Sustainable hypertension care – How can it be achieved?

Hypertension is a major cardiovascular risk factor on a global scale [1], and elevated blood pressure has been appointed the number one modifiable risk factor according to the World Health Organization, with worrying trends in most populations worldwide [2]. The number of people affected by hypertension is increasing year by year, in Western countries influenced mostly by ageing populations and in many low- or middle-income countries (LMIC) by an unhealthy change of lifestyle influencing obesity trends and salt intake [3]. Environmental changes and pollution of water, soil and air can also be part of the explanation for these epidemiological trends.

Substantial efforts have been devoted to research on hypertension, its epidemiology, causes and pathophysiology, but also how best to treat and implement these findings in clinical care and public health strategies. As described in several national and international guidelines, including the most recent one issued by the European Society of Hypertension (ESH) in June 2023 [4], there is a need to improve the care of hypertensive patients, not only for blood pressure control itself, but also for a more general cardiovascular risk factor control to prevent clinical events (cardiovascular disease, dementia, chronic kidney disease, retinopathy, etc.). Several antihypertensive drugs can be used, often in combination therapy when synergistic actions of these drugs can improve risk factor control and the achievement of blood pressure goals, even used as fixed single-pill combinations (SPC) [4]. Most guidelines recommend first-hand combinations of ACE inhibitors/angiotensin receptor blockers, a calcium antagonist, and a diuretic, but also other drugs can be used if needed [4].

In this issue of the Journal, Mancia et al. have summarized the present state of hypertension care and defined some of the challenges that must be recognized and overcome to make it possible that hypertensive patients can be treated effectively according to their risk status, and to attain blood pressure targets according to guidelines, based on evidence [5]. This might become a difficult task in the often-stressful everyday clinical practice. The focus on possible solutions at different levels is described, that is (a) patient-level solutions, (b) physician-level solutions and (c) healthcare-level solutions. Among these solutions, the authors mention easier and more effective ways of diagnosing, treating and following up patients with hypertension based on knowledge, motivation and shared decision-making. One tool to accomplish this is a wider use of SPCs that can even be developed into a polypill [6], if also, for example, a statin is added to 2–3 antihypertensive drugs within one pill or capsule. For physicians, it is important to increase knowledge about how to effectively treat hypertension and screen for other risk factors, as well as diagnosing hypertension modified organ damage (HMOD) of the heart, brain and kidneys. A huge problem to tackle is the lack of time and the insufficient number of physicians, mostly general practitioners, to handle the very large group of hypertensive patients in a time- and cost-effective way, thereby removing some stress on overburdened physicians (for their time needed to treat) and counteract clinical inertia. Finally, and perhaps even more important for public health on a larger scale, is to tailor the health care system itself to the needs of patients with hypertension. This means not only reimbursement of the antihypertensive drugs that are needed, as well as of equipment such as blood pressure–measuring devices, but also adequate staffing and accessible health services able to reach the millions of people that do not even know that their blood pressure is elevated, and to diagnose and treat them following a diagnosis of hypertension.

What can be further discussed is the concept of sustainable hypertension care for patients with hypertension, not only in LMIC [7] but also in Western countries. This means that patients should have the opportunity to measure their blood pressure, as well as the motivation, financial support, and access to healthcare facilities for controlling the elevated blood pressure. In addition, staffing with skilled nurses or even paramedics to screen and treat hypertension in collaboration with physicians can be tried [8], as well as the PolyPill and a wider use of modern technologies for e-health services. The latter strategy was recently tested in a randomized, controlled trial in primary health care in Sweden, when a mobile app was combined with home blood pressure monitoring to increase the degree of blood pressure control in the intervention group [9].

Even if risk factor control in hypertensive patients is still suboptimal, it is necessary to recognize more favourable time trends. Thirty years ago, the risk factor burden in treated hypertensive patients in Sweden was substantial [10], but this has improved in recent years. This is partly due to better drugs used in combinations and more widespread use of diagnostic tools such as ambulatory and home blood pressure recordings, as well as technical development to better characterize HMOD, for example using echocardiography, vascular imaging and improved algorithms for estimated renal function. Another important aspect is more media and public health awareness of hypertension as a threat to successful ageing and thereby increased motivation and adherence to treatment in at least a substantial number of hypertensive patients. This is, of course, also influenced by social and cultural factors, as hypertension treatment and control are still suboptimal to a higher degree in groups of patients living under adverse conditions.

In summary, the review by Mancia et al. [5] is timely and coincides with the new ESH Guidelines on Hypertension 2023 with the same first author [4]. The importance of recognizing challenges to an effective care at different levels (patient, physician, and community) is a merit of the paper, but one dilemma remains. Should we go for a more individualized treatment model (personalized medicine) based on extensive phenotyping, biomarker algorithms for cardiovascular risk assessment and tailoring the right medication combination to the individual patient with hypertension – a strategy that most specialists and researchers in the field would find attractive – or should we aim for a very simplified strategy based on sustainable hypertension care along the principles described before? The latter seems less attractive to specialists, for many good reasons, but if we acknowledge the real dimension of hypertension as an enormous public health problem, both in LMIC and Western countries, the conclusion must be that it would be better if the majority of patients are screened, diagnosed and treated to a reasonable level of risk factor control within limited resources, than that a substantially lower number of patients are fully screened and receive optimal treatment in every aspect, not only for hypertension but for all their cardiovascular risk factors at centres of excellence. Finally, in a world of current conflict and ongoing wars, it should also be stressed that structural interventions to support peace, safety and stability, as well as protection of the environment, could bring larger health benefits for cardiovascular prevention than individualized treatment programs for hypertension – food for thought!

The author has received modest honoraria for lectures on drug treatment of diabetes and lipid disorders from Amgen, AstraZeneca, Boehringer Ingelheim, Novartis and Novo Nordisk.