Asian management of hypertension: Current status,home blood pressure,and specific concerns in Pakistan

Hypertension has reached epidemic proportions in Pakistan, and cardiovascular disease accounts for half of all non‐communicable diseases in the country. Although home blood pressure monitoring (HBPM) is being used in Pakistan, it is not routine practice, and cost is a major barrier to uptake. Other barriers include a lack of awareness of the utility of HBPM among patients and physicians, low education literacy levels in the general population, variability of results obtained using HBPM due to the presence of a large number of non‐validated monitors on the market, and a lack of awareness among physicians about the correct methodology for using HBPM. The Pakistan Hypertension League (PHL) does recommend use of a validated digital HBPM device for BP measurement. Recent data suggest that calcium channel blockers are the most commonly used antihypertensive agents, with ß‐blockers and angiotensin receptor blockers also widely used. Traditional medicine remains popular in Pakistan because it is more accessible, especially in rural areas, and is less expensive than conventional antihypertensives. The growing burden of hypertension and cardiovascular disease in Pakistan is compounded by the poor socioeconomic status of a fairly large proportion of the population, and lack of literacy and education. There is also a shortage of adequately trained medical personnel to take care of the increasing number of patients. The PHL and Pakistan Cardiac Society are working to increase awareness of hypertension at both the population and government levels.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Thailand

The prevalence of hypertension is increasing, but rates of awareness, treatment, and blood pressure (BP) control are also increasing. In terms of cardiovascular disease, the prevalence of coronary artery disease (CAD) and stroke is similar, but stroke mortality is higher than that from CAD. Home BP monitoring (HBPM) is an important tool for determining the presence of white‐coat or masked hypertension, facilitating drug cost savings or effective cardiovascular risk management strategies, respectively. However, there are a number of barriers to use of HBPM in Thailand. These include lack of availability (particularly in lower socioeconomic groups), lack of awareness of the importance of white‐coat and masked hypertension, and concerns about device reliability. The latest Thai Hypertension Society guidelines recommend that physicians and nurses encourage their patients to use their HBPM devices, and these are increasingly being utilized in clinical practice for both diagnostic purposes and therapeutic monitoring. Calcium channel blockers are the most commonly used antihypertensive agents in Thailand, followed by angiotensin receptor blockers, ß‐blockers, and diuretics. Angiotensin‐converting enzyme inhibitors are used less often due to drug‐related cough, and the use of fixed drug combinations is low because of their high cost and more complex reimbursement process. Ongoing work is needed to improve the primary prevention and effective treatment of hypertension in Thailand.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Indonesia

Over one‐third of the population in Indonesia has hypertension, almost two‐thirds of treated patients have uncontrolled blood pressure (BP), and the majority of patients with hypertension also have comorbidities. Home BP monitoring (HBPM) is a useful tool for diagnosing and managing hypertension. The use of HBPM is recommended by the latest consensus from the Indonesian Society of Hypertension (2019), and nearly, all doctors recommend HBPM for hypertensive patients. However, the use of HBPM in Indonesia is limited by the cost of devices and a perception that these devices are unreliable. In addition, knowledge about proper procedures is lacking. Withdrawal of mercury sphygmomanometers from the end of 2018 is expected to encourage the use of digital sphygmomanometers and the implementation of HBPM. The most common antihypertensive agent used in Indonesia varies by patient age, being angiotensin‐converting enzyme (ACE) inhibitors in those aged 40‐60 years and calcium channel blockers (CCBs) in older patients. Across all age groups, combination therapy with a CCB plus an angiotensin receptor blocker was common (41%‐42% of patients). The high prevalence of hypertension in Indonesia has an important economic impact, and approaches to increase awareness of the disease and adherence to therapy are needed, particularly given data showing the benefits of strict BP control.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in India

Systemic hypertension and its related complications are the important contributing factors for major adverse cardiovascular events all over the world. Evidence from Asia and even from India reveals that both its incidence and prevalence are increasing even in young population both in urban and rural areas. The HOPE (Hypertension Cardiovascular Outcome Prevention and Evidence) Asia network data clearly say that most of these hypertensive patients are undiagnosed and undertreated. Even among the treated patients, the regular follow‐up visits and compliance of antihypertensive drug intake are not effective. The blood pressure variability (BPV) and the exaggerated morning blood pressure surge (MBPS) leading to high cardiovascular mortality and morbidity have been demonstrated in many studies. The role of home blood pressure monitoring (HBPM) to detect BPV and MBPS to treat hypertensive patients more effectively has been published by the HOPE Asia Network. This article is to review the evidence and literature from the Indian perspective and the role of HBPM for the effective control of hypertension in general population.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Taiwan

Approximately 25% of the population in Taiwan has hypertension, and the rate has increased over time. Although age‐standardized cardiovascular mortality has decreased over the last 25 years, the annual stroke incidence has increased, and national health insurance reimbursement for cardiovascular disease (CVD) has grown by 22% over the last 10 years. Automatic oscillometric sphygmomanometer devices are increasingly available and affordable in Taiwan, making this the main method of out‐of‐office blood pressure (BP) measurement. Furthermore, home blood pressure monitoring (HBPM), along with shared informed decision making, could be beneficial in driving changes in health behavior and hypertension management. The 2015 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension recognize that home BP is a stronger predictor of CVD than office BP. Therefore, HBPM is recommended and implementation instructions provided. However, a home BP target that corresponds to the office BP used in the majority of clinical studies has yet to be clearly defined. Care for hypertension in Taiwan takes place more often in the hospital versus primary care setting. Combination therapy, often fixed drug combinations, is needed in 60% of patients to achieve BP control. Calcium channel blockers are the most commonly prescribed agents, followed by angiotensin receptor blockers. Overall, there is still substantial room for improvement in the awareness, treatment, and control rate of hypertension in Taiwan. HBPM has a central diagnostic and prognostic role in the management of hypertension.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in China

Increasing life expectancy in the population means that the prevalence of hypertension in China will increase over the coming decades. Although awareness and control rates have improved, the absolute rates remain unacceptably low. Cardiovascular disease (CVD) is the biggest killer in China, and sharp increases in the prevalence of CVD risk factors associated with rapid lifestyle changes will contribute to ongoing morbidity and mortality. This highlights the importance of effectively diagnosing and managing hypertension, where home blood pressure monitoring (HBPM) has an important role. Use of HBPM in China is increasing, particularly now that Asia‐specific guidance is available, and this out‐of‐office BP monitoring tool will become increasingly important over time. To implement these recommendations and guidelines, a Web‐based and WeChat‐linked nationwide BP measurement system is being established in China. Local guidelines state that both HBPM and ambulatory blood pressure monitoring should be implemented where available. In China, hypertension is managed most often using calcium channel blockers, followed by angiotensin receptor blockers or angiotensin‐converting enzyme inhibitors. Key barriers to hypertension control in China are low awareness and control rates.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Japan

Hypertension is highly prevalent in Japan, affecting up to 60% of males and 45% of females. Stroke is the main adverse cardiovascular event, occurring at a higher rate than acute myocardial infarction. Reducing blood pressure (BP) therefore has an important role to play in decreasing morbidity and mortality. The high use of home BP monitoring (HBPM) in Japan is a positive, and home BP is a better predictor of cardiovascular event occurrence than office BP. New 2019 Japanese Society of Hypertension Guidelines strongly recommend the use of HBPM to facilitate control of hypertension to new lower target BP levels (office BP < 130/80 mm Hg and home BP < 125/75 mm Hg). Lifestyle modifications, especially reducing salt intake, are also an important part of hypertension management strategies in Japan. The most commonly used antihypertensive agents are calcium channel blockers followed by angiotensin receptor blockers, and the combination of agents from these two classes is the most popular combination therapy. These agents are appropriate choices in South East Asian countries given that they have been shown to reduce stroke more effectively than other antihypertensives. Morning hypertension, nocturnal hypertension, and BP variability are important targets for antihypertensive therapy based on their association with target organ damage and cardiovascular events. Use of home and ambulatory BP monitoring techniques is needed to monitor these important hypertension phenotypes. Information and communication technology‐based monitoring platforms and wearable devices are expected to facilitate better management of hypertension in Japan in the future.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Malaysia

Cardiovascular disease (CVD) accounts for a third of all deaths in Malaysia. The background CV risk of Malaysia is much higher than that of developed countries in the west and in Asia. This high CV mortality is contributed by the high prevalence of CV risk factors especially hypertension which is very prevalent, coupled with low awareness and low control rates. This highlights the importance of home blood pressure measurements (HBPM). HBPM is an important adjunct in the management of hypertension, particularly to identify those unaware as well as white‐coat hypertension which is high in treated hypertensive patients in Malaysia. Ownership of HBPM devices in Malaysia is high, and this is an opportunity as well as timely to encourage more use of HBPM. The Malaysian national guidelines do not require HBPM for the diagnosis of hypertension but do recommend HBPM for specific situations. The most commonly prescribed anti‐hypertensives are calcium channel blockers, followed by renin‐angiotensin system blockers. Despite the wide availability of anti‐hypertensive agents, BP control rates remain low. It is important that strategies are in place to ensure that individuals are aware of the need to have their BP monitored regularly and this can be facilitated by the use of HBPM. Hence, there is a plan to develop a local HBPM consensus document. Strategies to reduce salt intake would also be beneficial. In summary, identification of those unaware and better control of BP with the help of HBPM would help reduce the burden of CV mortality and morbidity in Malaysia.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Vietnam

Hypertension and atherosclerotic diseases are becoming important public health issues in Vietnam. This is due, in part, to changing dietary patterns and lifestyles accompanying economic growth in the country. The most recent prevalence data suggest that 29% of the population has hypertension, and the rate of other cardiovascular risk factors is also high. Although use of home and ambulatory blood pressure monitoring (HBPM and ABPM) is increasing, Vietnamese physicians generally rely on office blood pressure (BP) for diagnosing and managing hypertension. A lack of availability and training are limiting factors. However, out‐of‐office BP monitoring is important to detect white‐coat and masked hypertension, and define the 24‐hour BP profile. This approach is recommended in current Vietnam Society of Hypertension and Vietnamese National Heart Association guidelines. Based on 2016 data, the most commonly used antihypertensive agents in Vietnam are angiotensin‐converting enzyme (ACE) inhibitors, followed by calcium channel blockers (CCBs) and diuretics, with ß‐blockers and angiotensin receptor blockers used less frequently. Combination therapy, usually with an ACE inhibitor plus CCB or diuretic, is quite common (used in 62% of patients). The participation of Vietnam in global hypertension initiatives and organizations has likely contributed to improved treatment and control rates over the last 10 years. Nevertheless, the prevalence of hypertension remains high and additional strategies are needed to reduce this and prevent cardiovascular disease.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Singapore

Despite reductions in hypertension prevalence and improvements in control rates in recent years, almost one‐third of all deaths in Singapore are due to cardiovascular disease and that proportion is growing. Ischemic heart disease is the most common cause of cardiovascular death, ahead of stroke. Local data suggest that awareness and support for home blood pressure monitoring (HBPM) is good, but there are reservations about the accuracy of HBPM devices and physicians cited a lack of time and resources to educate patients about HBPM. In addition, there was a knowledge gap around use of HBPM for evaluating treatment response. This is consistent with the emphasis of using HBPM for the diagnosis, rather than monitoring, of hypertension in the Singapore hypertension guidelines. In the absence of specific HBPM thresholds and targets, it is suggested that HOPE Asia Network consensus documents provide the most locally relevant guidance of the use of HBPM. Calcium channel blockers and angiotensin receptor blockers are the most commonly used antihypertensive agents in Singapore, and monotherapy was relatively uncommon (24%) of patients. Overall, more needs to be done in detecting and managing hypertension in Singapore to address rates of cardiovascular disease and cardiovascular disease mortality. Use of HBPM needs to be encouraged to improve adherence to treatment and optimize BP targets according to Asian perspectives and data.     

Current status of ambulatory blood pressure monitoring in Asian countries: A report from the HOPE Asia Network

Ambulatory blood pressure monitoring (ABPM) can measure 24‐hour blood pressure (BP), including nocturnal BP and diurnal variations. This feature of ABPM could be of value in Asian populations for preventing cardiovascular events. However, no study has yet investigated regarding the use of ABPM in actual clinical settings in Asian countries/regions. In this study, 11 experts from 11 countries/regions were asked to answer questionnaires regarding the use of ABPM. We found that its use was very limited in primary care settings and almost exclusively available in referral settings. The indications of ABPM in actual clinical settings were largely similar to those of home BP monitoring (HBPM), that is, diagnosis of white‐coat or masked hypertension and more accurate BP measurement for borderline clinic BP. Other interesting indications, such as nighttime BP patterns, including non‐dipper BP, morning BP surge, and BP variability, were hardly adopted in daily clinical practice. The use of ABPM as treatment guidance for detecting treated but uncontrolled hypertension in the Asian countries/regions didn't seem to be common. The barrier to the use of ABPM was primarily its availability; in referral centers, patient reluctance owing to discomfort or sleep disturbance was the most frequent barrier. ABPM use was significantly more economical when it was reimbursed by public insurance. To facilitate ABPM use, more simplified indications and protocols to minimize discomfort should be sought. For the time being, HBPM could be a reasonable alternative.     

Associations between fruit consumption and home blood pressure in a randomly selected sample of the general Swedish population

Frequent fruit consumption has been associated with lower office blood pressure. Less is known about associations between fruit consumption and home blood pressure. Our aim was to study the correlation between consumption of specific fruits and home blood pressure in a large randomly selected study population. The main outcome was systolic home blood pressure. Home blood pressure measurements were performed with calibrated oscillometric meters during seven consecutive days. Means for all available measurements were used. Validated food frequency questionnaires were used for estimating frequency of fruit consumption. The specified fruits were bananas, apples/pears and oranges/citrus fruit. Complete case analysis regarding fruit consumption, office‐ and home blood pressure measurements and other relevant variables was performed in 2283 study participants out of 2603 available. Multivariable linear regression analysis was performed. There were statistically significant associations between consumption of all fruit types and lower systolic home blood pressure unadjusted (p for trend; bananas, apples/pears and oranges/citrus fruit p < .001). The numerical differences between most and least frequent consumption of fruit were for bananas ‐2.7 mm Hg, apples/pears ‐3.9 mm Hg and for oranges/citrus fruit ‐3.4 mm Hg. When adjusted for covariates, both consumption of apples/pears and oranges/citrus fruit had an independent statistically significant association with lower blood pressure (p = .048 resp. p = .009). Future controlled interventional studies are needed to evaluate the effect of specific fruit on home blood pressure.     

Reimbursement of ambulatory blood pressure monitoring in the US commercial insurance marketplace

Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for confirming hypertension diagnosis and ongoing hypertension monitoring. However, reimbursement in the United States is variable and low compared with other advanced health care systems. We examined the reimbursement of ABPM and factors associated with successful reimbursement. A retrospective analysis of IBM MarketScan^® commercial claims database was conducted for patients ≥18 years with ≥1 ABPM claim from January 2012 to December 2016. The date of first the ABPM claim was used as the index date. Per‐beneficiary ABPM episode reimbursements were calculated by aggregating all ABPM‐related reimbursements within a 30‐day post‐index window, considered as an ABPM episode. Multivariable logistic regression was used to identify predictors of successful reimbursement. Of 20 875 beneficiaries with ABPM claims, 16 920 (81.0%) were reimbursed. The median reimbursement per beneficiary for an ABPM episode was $89 (Inter Quartile Range [IQR], $62, $132), driven primarily by reimbursement for the full procedure (median, $86; IQR, $66, $110). Comparing benefit plan types, consumer‐directed health plans provided the highest median reimbursement ($96; IQR, $61, $175). Successful reimbursement was associated with female patient sex (adjusted OR [aOR], 1.20; 95% CI, 1.11‐1.28), having a health maintenance organization (aOR 2.11; 95% CI, 1.82‐2.43) or point of service (aOR 2.08; 95% CI, 1.74‐2.49) as benefit plan types, claim filing by a specialist (aOR 1.26; 95% CI, 1.14‐1.40) and services provided at an outpatient hospital (aOR 1.17; 95% CI, 1.01‐1.35). Among commercially insured Americans, our data suggest significant variability in successful reimbursement. Accordingly, more uniform criteria for ABPM reimbursement may facilitate greater use of guideline‐recommended monitoring.     

Efficacy and safety of sacubitril/valsartan compared with olmesartan in Asian patients with essential hypertension: A randomized,double‐blind, 8‐week study

This study assessed the efficacy and safety of angiotensin receptor neprilysin inhibitor sacubitril/valsartan vs olmesartan in Asian patients with mild‐to‐moderate hypertension. Patients (N = 1438; mean age, 57.7 years) with mild‐to‐moderate hypertension were randomized to receive once daily administration of sacubitril/valsartan 200 mg (n = 479), sacubitril/valsartan 400 mg (n = 473), or olmesartan 20 mg (n = 486) for 8 weeks. The primary endpoint was reduction in mean sitting systolic blood pressure (msSBP) from baseline with sacubitril/valsartan 200 mg vs olmesartan 20 mg at Week 8. Secondary endpoints included msSBP reduction with sacubitril/valsartan 400 mg, and reductions in clinic and ambulatory BP and pulse pressure (PP) vs olmesartan. In addition, changes in msBP from baseline in the Chinese subpopulation, elderly (≥65 years), and in patients with isolated systolic hypertension (ISH) were assessed. Sacubitril/valsartan 200 mg provided a significantly greater reduction in msSBP than olmesartan 20 mg at Week 8 (between‐treatment difference: −2.33 mm Hg [95% confidence interval (CI) −4.00 to −0.66 mm Hg], P < 0.05 for non‐inferiority and superiority). Greater reductions in msSBP were also observed with sacubitril/valsartan 400 mg vs olmesartan 20 mg (−3.52 [−5.19 to −1.84 mm Hg], P < 0.001 for superiority). Similarly, greater reductions in msBP were observed in the Chinese subpopulation, in elderly patients, and those with ISH. In addition, both doses of sacubitril/valsartan provided significantly greater reductions from baseline in nighttime mean ambulatory BP vs olmesartan. Treatment with sacubitril/valsartan 200 or 400 mg once daily is effective and provided superior BP reduction than olmesartan 20 mg in Asian patients with mild‐to‐moderate hypertension and is generally safe and well tolerated.     

Reclassification of adolescent hypertension by ambulatory blood pressure monitoring using adult norms and association with left ventricular hypertrophy

2017 pediatric blood pressure (BP) guidelines applied adult BP norms to define clinic hypertension (HTN) in patients ≥ 13 years. 2014 pediatric ambulatory BP monitor (ABPM) guidelines recommend age‐ and sex‐specific percentile norms for patients < 18 years. The authors evaluated reclassification of HTN when applying adult ABPM norms in patients ≥ 13 years and assessed the association of left ventricular hypertrophy (LVH) with HTN. Charts of patients 13–17 years with ABPM 9/2018–5/2019 were reviewed for sex, age, height, weight, BP medication, ABPM results, and left ventricular mass index (LVMI). American Heart Association 2005 (AHA 2005), AHA 2017 (AHA 2017), and European Society of Hypertension 2018 (ESH 2018) guidelines for adult ABPM were compared with 2014 AHA pediatric norms (pABPM). HTN was defined by each guideline using only ABPM. ABPM and clinic BP were used to classify white coat hypertension (WCH) and masked hypertension (MH). LVH was defined as LVMI > 51 g/m^2.7. 272 patients had adequate ABPM. 124 patients also had echocardiogram. All adult norms resulted in significant reclassification of HTN. LVMI correlated significantly with systolic BP only. The odds of a patient with HTN having LVH was significant using AHA 2005 (OR: 8.75 [2.1, 36.4], p = .03) and ESH 2018 (OR: 4.94 [1, 24.3], p = .002). Significant reclassification of HTN occurs with all adult norms. HTN is significantly associated with LVH using AHA 2005 and ESH 2018. Applying pediatric norms for ABPM while using adult norms for clinic BP causes confusion. Guideline selection should balance misdiagnosis with over‐diagnosis.     

The association of nocturnal hypertension and nondipping blood pressure with treatment‐resistant hypertension: The Jackson Heart Study

Apparent treatment‐resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03–1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09–1.43). Over a median 7.3 years of follow‐up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.     

Prevalence of white coat and masked hypertension in Africa: A systematic review and meta‐analysis

Data on masked hypertension (MH) and white‐coat hypertension (WCH) in African populations are needed to estimate the true prevalence of hypertension in these populations because they have the highest burden of the disease. We conducted the first systematic review and meta‐analysis that summarized available data on the prevalence of WCH and MH in Africa. We searched PubMed and Scopus to identify all the articles published on MH and WCH in populations living in Africa from inception to November 30, 2017. We reviewed each study for methodological quality. A random‐effects model was used to estimate the prevalence of WCH and MH across studies. Eleven studies were included, all having a low‐risk of bias. The prevalence of masked hypertension was 11% (95% CI: 4.7‐19.3; 10 studies) in a pooled sample of 7789 individuals. The prevalence of WCH was 14.8% (95% CI: 9.4‐21.1; 8 studies) in a pooled sample of 4451 individuals. There was no difference on the prevalence of WCH and MH between studies in which participants were recruited from the community and the hospital. The prevalence of MH was higher in urban areas compared to rural ones; there was no difference for WCH. WHC and MH seem to be frequent in African populations, suggesting the importance of out‐of‐clinic BP measurement in the diagnosis and management of patients with hypertension in Africa, especially in urban areas for MH.     

Ambulatory blood pressure in the dash diet trial: Effects of race and albuminuria

We evaluated whether low‐grade albuminuria or black race modulates ambulatory blood pressure (BP) or nocturnal BP response to the DASH diet. Among 202 adults enrolled in the DASH multicenter trial who were fed the DASH or control diet for 8 weeks, reductions in 24‐hour daytime and nighttime SBP and DBP were significantly larger for DASH compared to control. Median changes in nocturnal BP dipping were not significant. Compared to urine albumin excretion of <7 mg/d, ≥7 mg/d was associated with larger significant median reductions in 24‐hour SBP (?7.3 vs ?3.1 mm Hg), all measures of DBP (24‐hour: ?5.9 vs ?1.8 mm Hg; daytime: ?9.9 vs ?4.0 mm Hg; nighttime ?9.0 vs ?2.0 mm Hg), and with increased nocturnal SBP dipping (2.3% vs ?0.5%). Black race was associated with larger median reduction in 24‐hour SBP only (?5.5 vs ?2.4 mm Hg). This analysis suggests greater effect of DASH on ambulatory BP in the presence of low‐grade albuminuria.     

Asian management of hypertension: Current status,home blood pressure,and specific concerns in Philippines (a country report)

Incidence of cardiovascular diseases (CVD) in the Philippines based on the Philippine Heart Association survey among hospital‐based population showed hypertension as the highest (38.6%), followed by stroke (30%), coronary artery disease (CAD) (17.5%), and heart failure (10.4%). Based on Philippine FNRI data, the prevalence of coronary, cerebrovascular, and peripheral arterial diseases were 1.1%, 0.9%, and 1.0%, respectively. Cardiovascular risk factor prevalence were the following: diabetes at 3.9%, dyslipidemia at 72%, smoking at 31%, obesity at 4.9% (BMI), and 10.2% and 65.6% by waist‐hip ratio in men and women, respectively. In a more recent study on risk factors, urban dwellers were more hypertensive, overweight, obese, and with impaired fasting glucose. More smokers and dyslipidemia by high TC, high non‐HDL‐C, and low HDL‐C were seen in those living in the rural areas. Subjects with higher level of education were more overweight, obese and have dyslipidemia by a high TC, TG, and LDL‐C while there were more smokers, low HDL‐C, and hypertensive participants who have reached a lower level of education. Latest data on prevalence of hypertension were 28% equal for males and females. Unaware was 9%. Treatment rate was 56%, compliance was 57%, and BP control rate was 20%. Antihypertensive medications used were beta‐blockers (36%), calcium channel blockers (CCB) (33%), angiotensin receptor blockers (ARB) (28%), ACE inhibitors (5%), and centrally acting agents (4%). Mortality from CVD was stroke, mostly infarct (22.6%), myocardial infarction (6.5%), and Heart Failure (6.5%)