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 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%)     

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 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 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 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 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 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 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 Korea

Hypertension is present in almost one‐quarter of women and one‐third of men in Korea. Although mortality rates from stroke and myocardial infarction (MI) appear to be decreasing, stroke is a more common cause of cardiovascular death than MI. This may be due to better control of hypertension, but national control rates have remained stable for more than a decade (at about 45%). Korean Society of Hypertension guidelines have recommended the use of home blood pressure monitoring (HBPM) since 2007, but a recent survey suggests that physicians have concerns about the accuracy of HBPM devices. Nevertheless, use of HBPM is indispensable to monitoring and achieving blood pressure (BP) control. Current diagnostic and treatment thresholds and recommendations are based on Asian consensus document guidance. Use of dual combination antihypertensive therapy is slightly more common than use of monotherapy in Korea, while triple combination therapy is used less often. Angiotensin receptor blockers and calcium channel blockers are the most popular choices for antihypertensive therapy and are the most widely used combination. HBPM plays an important role in evaluating and monitoring BP, particularly in Asians. Individualized cardiovascular risk assessment and better BP control are required to prevent cardiovascular diseases, but there is a need for local evidence relating to optimal BP thresholds and targets.     

Current status of home blood pressure monitoring in Asia: Statement from the HOPE Asia Network

Hypertension represents a major burden in Asia, with a high prevalence rate but poor level of awareness and control reported in many countries in the region. Home blood pressure monitoring has been validated as an accurate and reliable measure of blood pressure that can help guide hypertension treatment as well as identify masked and white‐coat hypertension. Despite its benefits, there has been limited research into home blood pressure monitoring in Asia. The authors reviewed the current evidence on home blood pressure monitoring in Asia, including but not limited to published literature, data presented at congresses, and national hypertension management guidelines to determine the current utilization of home blood pressure monitoring in clinical practice in the region. Public policies to enable greater access to home blood pressure monitoring and its use in clinical care would add considerably to improving hypertension outcomes in Asia.     

Cost estimation of hypertension management based on home blood pressure monitoring alone or combined office and ambulatory blood pressure measurements

This study aims at estimating the resources consumed and subsequent costs for hypertension management, using home blood pressure (BP) monitoring (HBPM) alone versus combined clinic measurements and ambulatory blood pressure monitoring (C/ABPM). One hundred sixteen untreated hypertensive subjects were randomized to use HBPM or C/ABPM for antihypertensive treatment initiation and titration. Health resources utilized within 12-months follow-up, their respective costs, and hypertension control were assessed. The total cost of the first year of hypertension management was lower in HBPM than C/ABPM arm (€1336.0 vs. €1473.5 per subject, respectively; P < .001). Laboratory tests' cost was identical in both arms. There was no difference in achieved BP control and drug expenditure (HBPM: €233.1 per subject; C/ABPM: €247.6 per subject; P = not significant), whereas the cost of BP measurements and/or visits was higher in C/ABPM arm (€393.9 vs. €516.9, per patient, respectively P < .001). The cost for subsequent years (>1) was €348.9 and €440.2 per subject, respectively for HBPM and C/ABPM arm and €2731.4 versus €3234.3 per subject, respectively (P < .001) for a 5-year projection. HBPM used alone for the first year of hypertension management presents lower cost than C/ABPM, and the same trend is observed in 5-year projection. The results on the resources consumption can be used to make cost estimates for other health-care systems.     

Diabetes and hypertension: blood pressure control and consequences

Diabetes and hypertension are the leading causes of end-stage renal disease in the Western world. Inadequate control of both systemic and glomerular capillary pressure in diabetics results in increasing hydraulic force and mechanical stretch on the glomeruli, with a subsequent increase in proteinuria and ultimately glomerulosclerosis. Therapeutic strategies that combine systemic and glomerular capillary pressure reduction result in reduced proteinuria and are ideal for preventing renal injury. Both experimental and clinical studies have demonstrated the importance of intensive control of blood pressure, preferably to systolic blood pressure (SBP) ≤ 130 mm Hg to delay progression of renal disease. In particular, drugs that block the renin-angiotensin system (RAS) offer the advantage of consistently reducing glomerular capillary pressure and proteinuria relative to changes in systemic blood pressure. This combination of events is ideal for delaying progression of renal disease. However, the use of drugs that block the RAS is not a surrogate for maintaining tight control of blood pressure.     

Association between mortality and blood pressure variability in hypertensive and normotensive elders: A cohort study

To evaluate the association between blood pressure variability (BPV) and mortality in the elderly, all blood pressure measurements recorded in a cohort of individuals 65 years and older were collected and the association between BPV coefficient of variation (BPV divided by mean arterial pressure) was calculated. Mortality during a 10‐year period was compared between BPV coefficient of variation quartiles. Overall, 39 502 individuals 65 years and older were included in the analysis, of which 31 737 (80.3%) were hypertensive; 12 817 (32.4%) individuals died during the study period. Mortality was lower in the second and third blood pressure quartiles compared with the first quartile in both the normotensive and hypertensive groups. In both normotensive and hypertensive individuals, mortality was higher in the fourth quartile, but it was more pronounced in normotensive individuals (odds ratio, 1.18; 95% confidence interval, 1.06–1.31 in hypertensive individuals vs odds ratio, 1.27; 95% confidence interval, 1.17–1.37 in normotensive individuals). High and low BPV are associated with mortality in both hypertensive and normotensive elders.     

Rationale and design for the Asia BP@Home study on home blood pressure control status in 12 Asian countries and regions

Home blood pressure (BP) monitoring is endorsed in multiple guidelines as a valuable adjunct to office BP measurements for the diagnosis and management of hypertension. In many countries throughout Asia, physicians are yet to appreciate the significant contribution of BP variability to cardiovascular events. Furthermore, data from Japanese cohort studies have shown that there is a strong association between morning BP surge and cardiovascular events, suggesting that Asians in general may benefit from more effective control of morning BP. We designed the Asia BP@Home study to investigate the distribution of hypertension subtypes, including white‐coat hypertension, masked morning hypertension, and well‐controlled and uncontrolled hypertension. The study will also investigate the determinants of home BP control status evaluated by the same validated home BP monitoring device and the same standardized method of home BP measurement among 1600 or more medicated patients with hypertension from 12 countries/regions across Asia.     

Role of home blood pressure telemonitoring in hypertension management: an update

Despite the increasing use of home blood pressure monitoring (HBPM) in daily practice and the growing awareness in the scientific community about its positive impact on the diagnostic and therapeutic management of patients with high blood pressure (BP), the potential advantages offered by HBPM have not yet been fully exploited. Indeed, use of the information offered by HBPM is often incomplete and imprecise, with the BP values reported by patients in handwritten logbooks being frequently inaccurate, illegible to physicians, or unreliable. Although a practical solution for improvement may come from the use of devices equipped with a storage memory, a step forward in this regard has been taken more recently with the introduction and refinement of systems for the remote telemonitoring of BP values measured at home. However, although several studies have provided evidence on the clinical usefulness of HBPM, only limited data are available on the clinical impact of home blood pressure (HBP) telemonitoring, because of a number of reasons. First, most of the available studies are characterized by a small sample size, and in some cases, the patients were neither randomized nor even matched with a control group. Moreover, technological solutions used in the different studies carried out so far are often heterogeneous, some of them being particularly difficult to use for the patients, thus limiting the effectiveness of the results. BP monitoring programmes, number of BP readings and transmission schedules are often different among the various studies. In addition, patient selection criteria are different from study to study. Finally, different study objectives and important diversities in the types of centres involved (ranging from general practices, to specialists' offices, hospitals or university centres) may have also influenced the quality of results. Large-scale randomized controlled studies, based on easy-to-use technologies, are thus still needed to show the superiority and clinical usefulness of HBP telemonitoring as compared with conventional HBPM. This study summarizes the evidence available on the clinical usefulness and current limitations of this approach, highlighting the results of meta-analyses and randomized controlled trials on this issue. The role of HBP teletransmission in the context of integrated patients' management programmes is also addressed, with indications for further progress in this field.