Managing hypertension in 2018: which guideline to follow?

Abstract

Hypertension is a global public health issue and a major cause of morbidity and mortality. Its prevalence is increasing in many Asian countries, with a number of countries with blood pressure above the global average. Although the average systolic blood pressure is decreasing worldwide since the 1980s at the rate of about 1 mm Hg systolic blood pressure per decade, it is increasing in low-income and middle-income countries, especially in the East and South Asian population. Of note, the much larger base Asian population results in a considerably larger absolute number of individuals affected. When compared with Western countries, hypertension among Asian populations has unique features in terms of its onset, clustering of associated cardiovascular risk factors, complications and outcomes. Moreover, only a minority of hypertensive individuals are receiving treatment and achieving control. Projected number of deaths related to hypertension dramatically increased in the last 25 years in some Asian regions with a disproportionately high mortality and morbidity from stroke compared with Western countries. The relation between blood pressure and the risk of stroke is stronger in Asia than in Western regions. Although new Guidelines for hypertension diagnosis and management have been recently released from Europe and North America, the unique features of Asian hypertensive patients raise concerns on the clinical applicability of Western Guidelines to Asian populations. To this purpose, we critically reviewed key elements from the most updated Guidelines. We also discussed their core concepts to verify the impact on hypertension prevention and management in Asian countries.

Keywords: Blood pressure; EBM; Guidelines; Prevention; hypertension; quality of care and outcomes.

Figure 1

Effects of the 2017 American College of Cardiology/American Heart Association hypertension guidelines on the prevalence of hypertension and eligibility for initiation and intensification of treatment in nationally representative populations from the USA and China. Data from Khera et al.

Figure 2

Relationship between the reduction in blood pressure (BP) and the risk of composite cardiovascular endpoints (triple: myocardial infarction, stroke and cardiovascular death; quadruple: myocardial infarction, stroke, cardiovascular death and congestive heart failure). Thirty trials are included for a total of 221 024 patients. For each trial, the difference in BP between randomised groups is depicted. Data from Verdecchia et al (with permission). BP, blood pressure.

Figure 3

Trial sequential analysis (TSA) of the effect of more intensive vs less intensive blood pressure reduction on cardiovascular mortality. See Verdecchia et al for guidance on TSA and plot interpretation (with permission). RRR, relative risk reduction; OR, odds ratio; CI, confidence interval.