Implementation of a community‐based hypertension control program in Matanzas,Cuba

Increased blood pressure is a leading risk factor for death worldwide, and improving the control of hypertension is a major health goal to reduce non‐communicable disease. Thus, in 2016, as part of a regional effort between the Pan American Health Organization and Cuban Ministry of Public Health to reduce cardiovascular risk and disease, a community demonstration project was implemented to enhance hypertension control. The intervention project was in a population of 25 868 people served by the Carlos Verdugo Martínez Polyclinic in Matanzas, Cuba. The project implemented interventions currently recommended in the World Health Organization HEARTS modules, including a standardized clinical training program with certification for blood pressure measurement, routine screening for hypertension in clinics and in the community, a simple directive pharmacologic treatment algorithm, and a registry with performance reporting and feedback. Qualitative and quantitative program monitoring and evaluation was established. In a 2010 national survey, the prevalence of hypertension and the rate of hypertension control were estimated to be 31% and 36%, respectively. Following less than one year of the full implementation of the program, the prevalence of hypertension, proportion of the hypertensive population registered as having hypertension, proportion of those drug‐treated who were controlled, and estimated population rate of control were 30%, 90%, 68%, and 58%, respectively. Based on these positive results, the program has been expanded to include another demonstration program initiated in a second region. In addition, preliminary efforts to disseminate and scale‐up aspects of the program to the full Cuban population have started.     

Two‐drug fixed‐dose combinations of blood pressure‐lowering drugs as WHO essential medicines: An overview of efficacy,safety, and cost

Cardiovascular diseases (CVD) are the world''s leading cause of death. High blood pressure (BP) is the leading global risk factor for all‐cause preventable morbidity and mortality. Globally, only about 14% of patients achieve BP control to systolic BP <140 mm Hg and diastolic BP <90 mm Hg. Most patients (>60%) require two or more drugs to achieve BP control, yet poor adherence to therapy is a major barrier to achieving this control. Fixed‐dose combinations (FDCs) of BP‐lowering drugs are one means to improve BP control through greater adherence and efficacy, with favorable safety and cost profiles. The authors present a review of the supporting data from a successful application to the World Health Organization (WHO) for the inclusion of FDCs of two BP‐lowering drugs on the 21st WHO Essential Medicines List. The authors discuss the efficacy and safety of FDCs of two BP‐lowering drugs for the management of hypertension in adults, relevant hypertension guideline recommendations, and the estimated cost of such therapies.     

Implementing standardized performance indicators to improve hypertension control at both the population and healthcare organization levels

The ability to reliably evaluate the impact of interventions and changes in hypertension prevalence and control is critical if the burden of hypertension‐related disease is to be reduced. Previously, a World Hypertension League Expert Committee made recommendations to standardize the reporting of population blood pressure surveys. We have added to those recommendations and also provide modified recommendations from a Pan American Health Organization expert meeting for “performance indicators” to be used to evaluate clinical practices. Core indicators for population surveys are recommended to include: (1) mean systolic blood pressure and (2) mean diastolic blood pressure, and the prevalences of: (3) hypertension, (4) awareness of hypertension, (5) drug‐treated hypertension, and (6) drug‐treated and controlled hypertension. Core indicators for clinical registries are recommended to include: (1) the prevalence of diagnosed hypertension and (2) the ratio of diagnosed hypertension to that expected by population surveys, and the prevalences of: (3) controlled hypertension, (4) lack of blood pressure measurement within a year in people diagnosed with hypertension, and (5) missed visits by people with hypertension. Definitions and additional indicators are provided. Widespread adoption of standardized population and clinical hypertension performance indicators could represent a major step forward in the effort to control hypertension.     

A perspective of private health care providers in the state of Madhya Pradesh on adopting key strategies of the India hypertension control initiative

The India Hypertension Control Initiative (IHCI) has been implemented in public health facilities. This study assessed the perspective of private physicians (PPs) on adopting the core strategies of the IHCI in Bhopal district of Madhya Pradesh. A semi‐structured interview was purposely applied to 30 PPs to obtain their opinions on standardized hypertension treatment protocols, patient‐centered services, and easy‐to‐use information system in their private practices. Verbatim data were recorded and analyzed thematically. Only 11 PPs followed the state hypertension treatment protocol. Among the remaining 19 PPs, the major reasons for not adopting protocol were (1) limited availability of single component hypertension drugs, (2) preferences for fixed dose combinations (FDCs), and (3) fear of either losing patients due to a lack of immediate blood pressure control or causing drug‐related adverse effects. None of the interviewed doctors had resources to provide patient‐centered care and use a digital health information system. Overall, the interviewed doctors identified that free supply of hypertension treatment protocol drugs, inclusion of FDCs in treatment protocol, increasing number of staff for follow‐up visits, and patient education, IT‐based solutions for patient records, employee incentives, and need for national data sharing policies are the key actions to accelerate the adoption of IHCI strategies in the private sector. This exploratory qualitative study suggests that engagement of private sector in the IHCI is feasible. Plans to expand the IHCI to the private sector should consider ensuring the wider availability of hypertension treatment protocol drugs and developing a simple user‐friendly digital platform for patient monitoring.     

Frontiers of cardiovascular polypills: From atherosclerosis and beyond

Fixed-dose combination (FDC) therapies (also known as polypills) remain underutilized in clinical practice despite over two decades of evidence from randomized controlled trials demonstrating increased adherence to multidrug therapy, improved cardiovascular disease (CVD) risk factor control, and lower incidence of cardiovascular events. Evidence demonstrates that FDC-based implementation strategies can substantially complement and augment current strategies for CVD risk prevention globally. The next decade is likely to extend the frontier of cardiovascular FDC therapies, particularly given expected advances in FDC manufacturing technology and accessibility. FDC-based anti-hypertensive therapies are emerging as integral components of a pragmatic blood pressure lowering strategy. Cardiovascular FDCs are rapidly approaching its coming of age, transforming from heavily hyped research tools to pragmatic clinical instruments. This review evaluates the current evidence for cardiovascular FDCs, barriers to current use, and potential next generation advances.     

Rationale,design, and baseline characteristics of the Salt Substitute in India Study (SSiIS): The protocol for a double‐blinded,randomized‐controlled trial

Reduced‐sodium, added‐potassium salt substitutes have favorable effects on blood pressure, but have not been tested in India. The Salt Substitute in India Study (SSiIS) is a double‐blinded, randomized‐controlled trial designed to investigate the effects of reduced‐sodium, added‐potassium salt substitution to replace usual cooking salt use and blood pressure (BP) among hypertensive patients in rural India. The primary objective is to assess effects on systolic blood pressure at 3 months. The secondary objectives are to determine effects on diastolic blood pressure, urinary sodium, and potassium levels, and to determine acceptability of the intervention. Eligible individuals received usual salt (100% sodium chloride) or salt substitute (70% sodium chloride and 30% potassium chloride) to replace all salt required for cooking and seasoning in the household. A total of 502 participants aged ≥18 years with a history of hypertension were successfully recruited and randomized in a 1:1 ratio to intervention or control, between November 2019 and January 2020. Mean blood pressure at baseline was 133.5/83.6 mm Hg and 96% were using one or more blood pressure‐lowering medications. The overall mean average 24‐hour urinary sodium excretion was 2825 (SD, 1166) mg/L, which corresponds to a urinary salt excretion of 10.4 g/d. Baseline findings suggest sodium intake in this population significantly exceeds World Health Organization recommendations. The SSiIS trial has successfully recruited participants and is well placed to determine whether salt substitution is an effective means of lowering blood pressure for rural Indian patients with hypertension.     

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

High blood pressure is the world’s leading cause of death, but despite treatment for hypertension being safe, effective, and low cost, most people with hypertension worldwide do not have it controlled. This article summarizes lessons learned in the first 2 years of the Resolve to Save Lives (RTSL) hypertension management program, operated in coordination with the World Health Organization (WHO) and other partners. Better diagnosis, treatment, and continuity of care are all needed to improve control rates, and five necessary components have been recommended by RTSL, WHO and other partners as being essential for a successful hypertension control program. Several hurdles to hypertension control have been identified, with most related to limitations in the health care system rather than to patient behavior. Treatment according to standardized protocols should be started as soon as hypertension is diagnosed, and medical practices and health systems must closely monitor patient progress and system performance. Improvement in hypertension management and control, along with elimination of artificial trans fat and reduction of dietary sodium consumption, will improve many aspects of primary care, contribute to goals for universal health coverage, and could save 100 million lives worldwide over the next 30 years.     

The impact of fixed‐dose combination versus free‐equivalent combination therapies on adherence for hypertension: a meta‐analysis

Nonadherence to antihypertensive medication is considered as a reason of inadequate control of blood pressure. This meta‐analysis aimed to systemically evaluate the impact of fixed‐dose combination (FDC) therapy on hypertensive medication adherence compared with free‐equivalent combination therapies. Articles were retrieved from MEDLINE and Embase databases using a combination of terms “fixed‐dose combinations” and “adherence or compliance or persistence” and “hypertension or antihypertensive” from January 2000 to June 2017 without any language restriction. A meta‐analysis was performed to parallel compare the impact of FDC vs free‐equivalent combination on medicine adherence or persistence. Studies were independently reviewed by two investigators. Data from eligible studies were extracted and a meta‐analysis was performed using R version 3.1.0 software. A total of nine studies scored as six of nine to eight of nine for Newcastle‐Ottawa rating with 62 481 patients with hypertension were finally included for analysis. Results showed that the mean difference of medication adherence for FDC vs free‐equivalent combination therapies was 14.92% (95% confidence interval, 7.38%–22.46%). Patients in FDC group were more likely to persist with their antihypertensive treatment, with a risk ratio of 1.84 (95% confidence interval, 1.00–3.39). This meta‐analysis confirmed that FDC therapy, compared with free‐equivalent combinations, was associated with better medication adherence or persistence for patients with hypertension. It can be reasonable for physicians, pharmacists, and policy makers to facilitate the use of FDCs for patients who need to take two or more antihypertensive drugs.     

Hypertension knowledge,attitudes, and practices of nurses and physicians in primary care in Ulaanbaatar Mongolia

Increased blood pressure is a leading risk for death globally, and interventions to enhance hypertension control have become a high priority. An important aspect of clinical interventions is understanding the knowledge, attitudes, and practices (KAP) of differing primary healthcare practitioners. We examined KAP surveys from 803 primary care practitioners in Ulaanbaatar, Mongolia (response rate 80%), using a comprehensive KAP survey developed by the World Hypertension League (WHL). The WHL KAP survey uniquely includes an assessment of key World Health Organization recommended interventions to enhance hypertension control. There were few substantive differences between healthcare professional disciplines. Primary care practitioners mostly had a positive attitude toward hypertension management. However, confidence and practice in performing specific tasks to control hypertension were suboptimal. A low proportion indicated they systematically screened adults for hypertension and many were not aware of the need to or were confident in prescribing more than two antihypertensive medications. It was the practice of a high proportion of doctors to not pharmacologically treat most people with hypertension who were at high cardiovascular risk. There was a reluctance by physicians to task share hypertension diagnosis, drug prescribing and assessing cardiovascular risk to nurses. The minority of health care professions use a hypertension management algorithm, and few have patient registries with performance reporting functions. There were few substantive differences based on the age, gender, and years of clinical practice of the practitioners. The study findings support the need for standardized education and training of primary care practitioners in Ulaanbaatar to enhance hypertension control.     

The role of angiotensin II inhibitors in arterial hypertension: clinical trials and guidelines

Despite many outstanding favorable results obtained over the past 30-40 years in the treatment of hypertension, several goals of antihypertensive therapy remain unmet. One of them concerns the epidemiological evidence that only 25% of treated hypertensive patients have optimal blood pressure control. Clinical use of new antihypertensive drugs is aimed at achieving the above-mentioned goals, and in particular, at providing more effective blood pressure control, greater cardiovascular protection, and better patient compliance to antihypertensive drug treatment. This paper will examine the main clinical features of angiotensin II receptor blockers, highlighting the results of clinical studies performed thus far, and the main goals of ongoing clinical trials with these drugs. Finally, the role of these compounds in the therapeutic approach to the hypertensive state according to the recent guidelines of the World Health Organization/International Society of Hypertension will be outlined.     

Brief online certification course for measuring blood pressure with an automated blood pressure device. A free new resource to support World Hypertension Day Oct 17, 2020

Detection, diagnosis, and treatment of hypertension require accurate blood pressure assessment. However, in clinical practice, lack of training in or nonadherence to measurement recommendations, lack of patient preparation, unsuitable environments where blood pressure is measured, and inaccurate and inappropriate equipment are widespread and commonly lead to inaccurate blood pressure readings. This has led to calls to require regular training and certification for people assessing blood pressure. Hence, the Pan American Health Organization in collaboration with Resolve to Save Lives, the World Hypertension League, Lancet Commission on Hypertension Group, and Hypertension Canada has developed a free brief training and certification course in blood pressure measurement. The course is available at www. The release of the online certification course is timed to help support World Hypertension Day. This year World Hypertension Day has been delayed to October 17 due to the COVID‐19 pandemic. For 2020, the World Hypertension League calls on all health care professionals, health care professional organizations, and indeed all of society, to assess the blood pressure of all adults, measure blood pressure accurately, and achieve blood pressure control in those with hypertension.     

Dietary influences on blood pressure: the effect of the Mediterranean diet on the prevalence of hypertension

Hypertension has long been recognized as a major risk factor for several common cardiovascular diseases. The World Health Organization reports that the number of people with hypertension worldwide is estimated at 600 million, while 3 million will die annually as a result of hypertension. There is evidence to support that several factors related to lifestyle habits may influence blood pressure levels. Among these, the beneficial effect of diet on human health, as well as on the control of hypertension, has been underlined in several studies. Moreover, adherence to a Mediterranean diet has been associated with reduced all-cause mortality and, especially, coronary heart disease. The effect of this traditional diet on blood pressure levels has not been well understood and appreciated. This review summarizes the current understanding of the dietary influences on blood pressure control and the findings of observational and clinical studies that have evaluated the effect of the Mediterranean dietary pattern on the prevalence of chronic essential hypertension.     

代谢综合征与微炎性反应

代谢综合征(MS)是指以糖尿病、肥胖、血脂异常、高血压等为表现的临床症候群,由世界卫生组织在1998年正式命名.随着对MS研究的不断深入,现在普遍认为MS患者体内存在微炎性反应(microinflammation),并且这种微炎性反应还在进一步加重MS,并促进一些临床并发症的出现,具体表现在胰岛素抵抗的加重、高血压的恶化、动脉粥样硬化或心血管疾病的出现以及慢性肾脏病的进展等.本文就近年来关于MS和微炎性反应关系的研究作一综述.     

Evaluation of rifampicin bioequivalence in fixed-dose combinations using the WHO/IUATLD recommended protocol.

For an accurate assessment of rifampicin bioequivalence from fixed-dose combinations (FDCs), and to reduce the time and cost constraints associated with bioequivalence studies, the World Health Organization and the International Union Against Tuberculosis and Lung Disease have developed a simplified screening protocol. This study was undertaken with the objective of testing the applicability of this protocol for all types of FDCs. Data were obtained for volunteers common to three studies, and pharmacokinetic parameters were evaluated by different statistical tests. From the results, it has been demonstrated that the simplified screening protocol is suitable for evaluating the bioequivalence of rifampicin in all the types of FDCs available on the market.     

Modification to improve efficiency of sampling schedules for BA/BE testing of FDC anti-tuberculosis drugs.

SETTING: The assessment of rifampicin (RMP) containing fixed-dose combination (FDC) formulations using in vivo bioequivalence testing is widely accepted. It would be advantageous for both the drug regulatory authorities and drug manufacturers, for optimum minimum blood testing time intervals that encompass all anti-tuberculosis active constituents in the FDC to be established. OBJECTIVE: To determine the optimum blood sampling schedule for testing novel FDC anti-tuberculosis drugs, isoniazid, RMP, pyrazinamide and ethambutol DESIGN: The results of 12 different single-dose, two-way cross-over designs are presented. The studies determined the bioavailability and bioequivalence of RMP-containing FDCs, and conformed with the requirements of the South African national drug regulatory authority for each of the active constituents. RESULTS: The pharmacokinetic parameters to determine bioavailability and the Hauschke method to determine bioequivalence revealed that a six-point time protocol, namely 0, 1, 2, 4, 6 and 8 h, provides a good approximation of the area under the curve, and that an 11-point time protocol of 0, 0.25, 0.5, 1, 1.5, 2, 2.5, 3, 4, 6 and 8 h provided information comparable to the conventional 15 time-points for FDCs containing up to four drugs. CONCLUSION: The findings provide concrete economic benefit and convenience for quality assurance testing of existing and novel FDCs.     

Monitoring and evaluation framework for hypertension programs. A collaboration between the Pan American Health Organization and World Hypertension League

The Pan American Health Organization (PAHO)–World Hypertension League (WHL) Hypertension Monitoring and Evaluation Framework is summarized. Standardized indicators are provided for monitoring and evaluating national or subnational hypertension control programs. Five core indicators from the World Health Organization hearts initiative and a single PAHO‐WHL core indicator are recommended to be used in all hypertension control programs. In addition, hypertension control programs are encouraged to select from 14 optional qualitative and 33 quantitative indicators to facilitate progress towards enhanced hypertension control. The intention is for hypertension programs to select quantitative indicators based on the current surveillance mechanisms that are available and what is feasible and to use the framework process indicators as a guide to program management. Programs may wish to increase or refine the number of indicators they use over time. With adaption the indicators can also be implemented at a community or clinic level. The standardized indicators are being pilot tested in Cuba, Colombia, Chile, and Barbados.     

Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low‐ and middle‐income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems–strengthening approach that advocates for standardized hypertension management using evidence‐based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team‐based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease‐related morbidity and mortality.     

International Society of Hypertension (ISH): statement on blood pressure lowering and stroke prevention

The ISH Statement on blood pressure lowering and stroke prevention was finalized after presentation and discussion at the World Health Organization and International Society of Hypertension (WHO-ISH) Meeting on Stroke and Blood Pressure, held in Melbourne Australia, 5-7 December 2002. The meeting was conducted under the auspice of the Austin Hospital Medical Research Foundation, Melbourne.     

Survey on treatment of hypertension and implementation of World Health Organization/International Society of Hypertension risk stratification in primary care in Belgium

OBJECTIVE : To gain insight into the prevalence, treatment and control of hypertension and into the implementation of the 1999 World Health Organization/International Society of Hypertension guidelines for the management of hypertension in general practice in Belgium. DESIGN : A prospective cross-sectional survey. SETTING : Primary care. METHODS : Participating physicians enrolled the first 15 men, at least 55 years old, who visited the surgery, measured their blood pressure with a validated automatic device and recorded data on age, medical history, drug utilization, cardiovascular risk factors and target organ damage. Patients were considered to have hypertension when systolic blood pressure was >or= 140 mmHg, diastolic blood pressure was >or= 90 mmHg or when they were under antihypertensive therapy. RESULTS : Among 3761 evaluable patients, 74% were considered to be hypertensive, 80% of whom were treated with antihypertensive drugs. Blood pressure was under control in 38% of the treated patients and in 31% of all hypertensives. Among the 1316 hypertensive patients in whom risk stratification was possible, 47, 56 and 86% of the patients in, respectively, the medium, high and very high risk groups were treated with antihypertensive drugs. Among the treated patients, 46, 37 and 31%, respectively, had reached goal pressure. Within each risk category, patients were treated more frequently when baseline blood pressure was higher. Logistic regression analysis revealed that hypertension grade and level of risk contributed independently to the odds of being treated. CONCLUSIONS : The results indicate that a large number of older hypertensive men are treated with antihypertensive drugs in primary care, but that the goal blood pressure is not reached in a substantial number of patients due to undertreatment. Furthermore, whereas patients at higher risk are treated more frequently than patients at lower risk, blood pressure itself remains an important factor for the initiation of antihypertensive drug therapy within each risk category.     

Reduction of left ventricular hypertrophy in hypertensive patients after treatment with celiprolol

Long-term treatment with celiprolol, a new cardioselective beta blocker, significantly reduced blood pressure in 14 patients with essential hypertension (World Health Organization stages I to II). Heart rates remained within the normal range throughout treatment and no significant side effects were observed. In 4 patients, end-systolic septum thickness was measured, and evidence was obtained that the extent of left ventricular hypertrophy was reduced. These findings indicate that celiprolol can be used for the successful long-term treatment of essential hypertension, and that such treatment reduces left ventricular hypertrophy induced by high blood pressure.