Hypertension control in Argentina, in the middle of a long road

Abstract

In Argentina, cardiovascular diseases are the leading cause of death and represent 1/3 of total mortality. In 2017, hypertension prevalence for inhabitants ≥18 years old was 36.3%, and its level of knowledge and control (<140/90 mm Hg) were 61% and 24%, respectively. Furthermore, 56% of people treated with antihypertensive drugs do not reach therapeutic goal. In addition to this, prevalence of other risk factors, such as sedentary lifestyle, overweight‐obesity, high blood glucose/diabetes, and high cholesterol, has worsened in the last 5 years. The governmental initiative "Less Salt More Life" intends to reduce salt consumption in the entire population and promoted a National Law, which establishes the progressive salt reduction in processed foods. This initiative is probably related to the reduction of salt use after cooking or sitting at the table, observed in the Risk Factors National Survey. Furthermore, previously published studies showed, in relatively small samples from Argentina, that populational blood pressure can be decreased and hypertension control can be improved using community‐based or multicomponent intervention programs. However, no specific designed national effort for hypertension control is now officially applied. In consequence, we believe that, in order to increase hypertension control, the effort should not focus on developing new strategies, but on quickly implementing and maintaining those local multicomponent interventions that have already proven to be effective.

Cardiovascular diseases are the leading cause of morbidity and mortality in developed and developing countries. Cardiovascular mortality was in Argentina of 233.8 per 100 000 inhabitants, which represents 28.9% of total mortality and 101 928 deaths.1

In 2017, hypertension prevalence in individuals ≥18 years old was of 36.3%, and its level of knowledge and control (<140/90 mm Hg) 61% and 24%, respectively.2 The 55.5% of hypertensive patients were under pharmacological treatment, and the treatment efficacy, understood as the controlled/treated ratio × 100, was of 43.6%, which means that 56 out of every 100 patients treated with antihypertensive drugs had not reached the therapeutic goal. Compared with the PURE study3, which involved 142 042 individuals from 35 to 70 years old from urban and rural communities in high‐, medium‐, and low‐income countries, the percentage rates of knowledge and treatment were similar to those found for the South American region (57.1% and 52.8%, respectively), while the control rate and treatment efficacy rate (systolic BP <140 mm Hg) were lower in the PURE study (18.8% and 35.5%, respectively).

The relationship between BP categories and cardiovascular (CV) events was evaluated for a cohort from Buenos Aires province.4 This study showed a progressive increase in CV events through the BP categories in individuals <55 years old, for both sexes. However, in subjects ≥55 years a J‐curve phenomenon was observed, with the lowest incidence in the high‐normal BP category.

In addition to this high prevalence and low hypertension control, and the increased risk of CV events from high‐normal BP levels, there are also other risk factors. Recently, the 4th Risk Factors National Survey5 showed, with self‐reported data, that 65% of the Argentinian population undertakes low levels of physical activity, 62% has overweight‐obesity, 16% adds salt to food, only 6% consumes at least five daily servings of fruits and vegetables, 22% consume tobacco, and at last, prevalence of high glycemia/diabetes and high cholesterol are of 13% and 29%, respectively. It should be noted that physical activity, overweight‐obesity and the prevalence of high glycemia/diabetes demonstrated worse results compared to those obtained in 2013.

In view of the magnitude of the aforementioned data, it is clear that, among other measures, special attention must be paid to both hypertension prevention and control of hypertension. The World Hypertension League has recently summarized the reasons why urgent prevention and control of high BP is necessary.6 Increased BP (systolic BP >120 mm Hg) was the cause of an estimated 10.3 million deaths and 208 million disability‐adjusted life years in 2013 and the cause of 50% of heart disease and stroke; one half of the BP‐related diseases occurred in persons with prehypertension levels. Furthermore, hypertension is a public health epidemic since approximately 40% of adults >25 years old are hypertensive and, in many countries, another 20% have prehypertension. On the other hand, hypertension disproportionately impacts low‐ and middle‐income countries: 2/3 of the hypertensive population live in economically developing countries and in those countries heart disease and stroke occur in younger people. In addition to this, BP‐related disease has a major impact on healthcare spending, for an estimated 10% of it is directly related to increased BP and its complications.

To contribute with hypertension prevention and control the initiative "Less Salt More Life", implemented by the Ministry of Health starting on 2011, intends to reduce salt consumption in the complete population.7 This initiative includes three components: the population awareness concerning the need to reduce the amount of salt added to the meals, which is developed through advertising spots and various graphic tools, the progressive sodium reduction in processed foods, through agreements with the food industry, and the salt reduction in bread, through agreements with the baking industry. The project has been reflected partially in the National Law 26.905, which establishes the progressive reduction of salt used in processed foods, regulates the inclusion of warnings about the risks of excessive salt consumption on products packaging, promotes the elimination of salt shakers on restaurant tables, and sets a maximum size of 500 mg for individual packages of salt. The initiative is probably related to the reduction of affirmative responses to the survey’s question "always/almost always uses salt after cooking or sitting at the table" of the Risk Factors National Survey, from 23.1% (95% CI 21.9‐24.5) in the year 2005 to 16.4% (95% CI 15.6‐17.3) in 2018.5

On another hand, in order to improve hypertension knowledge, it is necessary to regularly measure BP in the whole population and communicate the values and the condition of each inhabitant. In this direction, in May 2018, the Argentine Society of Arterial Hypertension registered BP in more than 70 000 inhabitants during the campaign "Know and Control Your Blood Pressure."8

In order to improve the control and the treatment efficacy, it is fundamental to facilitate access to care and antihypertensive drugs, to increase treatment adherence and to reduce medical inertia in both, diagnosis and treatment of hypertension. Unfortunately, a large percentage of individuals in low‐ and middle‐income countries do not have access to more than one antihypertensive drug and, when available, they are often inaccessible.9 In this regard, during the second half of 2018, 32% of the Argentinian population was below the poverty line.10

In Argentina, lack of adherence is observed in 52% of hypertensive patients after 6 months of treatment11, and therapeutic inertia is reflected on the fact that more than 70% of patients with pharmacological treatment receive only one antihypertensive drug,2, 12 showing a similar situation to that observed in the PURE study.2, 9

The feasibility of implementing programs for arterial hypertension prevention and control has been evaluated in Argentina by two studies. One of them consisted in a community CV prevention program implemented in Rauch city, located in the east‐center of Buenos Aires province and 277 km away from Buenos Aires city. In 1997, in a random population sample, high prevalence of arterial hypertension, overweight‐obesity, smoking, and high sodium consumption were found.13 In view of these results, a community program aimed at the whole population was initiated in the same year. The program main strategies were dissemination, by the local press, of the results of the survey, highlighting aspects of arterial hypertension importance and CV prevention, free provision of antihypertensive drugs to hypertensive individuals, BP measurement by nurses in each medical consultation as a matter of routine, healthy diet promotion through seminars given by nutritionists and home vegetable gardens encouraged by free seed delivery, and physical activity promotion encouraged by Physical Education teachers14. Six years later, systolic BP had decreased from 137.98 ± 0.57 to 132.49 ± 0.53 mm Hg (P < .01) and diastolic BP from 88.73 ± 0.38 to 81.87 ± 0.33 mm Hg (P < .01). BP decreased in both sexes, in all age groups and also in the subgroup without antihypertensive drugs. The systolic BP decrease was accompanied by a shift to the left of the systolic BP cumulative curve and a flattening to the right, demonstrating the program impact on the whole community and on hypertensive, respectively.14 This program ended in 2003. Eight years after the end of the program, the development of combined CV events (fatal and non‐fatal myocardial infarction, fatal and non‐fatal stroke, myocardial revascularization and hospitalization due to unstable angina pectoris) was evaluated according to systolic BP changes during the program (increase, no change, or decrease).15 Those who increased the systolic BP during the program had an adjusted hazard ratio of CV events that doubled those who decreased or did not modify their systolic BP levels.

Recently, the results of a randomized clinical study on the multicomponent intervention effects on BP control in low‐income hypertensive patients were published.16 The study was conducted during 18 months in patients who were assisted in Primary Health Care Centers (PHCC). The intervention was applied to hypertensive patients assisted in nine PHCC, and hypertensive patients treated in a usual way in other nine PHCC were taken as a control group. The intervention included home strategies, strategies for the physicians of the PHCC, and text message sending. At the household level, the activities were directed by community social workers. Home strategies, applied to patients and their families, included training in healthy lifestyle changes, medication adherence, and weekly BP self‐monitoring. A BP self‐monitoring device and pills organizers were given to each hypertensive patient. Training of primary care physicians was focused on standard treatment algorithms for the BP stepwise management according to clinical guidelines. Text messages reminding the patients to take the medication and perform the BP self‐monitoring were sent on a weekly basis. At the end of the intervention, systolic and diastolic BP had fallen 6.6 mm Hg (95% IC 4.6‐8.6, P < .001) and 5.4 mm Hg (95% CI 4.0‐6.8, P < .001), respectively, and the treatment efficacy had increased around 20% in the intervened group compared to the control group. This multicomponent intervention was cost effective.17

It is important to point out that despite the feasibility of the described interventions, no specific programs to improve hypertension control are officially applied in Argentina. Therefore, and in agreement with other authors,18 it is probable that in order to increase hypertension control, effort should not be focused on developing new strategies, but on quickly implementing and sustaining the local models that have already proven to be effective.

CONFLICT OF INTEREST

None disclaimers.

Carbajal HA, Salazar MR. Hypertension control in Argentina, in the middle of a long road. J Clin Hypertens. 2019;21:1604–1606. 10.1111/jch.13691