Management of Hypertension:Do We Know All the Questions?

Economic Review, June 2011 | Go to article overview

Management of Hypertension:Do We Know All the Questions?


Hypertension in Pakistan remains a major health problem; with a prevalence of 17.9% in the adult population, there are an estimated 10 million hypertensives. The effects of hypertension on cardiovascular and renal mortality and morbidity are well-established worldwide. Unfortunately we know very little about the characteristics of hypertension in our population. There are no studies of enough power dealing with the risk factors, course, management and its effects on cardiovascular mortality and morbidity in Pakistan. There are suggestions from studies on the immigrant population in the UK that the incidence of and rate of complications from hypertension are, in fact, much higher in the Indo-Pakistani community than the Whites. It is therefore not possible to draw any conclusions about management of hypertension in Pakistan from our local experience. The best we can do is to try to implement the management principles known from international studies, on our population.

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The optimal management of hypertension can be approached by asking several questions and trying to answer them with the available evidence. That the treatment of hypertension significantly reduces mortality and morbidity is now established beyond doubt. Should we treat all hypertensive? Patients with moderate to severe hypertension, those with other risk factors for cardiovascular/renal complications and those with target organ damage should always be treated. Decision to treat patients with mild hypertension should be individualized based on their risk profile4. Are non-pharmacological measures of an value? This question has not been addressed as rigorously as that of pharmacological intervention. The measures, which have been found to be beneficial are reduction of weight in overweight individuals and aerobic exercise in sedentary people, increased consumption of potassium and magnesium. A diet rich in fruits and vegetables and low in animal fat also has positive effects. Reduction of dietary sodium helps lower blood pressure in the majority of hypertensives. The benefit of these measures is modest; these should be used as primary therapy in people not requiring pharmacological treatment and should be part of the treatment plan for those who do. Are all antihypertensive equally effective in controlling hypertension? Although the response to these medicines varies to some extent with age, sex, stage of hypertension and ethnicity, in most clinical situations all classes of drugs have been found to be equally efficacious. (Most of these have also been studied in small groups of Pakistani patients and found to be effective) The more important question is: are they equally effective in reducing mortality and morbidity? Until recently the only drugs known to have this benefit were diuretics and beta-blockers. Several large studies completed recently have shown that other classes of drugs via, calcium channel blockers and ACE inhibitors also have similar benefits for morbidity and mortility. Is any class of drugs better than others? This question is more difficult to answer based on the present state of evidence. The factors to consider are: any extra advantages (in general and in specific groups of patients). disadvantages and side effects profile (so-called quality of life issues) of the different classes of drugs over and above their blood pressure lowering effect. The evidence is mixed, at best. Based on some studies claims have been made about the added advantages of ACE inhibitors (and AT-2 receptor antagonists): regression of left ventricular hypertrophy (an independent risk factor for increased mortality) prevention and delaying of progression of diabetic nephropathy and better tolerance. None of these can be used as an argument for their superiority, however. Most of the regression in LVH can be achived by almost all anti-hypertensive drugs with adequate long term control of blood pressure: in any case reducing LVH independently has never been shown to reduce mortality. …

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