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

Abstract

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.

1. CARDIOVASCULAR DISEASE INCIDENCE AND HYPERTENSION MANAGEMENT IN PAKISTAN

Hypertension is a growing problem in the Pakistani population and has assumed epidemic proportions. In one survey conducted in the two largest provinces of Pakistan in 2014‐2015 (n = 7669), 50% of the adult sample had hypertension (blood pressure [BP] ≥140/90 mm Hg), 30% were aware of their hypertension but only 18% were on medication, and the control rate was 6%.1 The proportion of patients with hypertension was also high in a nationwide survey conducted in 2016‐2017 (46%).2 The rate of diabetes was also high (26% with diabetes and 14% with prediabetes), further increasing cardiovascular risk.2 Thus, there is an epidemic of both hypertension and diabetes in Pakistan. It is therefore not surprising that rates of cardiovascular disease (CVD) are also increasing. There is a lack of good national data on CVD, but the World Health Organization reports that 58% of all deaths in Pakistan are due to non‐communicable diseases, and half of these are due to CVD.3

2. CURRENT STATUS OF HBPM IN THE MANAGEMENT OF HYPERTENSION IN PAKISTAN

Studies on the use of home BP monitoring (HBPM) in Pakistan are small and scarce. Although 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 its utility 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 of correct methodology in the use of HBPM.

A 2017 study reported that 61.7% of 405 hypertensive patients from Karachi owned a sphygmomanometer (more than 50% digital), although more than half of these had not received any advice to do so. Despite the relatively high frequency of HBPM ownership in this population, only 9% of those with a device checked their BP two or more times a day, while 59% checked their BP once a week or less. Almost 80% had no specific time for checking their BP and 33% took no precautions when measuring BP. This study is not representative of Pakistan because it was performed in tertiary hospitals in a metropolitan city in a population with higher income and education levels, and more exposure to news media and the Internet, than in the country as a whole. Nonetheless, it shows that physician prescription of HBPM is inadequate and that health care professionals are not providing patients with information about correct device usage.

3. PAKISTAN SUB‐ANALYSIS OF THE ASIABP@HOME STUDY

The AsiaBP@Home study was designed to investigate the distribution of hypertension subtypes, including white‐coat hypertension, masked morning hypertension, and well‐controlled and uncontrolled hypertension. The study used the same validated HBPM and the same standardized method of home BP measurement in patients with hypertension from 12 countries/regions across Asia.4, 5

The Pakistani cohort from the AsiaBP@Home study was relatively young compared with the overall study population, and there were fewer smokers and alcohol users compared with the overall study population. However, they had the highest average body mass index of any country (30.2 kg/m²), more than a quarter had diabetes and more than half had hyperlipidemia. At conventional cutoff values, 72% of patients had well‐controlled morning home SBP and 65% had well‐controlled clinic SBP. At the lower BP thresholds, morning home and clinic SBP were well controlled in 58% and 49% of patients, respectively. Rates of white‐coat hypertension, masked uncontrolled morning hypertension, and sustained uncontrolled morning SBP were 17%, 10%, and 17%, respectively, at conventional BP cutoff values, and 20%, 12%, and 30% at the lower cutoff values (Figure 1). Measures of BP variability (BPV), including coefficient of variation, average real variability, and variability independent of the mean, were particularly poor in the subgroup of patients from Pakistan. These data are the only information available on BPV in Pakistan, and this is something that needs further investigation.

Figure 1.

Distributions of blood pressure (BP) control status based on different clinic and morning home BP thresholds in the Pakistan sub‐analysis from the AsiaBP@Home study. Left panel represents the results based on cutoff values of 140 mm Hg for clinic systolic BP (SBP) and 135 mm Hg for home SBP. Right panel represents the results based on cutoff values of 130 mm Hg for both clinic SBP and home SBP

4. POSITIONING OF HBPM IN THE 2018 PAKISTAN HYPERTENSION GUIDELINES

The Pakistan Hypertension League (PHL) recommends use of a validated digital HBPM device for BP measurement,6 and guidelines are consistent with those from National Institute for Health and Care Excellence (NICE)7 and the HOPE Asia Network.8, 9 In addition, the PHL guideline advocates a two‐tier system for hypertension treatment goal.6 If there is evidence of CVD, diabetes mellitus or chronic kidney disease, or if 10‐year risk of CVD is >10%, the recommended goal is 130/80 mm Hg. For those without these comorbidities/risk, the goal is 140/90 mm Hg. Approximately half of hypertensives in Pakistan would fall into each category. Therefore, the current PHL recommendations are probably appropriate because there is little evidence of significant benefit for lower BP goals in patients with mild hypertension without comorbidities.

5. TRADITIONAL ANTIHYPERTENSIVE THERAPY AND POPULAR ANTIHYPERTENSIVE DRUGS IN PAKISTAN

Data from Karachi in 2015 reported ß‐blockers as the most commonly used antihypertensive agent (33%), followed by angiotensin‐converting enzyme (ACE) inhibitors (18%), calcium channel blockers (CCBs; 13%), and angiotensin receptor blockers (ARBs; 8%). In contrast, the AsiaBP@Home study, which included a broader range of patients, found that CCBs were the most commonly used antihypertensives in Pakistan (61%), with ß‐blockers (49%) and ARBs (47%) also widely used.

Traditional medicine remains popular in Pakistan because it is more accessible, especially in rural areas, and is cheaper. Most often it is “Hikmat” but there are other forms, including “Unani” and homeopathy. The “Hakeems” (those who practice “Hikmat”) use a multitude of herbs, etc Those used for treatment of hypertension include various combinations of aniseed, black cumin, rose water, salt peter, coriander seeds, turmeric powder, licorice, celery seeds, and Indian snake root (rauwolfia serpentina). Many traditional medicine practitioners also grind up conventional medicines and mix them with the herbs.

6. SPECIFIC CONCERNS AND PERSPECTIVES FOR HYPERTENSION MANAGEMENT IN PAKISTAN

The main concern in Pakistan is the rapidly increasing proportion of the population with hypertension (and also with diabetes), which is contributing to an epidemic of CVD. This increase in non‐communicable disease comes in the setting of significant communicable diseases (eg, diarrhea and tuberculosis) as well. All this 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. Thus, many individuals remain unaware that they have hypertension. Many more do not receive correct advice about disease management and even if medications are available, affordability makes long‐term adherence difficult.

The medical community in general, and the PHL and Pakistan Cardiac Society (PCS) in particular, have been trying to increase awareness of hypertension at a population and government level. This is challenging because hypertension is often asymptomatic and is therefore likely to be ignored by patients and, unfortunately, also by the government. Furthermore, with only about 2% of gross domestic product (GDP) allocated to health care, there are not enough resources to cater to all health sector needs. The PHL and PCS have arranged awareness sessions for the public, including participation in the May Measurement Month initiative launched by the International Society of Hypertension (ISH). PHL has also started ISH‐approved certification courses in hypertension for family practitioners and junior doctors. The aim is to reinforce and enhance the knowledge of those already in practice, to help them keep pace with new developments in the field, and provide better service to patients for the diagnosis and management of hypertension.

CONFLICT OF INTEREST

The author has received honoraria from Bayer, Pfizer, ICI, Novartis, and Servier; and travel, accommodation, and conference registration support from Atco Pharmaceuticals, Werrick Pharma, Highnoon Laboratories, ICI, OBS, Pfizer, CCL, and Hilton Pharma.

AUTHOR CONTRIBUTION

This is a single author review paper.

Siddique S. Asian management of hypertension: Current status, home blood pressure, and specific concerns in Pakistan. J Clin Hypertens. 2020;22:501–503. 10.1111/jch.13778