcare globally, with particular impacts on diabetes and hypertension care. This review will examine the impact of pandemic disruptions of diabetes and hypertension care services and the evidence for interventions to mitigate or reverse pandemic disruptions in the Latin America and Caribbean (LAC) region.

METHODS AND ANALYSES

This scoping review will examine care delivery disruption and approaches for recovery of primary healthcare in the LAC region during the COVID-19 pandemic, focusing on diabetes and hypertension awareness, detection, treatment and control. Guided by Arksey and O'Malley's scoping review methodology framework, this protocol adheres to the Joanna Briggs Institute guidelines for scoping review protocols and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance for protocol development and scoping reviews. We searched MEDLINE, CINAHL, Global Health, Embase, Cochrane, Scopus, Web of Science and LILACS for peer-reviewed literature published from 2020 to 12 December 2022 in English, Spanish or Portuguese. Studies will be considered eligible if reporting data on pandemic disruptions to primary care services within LAC, or interventions implemented to mitigate or reverse pandemic disruptions globally. Studies on COVID-19 or acute care will be excluded. Two reviewers will independently screen each title/abstract for eligibility, screen full texts of titles/abstracts deemed relevant and extract data from eligible full-text publications. Conflicts will be resolved through discussion and with the help of a third reviewer. Appropriate analytical techniques will be employed to synthesise the data, for example, frequency counts and descriptive statistics. Quality will be assessed using the Newcastle Ottawa Quality Assessment Scale.

ETHICS AND DISSEMINATION

No ethics approval was needed as this is a scoping review of published literature. Results will be disseminated in a report to the World Bank and the Pan American Health Organization, in peer-reviewed scientific journals, and at national and international conferences.

Trends in hypertension prevalence, awareness, treatment, and control: an 8-year follow-up study from rural North India

Hypertension is a major contributor to global CVD burden. LMICs including India is challenged with rising hypertension prevalence, yet limited studies are available on temporal change and incidence among community-cohorts. This study aimed to describe trends in hypertension prevalence, awareness, treatment, and control over 8 years among a rural community-cohort from Haryana, India. The study also lends towards an analysis of incidence. Adults ≥ 30 years (N = 1542) recruited during baseline cross-sectional study between 2011 and 2014 were followed up after a median 8.1 years. At endline, demographic/lifestyle characteristics and blood pressure were re-examined. Overall median SBP significantly increased from 120 mmHg at baseline to 125.5 mmHg at endline (p < 0.001), while hypertension prevalence increased from 34.4% (95% CI 32.0-36.9) to 40.4% (95% CI 37.5-43.4) (p = 0.002). Age-standardized hypertension incidence was 30.2% (95% CI 26.7-35.2) over 8 years. Among hypertensive group, awareness, treatment, and control increased from 9.6, 8.8 and 5.0% to 31.8, 27.3 and 9.6% (p < 0.05), respectively. Increasing trend in SBP and hypertension prevalence was observed as the cohort ages. This increase is supported by the high incidence of hypertension. Nevertheless, our study highlights positive trends in hypertension care cascade but poor control, suggesting that this trend may not be adequately impactful to reduce hypertension burden.

Monitoring of Non-communicable Diseases in a Primary Healthcare Setting in India: A Quality Improvement Initiative

Background The majority of patients with non-communicable diseases (NCDs) seek care in a primary healthcare setting. There is a lack of effective monitoring of patients with NCD, which leads to poor disease control and an increase in morbidity and mortality. We wanted to explore the feasibility of maintaining patient health record and utilising it for disease monitoring in a primary healthcare setting. Therefore, we aimed to increase the availability of patient health records from 0% to 100% using the principles of quality improvement (QI) among patients with hypertension and/or diabetes within six weeks and to use these records for assessing the disease control status of patients through cohort monitoring approach. Methods This QI initiative was conducted at an urban health centre (UHC) located at Dakshinpuri, New Delhi. We specifically focused on two major NCDs: diabetes and hypertension. We formed a QI team and identified the gaps using fishbone analysis and a process flow diagram. We used the model for improvement and the Plan-Do-Study-Act (PDSA) framework. We conducted repeated rapid PDSA cycles for the designed intervention and monitored the change every week using a run chart. The data from the patient health record were entered into Microsoft Excel (Microsoft^® Corp., Redmond, WA) using Google Forms (Google, Inc., Mountain View, CA) and Epicollect5 (Oxford Big Data Institute, Oxford, England). We used the cohort monitoring approach of the India Hypertension Control Initiative to assess the quarterly control rate for hypertension and diabetes at the UHC. Results The root cause analysis revealed that the lack of a policy for keeping patient records and the lack of perceived need in the past were the primary reasons behind the absence of NCD health records. In brainstorming sessions with the QI team, we designed a paper-based patient health record system involving unique identity (ID) generation, an index register, an NCD record file and an NCD passbook (Dhirghayu card) for each patient. We reorientated the process of patient flow and devised a mechanism for record-keeping at the UHC. This initiative increased the availability of patient health records from 0% to 100% in the initial three weeks. The system of maintaining patient health records was well received by the patients and was better utilised by treating physicians for NCD management. After the intervention, we were able to use the data from the NCD file to assess the quarterly control rates of the patients with hypertension and/or diabetes. Conclusion Our study showed that patients' health records can be generated and maintained in a primary healthcare setting by using the principles of quality improvement. These records can be utilised for the disease monitoring of patients with hypertension and/or diabetes, which can lead to better disease control. The sustainability of this initiative and the performance of the health facility can be assessed in future studies using annual control rates.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension

ABSTRACT

Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

Advancement in the Cuffless and Noninvasive Measurement of Blood Pressure: A Review of the Literature and Open Challenges

Hypertension is a chronic condition that is one of the prominent reasons behind cardiovascular disease, brain stroke, and organ failure. Left unnoticed and untreated, the deterioration in a health condition could even result in mortality. If it can be detected early, with proper treatment, undesirable outcomes can be avoided. Until now, the gold standard is the invasive way of measuring blood pressure (BP) using a catheter. Additionally, the cuff-based and noninvasive methods are too cumbersome or inconvenient for frequent measurement of BP. With the advancement of sensor technology, signal processing techniques, and machine learning algorithms, researchers are trying to find the perfect relationships between biomedical signals and changes in BP. This paper is a literature review of the studies conducted on the cuffless noninvasive measurement of BP using biomedical signals. Relevant articles were selected using specific criteria, then traditional techniques for BP measurement were discussed along with a motivation for cuffless measurement use of biomedical signals and machine learning algorithms. The review focused on the progression of different noninvasive cuffless techniques rather than comparing performance among different studies. The literature survey concluded that the use of deep learning proved to be the most accurate among all the cuffless measurement techniques. On the other side, this accuracy has several disadvantages, such as lack of interpretability, computationally extensive, standard validation protocol, and lack of collaboration with health professionals. Additionally, the continuing work by researchers is progressing with a potential solution for these challenges. Finally, future research directions have been provided to encounter the challenges.

Barriers to effective hypertension management in rural Bihar, India: A cross-sectional, linked supply- and demand-side study

Effective management of hypertension in low- and middle-income settings is a persistent public health challenge. This study examined supply- and demand-side barriers to receiving quality care and achieving effective hypertension management in rural Bihar, India. A state-representative household survey collected information from adults over 30 years of age on characteristics of the hypertension screening, diagnosis, and management services they received. A linked provider assessment determined the percent of providers who provided quality hypertension care (i.e., had a functioning BP measurement device, measured a patient's BP, could correctly diagnose hypertension, had at least one first-line antihypertension medication, and could prescribe correctly based on standard guidelines). Patients were linked with their provider to determine the quality-adjusted coverage of hypertension management and logistic regression analysis was conducted to determine characteristics associated with receiving quality care. A total of 14,386 patients and 390 providers were studied. Nearly a quarter (22.5%) of adults had never had their BP measured before and 8.1% of adults reported a previous hypertension diagnosis. Less than one third (31.0%) of all interviewed providers demonstrated ability to provide quality hypertension care, and quality varied between provider types (14.8% of private homeopathic, 25.2% of informal, 40.0% of private modern medicine, and 60.0% of public providers gave quality care). While 95.8% of diagnosed individuals received some treatment, only 10.9% of patients received care from quality local providers. Nearly 45% of individuals with hypertension received care from non-local providers. Individuals from the general caste with comorbidities living in villages with more high-quality providers were most likely to receive quality care from a local provider. Whereas the coverage of services for individuals diagnosed with hypertension is high, the quality of these services is suboptimal for economically and socially vulnerable populations, which limits effective management and control of hypertension in rural Bihar. Efforts should be targeted towards providers to initiate quality treatment upon diagnosis, including correct prescription of antihypertensives.

Developing population-based hypertension control programs

Hypertension remains the leading cause of cardiovascular disease globally despite the availability of safe and effective treatments. Unfortunately, many barriers exist to controlling hypertension, including a lack of effective screening and awareness, an inability to access treatment and challenges with its management when it is treated. Addressing these barriers is complex and requires engaging in a systematic and sustained approach across communities over time. This analysis aims to describe the key elements needed to create an effective delivery system for hypertension control. A successful system requires political will and supportive leadership at all levels of an organization, including at the point of care delivery (office or clinic), in the health care system, and at regional, state and national levels. Effective screening and outreach systems are necessary to identify individuals not previously diagnosed with hypertension, and a system for follow up and tracking is needed after people are diagnosed. Implementing simple protocols for treating hypertension can reduce confusion among providers and increase treatment efficiency. Ensuring easy access to safe, effective and affordable medications can increase blood pressure control and potentially decrease health care system costs. Task-sharing among members of the health care team can expand the services that are delivered. Finally, monitoring of and reporting on the performance of the health care team are needed to learn from those who are doing well, disseminate ideas to those in need of improvement and identify individual patients who need outreach or additional care. Successful large-scale hypertension programs in different settings share many of these key elements and serve as examples to improve systems of hypertension care delivery throughout the world.

The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries

BACKGROUND

Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition's current socioeconomic gradients and how these are likely to change in the future as countries develop economically.

OBJECTIVES

This cross-sectional study aimed to determine how hypertension prevalence in LMICs varies by individuals' education and household wealth, and how these socioeconomic gradients in hypertension prevalence are associated with a country's gross domestic product (GDP) per capita.

METHODS

We pooled nationally representative household survey data from 76 LMICs. We disaggregated hypertension prevalence by education and household wealth quintile, and used regression analyses to adjust for age and sex.

RESULTS

We included 1,211,386 participants in the analysis. Pooling across all countries, hypertension prevalence tended to be similar between education groups and household wealth quintiles. The only world region with a clear positive association of hypertension with education or household wealth quintile was Southeast Asia. Countries with a lower GDP per capita had, on average, a more positive association of hypertension with education and household wealth quintile than countries with a higher GDP per capita, especially in rural areas and among men.

CONCLUSIONS

Differences in hypertension prevalence between socioeconomic groups were generally small, with even the least educated and least wealthy groups having a substantial hypertension prevalence. Our cross-sectional interaction analyses of GDP per capita with the socioeconomic gradients of hypertension suggest that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

Hypertension treatment cascade in India: results from National Noncommunicable Disease Monitoring Survey

Hypertension is a major risk factor for ischemic heart disease and stroke. We estimated prevalence, awareness, treatment, and control of hypertension along with its determinants in India. We used data from the National NCD Monitoring Survey-(NNMS-2017-2018) which studied one adult (18-69 years) from a representative sample of households across India and collected information on socio-demographic variables, risk factors for NCDs and treatment practices. Blood pressure was recorded digitally and hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg or currently on medications. Awareness was defined as being previously diagnosed with hypertension by a health professional; on treatment as taking a dose of medication once in the last 14 days and; control as SBP < 140 mmHg and DBP < 90 mmHg. Multivariate Logistic regression was performed to estimate determinants. Out of 10,593 adults with a blood pressure measurement (99.4%), 3017 (28.5%; 95% CI: 27.0-30.1) were found to have hypertension. Of these hypertensives, 840 (27.9%; 95% CI: 25.5-30.3) were aware, 438 (14.5%; 95% CI: 12.7-16.5) were under treatment and, 379 (12.6%; 95% CI: 11.0-14.3) were controlled. Significant determinants of awareness were being in the age group 50-69 years (aOR 2.45 95% CI: 1.63-3.69), women (1.63; 95% CI: 1.20-2.22) and from higher wealth quintiles. Those in the age group 50-69 (aOR 4.80; 95% CI: 1.74-13.27) were more likely to be under treatment. Hypertension control was poorer among urban participants (aOR 0.55; 95% CI: 0.33-0.90). Significant regional differences were noted, though without any clear trend. One-fifth of the patients were being managed at public facilities. The poor population-level hypertension control needs strengthening of hypertension services in the Universal Health Coverage package.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

Essential medicines and technology for hypertension in primary healthcare facilities in Ebonyi State, Nigeria

Introduction

Cardiovascular diseases (CVDs) now constitute major cause of morbidity and mortality in middle and low income countries including Nigeria. One of the major efforts at controlling CVDs in Nigeria includes expanding universal access to care through the primary healthcare (PHC) system. The study was to assess essential medicines and technology for control of hypertension in PHC facilities in Ebonyi Nigeria.

Methods

The study used mixed method cross-sectional survey to assess availability, affordability and accessibility of essential medicines and technology in 45 facilities and among their patients with hypertension (145).

Results

Most of the PHC facilities (71.1%) assessed were rural. The heads of facilities were mainly community health extension workers (86.7%). One (2.2%) facility had a pharmacy technician. All facilities had been supervised by the regulatory authority in the last one year. Out of 15 anti-hypertensive drugs assessed, 10 were available in some facilities (2.2%–44.4%) but essential drug availability was low (<80%). Only mercury sphygmomanometers were available in all facilities with 82.2% functioning. Stethoscopes were available in all facilities and 95.6% were functional. Glucometers were present in 20.0% of facilities and were all functional.

All the respondents (100.0%) reported they could not afford their anti-hypertensive drugs. Median monthly income was 8,000 Nigerian Naira (range = 2,000–52,000). Median monthly cost of anti-hypertensive drugs was 3,500 Naira (range = 1,500–10,000). For 99 (68.3%) of the respondents, the facilities were accessible. Median cost of transportation for care was 400 Naira (range = 100–2,000).

Conclusion

Gaps still exist in the provision of hypertension control services in PHC facilities in Ebonyi State, Nigeria. The essential drugs were not always available, and cost of the drugs were still a challenge to the patients. There is urgent need to expand health insurance coverage to rural communities to ameliorate the catastrophic out-of-pocket health expenditures and improve control of CVDs.

The effect of acute alcohol ingestion on systemic hemodynamics and sleep architecture in young, healthy men

Objective Heightened nocturnal blood pressure (BP) may be attributed to the disruption of sleep, a condition worsened by alcohol ingestion. This study investigated the effects of acute alcohol ingestion on hemodynamics and sleep architecture in a young, healthy cohort of male. METHODS: Subjects (n = 17) underwent acute alcohol ingestion reaching a breath alcohol content of 0.08. Each subject endured a battery of hemodynamic tests and had their sleep architecture and nocturnal blood pressure monitored pre- and post-ingestion. Results: Systolic blood pressure (SBP) increased both 30 minutes and 12 hours after alcohol. Ambulatory nocturnal SBP significantly increased after alcohol compared to baseline measures. Minutes of total, rapid eye movement, and light sleep all increased after alcohol ingestion, while a decrease was observed for sleep latency. Conclusions: An acute bout of heavy alcohol consumption may attenuate nocturnal BP dipping that, in turn, may hasten the progression of hypertension-related cardiovascular disease.

Effect of leisure-time physical activity in controlling hypertension: a systematic review and meta-analysis protocol

INTRODUCTION

Hypertension is a major risk factor for cardiovascular diseases. In 2015, over 1.13 billion individuals worldwide had hypertension. Globally, it results in 10.8 million deaths every year. Around half of the individuals do not continue treatment with medicine to control blood pressure. Physical activity, a non-pharmacological option of treatment, reduces blood pressure. We aim in this research to examine the effect of leisure-time physical activity in controlling blood pressure.

METHODS AND ANALYSIS

We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to conduct this study. We will perform a systematic search in Medline/PubMed, Embase, Scopus, Web of Science, Physical Education Index (ProQuest) and CENTRAL (the Cochrane Library). Both experimental and observational studies will be included. The study population would be people with hypertension. Two reviewers will perform screening of the articles, bias assessment and data extraction independently. We will use the Joanna Briggs Institute Critical Appraisal Tools to assess the risk of bias. We will conduct a meta-analysis if it is applicable.

ETHICS AND DISSEMINATION

The results will be published in peer-reviewed journals and presented at relevant scientific seminars and conferences. Ethical approval is not applicable.

PROSPERO REGISTRATION NUMBER

CRD42021260751.

Patient-Centered, Sustainable Hypertension Care: The Case for Adopting a Differentiated Service Delivery Model for Hypertension Services in Low- and Middle-Income Countries

Expanding hypertension services in low- and middle-income countries requires efficient and effective service delivery approaches that meet the needs and expectations of people living with hypertension within the resource constraints of existing national health systems. Ideally, a hypertension program will extend treatment coverage while maintaining service quality, maximizing efficient resource utilization and improving clinical outcomes. In this article, we discuss lessons learned from HIV differentiated service delivery initiatives, and make the case that the same approach should be adopted for hypertension programs.

Initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy in patients with hypertension (QUARTET): a phase 3, randomised, double-blind, active-controlled trial

BACKGROUND

Treatment inertia is a recognised barrier to blood pressure control, and simpler, more effective treatment strategies are needed. We hypothesised that a hypertension management strategy starting with a single pill containing ultra-low-dose quadruple combination therapy would be more effective than a strategy of starting with monotherapy.

METHODS

QUARTET was a multicentre, double-blind, parallel-group, randomised, phase 3 trial among Australian adults (≥18 years) with hypertension, who were untreated or receiving monotherapy. Participants were randomly assigned to either treatment, that started with the quadpill (containing irbesartan at 37·5 mg, amlodipine at 1·25 mg, indapamide at 0·625 mg, and bisoprolol at 2·5 mg) or an indistinguishable monotherapy control (irbesartan 150 mg). If blood pressure was not at target, additional medications could be added in both groups, starting with amlodipine at 5 mg. Participants were randomly assigned using an online central randomisation service. There was a 1:1 allocation, stratified by site. Allocation was masked to all participants and study team members (including investigators and those assessing outcomes) except the manufacturer of the investigational product and one unmasked statistician. The primary outcome was difference in unattended office systolic blood pressure at 12 weeks. Secondary outcomes included blood pressure control (standard office blood pressure <140/90 mm Hg), safety, and tolerability. A subgroup continued randomly assigned allocation to 12 months to assess long-term effects. Analyses were per intention to treat. This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, ACTRN12616001144404, and is now complete.

FINDINGS

From June 8, 2017, to Aug 31, 2020, 591 participants were recruited, with 743 assessed for eligibility, 152 ineligible or declined, 300 participants randomly assigned to intervention of initial quadpill treatment, and 291 to control of initial standard dose monotherapy treatment. The mean age of the 591 participants was 59 years (SD 12); 356 (60%) were male and 235 (40%) were female; 483 (82%) were White, 70 (12%) were Asian, and 38 (6%) reported as other ethnicity; and baseline mean unattended office blood pressure was 141 mm Hg (SD 13)/85 mm Hg (SD 10). By 12 weeks, 44 (15%) of 300 participants had additional blood pressure medications in the intervention group compared with 115 (40%) of 291 participants in the control group. Systolic blood pressure was lower by 6·9 mm Hg (95% CI 4·9-8·9; p<0·0001) and blood pressure control rates were higher in the intervention group (76%) versus control group (58%; relative risk [RR] 1·30, 95% CI 1·15-1·47; p<0·0001). There was no difference in adverse event-related treatment withdrawals at 12 weeks (intervention 4·0% vs control 2·4%; p=0·27). Among the 417 patients who continued, uptitration occurred more frequently among control participants than intervention participants (p<0·0001). However, at 52 weeks mean unattended systolic blood pressure remained lower by 7·7 mm Hg (95% CI 5·2-10·3) and blood pressure control rates higher in the intervention group (81%) versus control group (62%; RR 1·32, 95% CI 1·16-1·50). In all randomly assigned participants up to 12 weeks, there were seven (3%) serious adverse events in the intervention group and three (1%) serious adverse events in the control group.

INTERPRETATION

A strategy with early treatment of a fixed-dose quadruple quarter-dose combination achieved and maintained greater blood pressure lowering compared with the common strategy of starting monotherapy. This trial demonstrated the efficacy, tolerability, and simplicity of a quadpill-based strategy.

FUNDING

National Health and Medical Research Council, Australia.

The relationship between rotating shift work and blood pressure among nurses working in hospitals of Abadan, Iran

Hypertension is a major risk factor for developing cardiovascular disease. Various factors such as occupational and environmental risk factors affect blood pressure. Shift work is considered to be an occupational stressor. The aim of this study was to determine the relationship between rotating shift work and blood pressure among nurses working in hospitals associated with faculty of medical science. This cross-sectional and descriptive-analytic study was conducted on nurses who worked in three hospitals associated with faculty of medical science, located in Abadan, southwest of Iran from September until December 2019. The sample size was 120 participants and divided into 60 rotating shift workers and 60 day workers (non-shift workers). The nurses were selected through the stratified random sampling technique. Demographic data, smoking status, and medical and occupational history were collected through a check list and interviews. Blood pressure was measured using a digital sphygmomanometer. Data were analyzed by the Mann-Whitney U, chi-square, Pearson's correlation coefficient and logistic regression by using SPSS software version 22. There was statistically significant difference in blood pressure between day workers and rotating shift workers (p ≤ 0.001). By logistic regression analyses, and even after adjusting for confounding variables, rotating shift work was associated with a higher prevalence of hypertension (OR: 1.76 [95%CI: 1.11-2.80]). The findings of this study showed that rotating shift workers have a higher incidence of hypertension than day workers. Therefore, a particular follow-up of rotating shift workers should be recommended to screen workers for hypertension.

Cost-Effectiveness of Improved Hypertension Management in India through Increased Treatment Coverage and Adherence: A Mathematical Modeling Study

Background:

Despite the availability of effective and affordable treatments, only 14% of hypertensive Indians have controlled blood pressure. Increased hypertension treatment coverage (the proportion of individuals initiated on treatment) and adherence (proportion of patients taking medicines as recommended) promise population health gains. However, governments and other payers will not invest in a large-scale hypertension control program unless it is both affordable and effective.

Objective:

To investigate if a national hypertension control intervention implemented across the private and public sector facilities in India could save overall costs of CVD prevention and treatment.

Methods:

We developed a discrete-time microsimulation model to assess the cost-effectiveness of population-level hypertension control intervention in India for combinations of treatment coverage and adherence targets. Input clinical parameters specific to India were obtained from large-scale surveys such as the Global Burden of Disease as well as local clinical trials. Input hypertensive medication cost parameters were based on government contracts. The model projected antihypertensive treatment costs, avoided CVD care costs, changes in disability-adjusted life year (DALYs) and incremental cost per DALY averted (represented as incremental cost-effectiveness ratio or ICER) over 20 years.

Results:

Over 20 years, at 70% coverage and adherence, the hypertension control intervention would avert 1.68% DALYs and be cost-saving overall. Increasing adherence (while keeping coverage constant) resulted in greater improvement in cost savings compared to increasing coverage (while keeping adherence constant). Results were most sensitive to the cost of antihypertensive medication, but the intervention remained highly cost-effective under all one-way sensitivity analyses.

Conclusion:

A national hypertension control intervention in India would most likely be budget neutral or cost-saving if the intervention can achieve and maintain high levels of both treatment coverage and adherence.

Hypertension in Low- and Middle-Income Countries

In recent decades low- and middle-income countries (LMICs) have been witnessing a significant shift toward raised blood pressure; yet in LMICs, only 1 in 3 are aware of their hypertension status, and ≈8% have their blood pressure controlled. This rising burden widens the inequality gap, contributes to massive economic hardships of patients and carers, and increases costs to the health system, facing challenges such as low physician-to-patient ratios and lack of access to medicines. Established risk factors include unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity. Emerging risk factors include pollution (air, water, noise, and light), urbanization, and a loss of green space. Risk factors that require further in-depth research are low birth weight and social and commercial determinants of health. Global actions include the HEARTS technical package and the push for universal health care. Promising research efforts highlight that successful interventions are feasible in LMICs. These include creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. As the blood pressure trajectory continues creeping upward in LMICs, contextual research on effective, safe, and cost-effective interventions is urgent. New emergent risk factors require novel solutions. Lowering blood pressure in LMICs requires urgent global political and scientific priority and action.

The 2020 "WHO Technical Specifications for Automated Non-Invasive Blood Pressure Measuring Devices With Cuff"

High systolic blood pressure (BP) is the single leading modifiable risk factor for death worldwide. Accurate BP measurement is the cornerstone for screening, diagnosis, and management of hypertension. Inaccurate BP measurement is a leading patient safety challenge. A recent World Health Organization report has outlined the technical specifications for automated noninvasive clinical BP measurement with cuff. The report is applicable to ambulatory, home, and office devices used for clinical purposes. The report recommends that for routine clinical purposes, (1) automated devices be used, (2) an upper arm cuff be used, and (3) that only automated devices that have passed accepted international accuracy standards (eg, the International Organization for Standardization 81060-2; 2018 protocol) be used. Accurate measurement also depends on standardized patient preparation and measurement technique and a quiet, comfortable setting. The World Health Organization report provides steps for governments, manufacturers, health care providers, and their organizations that need to be taken to implement the report recommendations and to ensure accurate BP measurement for clinical purposes. Although, health and scientific organizations have had similar recommendations for many years, the World Health Organization as the leading governmental health organization globally provides a potentially synergistic nongovernment government opportunity to enhance the accuracy of clinical BP assessment.

Prices of combination medicines and single-molecule antihypertensive medicines in India's private health care sector

More than half of patients with hypertension require two or more medicines to control blood pressure. Combinations of anti‐hypertensive medicines are available as Single Pill Combinations (SPCs) or Single Agent Pills (SAPs). SPCs of two or more anti‐hypertensive medicines facilitate simpler dosing schedules, decrease pill burden, increase adherence to medicine, and simplify procurement and distribution. Despite this, equivalent combinations of separate pills (SAPs) are often prescribed instead of SPCs under the assumption that SAPs are priced lower. This study compared prices of anti‐hypertensive SPCs and equivalent SAPs in the private health care sector of India. High sales volume anti‐hypertensive SPCs and SAPs were selected from 2018 private sector pharmaceutical sales data. SPCs and SAPs price information was collected from online pharmacy websites between November 2019 and January 2020. Anti‐hypertensive SPCs represent approximately 39.1% of India's private sector anti‐hypertensive drug market. Multiple manufacturers produce the same top‐selling SPCs, suggesting a viable and competitive market. A comparison of SPCs and SAPs across different manufacturers showed that the lowest prices of both SPCs and the sum of component SAPs were nearly identical across different manufacturers. An analysis of dual‐drug SPCs and SAPs by the same manufacturer showed that most manufacturers (five of six) had priced their SPCs higher than SAPs. These observations suggest that the price of SPCs could be lowered to match the combined price of the component SAPs, and manufacturing costs and market forces do not present a barrier to the implementation of anti‐hypertensive SPCs.

Digital Health Approaches for the Assessment and Optimisation of Hypertension Care Provision

Although many aspects of our lives have been transformed by digital innovation, widespread adoption of digital health advancements within the health care sector in general, and for hypertension care specifically, has been limited. However, it is likely that, over the next decade, material increases in the uptake of digital health innovations for hypertension care delivery will be seen. In this narrative review, we summarise those innovations thought to have the greatest chance for impact in the next decade. These include provision of virtual care combined with home blood pressure (BP) telemonitoring, use of digital registries and protocolised care, leveraging continuous BP measurement to collect vast amounts of individual and population-based BP data, and adoption of digital therapeutics to provide low-cost scalable interventions for patients with or at risk for hypertension. Of these, home BP telemonitoring is likely the most ready for implementation, but it needs to be done in a way that enables efficient guideline-concordant care in a cost-effective manner. In addition, efforts must be focused on implementing digital health solutions in a manner that addresses the major challenges to digital adoption. This entails ensuring that innovations are accessible, usable, secure, validated, evidence based, cost-effective, and integrated into the electronic systems that are already used by patients or providers. Increasing the use of broader digital innovations such as artificial/augmented intelligence, data analytics, and interactive voice response is also critically important. The digital revolution holds substantial promise, but success will depend on the ability of collaborative stakeholders to adopt and implement innovative, usable solutions.

Reducing Premature Mortality from Cardiovascular and Other Non-Communicable Diseases by One Third: Achieving Sustainable Development Goal Indicator 3.4.1

Non-communicable diseases (NCDs) are the world's leading causes of death and disability, with cardiovascular disease (CVD) accounting for half of NCD deaths. An ambitious global target established by the United Nations Sustainable Development Goals - indicator 3.4.1 - aims to reduce the risk of premature death among people aged 30-69 years from CVD, cancer, diabetes, and chronic lung disease by one third by 2030. This article reviews the science and practice informing what is required to achieve this target, identifying seven interventions that can accelerate progress: 1) tobacco control; 2) treatment to reduce cardiovascular risk; 3) reduction of dietary sodium; 4) reduction of household air pollution; 5) elimination of artificial trans fat; 6) reduction of alcohol use; and 7) prevention, detection, and treatment of cancers. Achieving the target is possible - there has already been progress in some areas, particularly related to CVD reduction - but only if there is faster, more concerted action.

Factors affecting self-management of hypertensive patients attending family medicine clinics in Riyadh, Saudi Arabia

Background/Aim:

Hypertension (HBP) is a chronic disease that has become a public health problem, which has been attributed to numerous risk factors. However, despite numerous HBP management and behavioral treatment guidelines, HBP is poorly controlled among patients due to insufficient care. We conducted this study to identify the prevalence of self-management behaviors and to explore factors affecting self-management behaviors for controlling HBP among hypertensive patients.

Methods:

We conducted a survey using the Hypertension Self-Care Profile (HBP-SCP) and the Hill-Bone Adherence Scale among diagnosed HBP patients attending the Family Medicine clinics of King Saud Medical City in Riyadh, Saudi Arabia in January 2019. All patients of Saudi nationality aged 18 years and above were included in the study.

Results:

A total of 187 patients responded to the survey, 95 (50.8%) males and 92 (49.2%) females. Only 93 patients (49.7%) monitor their BP at home, and 68 (36.4%) always measure their BP. Ninety-one patients (48.7%) said that measuring their BP is not important. The most common reason for not taking the anti-HBP medications is they forget to take the medications in 87 (46.5%) of patients. Seventy-two patients (38.5%) did not restrict salt intake, and 51 patients (27.3%) had no time for exercise. More than half of the patients (51.3%) were not motivated to regularly exercise and 56.7% were motivated to limit salt-intake. Confidence to exercise, check BP at home, and eat low-salt foods were also low at 52.4–53.5%. Significant factors including gender, age, BMI, duration of HBP, and presence of cardiac disease were found to be related toward behavior, motivation, and confidence to self-care.

Conclusion:

Compliance, behavior, motivation, and self-care among hypertensive patients visiting the primary care clinics in our representative population are low. Various factors were found to be related to poor behavior, poor motivation, and less confidence to do home BP monitoring, to exercise more, restrict salt intake, and value the control of HBP. There is a need for health practitioners to assess self-care activities and blood pressure control, and educate patients the importance of HBP monitoring and teaching practical techniques to boost their confidence and motivation to achieve a better behavior, self-care, and compliance to management.