Management Of Hypertension In India Research Articles

Therapeutic Usefulness of a Novel Calcium Channel Blocker Azelnidipine in the Treatment of Hypertension: A Narrative Review.

The prevalence of hypertension and comorbidities such as metabolic syndrome, diabetes mellitus, and chronic kidney disease in India is alarmingly high. Amlodipine, an older-generation calcium channel blocker (CCB), is currently the gold standard for hypertension management in India. However, it has several disadvantages, including reflex tachycardia and pedal edema. Therefore, an effective antihypertensive agent that does not cause these adverse effects and provides end-organ protection is required for the holistic management of hypertension in the country. Azelnidipine is a new-generation CCB that has recently been approved for the treatment of hypertension in India. This review provides an overview of the utility of azelnidipine for hypertension control, including comparisons with traditional CCBs such as amlodipine. It discusses the key antihypertensive effects of azelnidipine as well as its advantages in the prevention of tachycardia and associated complications. In addition, this review highlights the extensive cardio- and renoprotective activities of azelnidipine, including its effects on systolic and diastolic function and urinary albumin excretion. Overall, this substantial body of evidence supports the use of azelnidipine for the treatment of hypertension, especially in India. It suggests that the adoption of azelnidipine as the new gold standard CCB could help India battle its hypertension epidemic.

Patient compliance, comorbidities, and challenges in the management of hypertension in India

Background and Objectives: As of now, only one-third of those with hypertension in India are unaware of the existence of this condition, and only a negligible share of those diagnosed can control it through medication. There is a need to understand the characteristics and behaviors of patients treated for hypertension for generating evidence for better management of this condition. In this context, the study examines the key factors associated with uncontrolled blood pressure (BP) levels in patients under medication for hypertension.Subject and Methods: Data from the nationally representative Longitudinal Ageing Study of India survey, 2017–18, are used for the analysis. This study is restricted to 12,353 respondents aged 45 years and above who were already diagnosed with hypertension before the survey and are under medication. BP level at the point of the survey was used to classify the respondents as hypertension under control (systolic <140 mm and diastolic <90 mm), Grade-1 Hypertension (systolic 14–159 mm or diastolic 90–99 mm), Grade-2 Hypertension (systolic160–179 mm or diastolic 100–109 mm), and Grade-3 Hypertension (systolic 180 or above mm or diastolic 110 or above mm). Bivariate and multivariate logistic regression analysis is performed to study the association between hypertension control in these patients and their demographic, socioeconomic, and behavioural characteristics.Results: A critical proportion of respondents have uncontrolled hypertension of Grade 1 (31%), Grade 2 (15%), and Grade 3 (2%), despite taking medication for the same. As compared to their remaining counterparts, the risk of uncontrolled hypertension is high in rural areas (odds ratio [OR] = 1.37, 95% confidence interval [CI], P < 0.01), old-adults living alone (OR = 1.63, 95% CI, P < 0.05), patients having no schooling (OR = 1.18, 95% CI, P < 0.05), patients with obesity (OR = 1.2, 95% CI, P < 0.05), moderate alcohol drinkers (OR = 2.1, 95%CI, P < 0.01), abusive alcohol drinkers (OR = 1.6, 95% CI, P < 0.01).Interpretation and Conclusions: Poor control over BP levels among patients from rural areas, the poorest and most vulnerable sections, supports the governmental efforts initiated since 2018 to expand community-level screening and provisioning of noncommunicable diseases, including that for hypertension. In addition, concrete efforts for health promotion within patients under medication for hypertension too are essential for better management of this condition.

Cost-Effectiveness of Improved Hypertension Management in India through Increased Treatment Coverage and Adherence: A Mathematical Modeling Study.

Background:Despite the availability of effective and affordable treatments, only 14% of hypertensive Indians have controlled blood pressure. Increased hypertension treatment coverage (the proportion of individuals initiated on treatment) and adherence (proportion of patients taking medicines as recommended) promise population health gains. However, governments and other payers will not invest in a large-scale hypertension control program unless it is both affordable and effective.Objective:To investigate if a national hypertension control intervention implemented across the private and public sector facilities in India could save overall costs of CVD prevention and treatment.Methods:We developed a discrete-time microsimulation model to assess the cost-effectiveness of population-level hypertension control intervention in India for combinations of treatment coverage and adherence targets. Input clinical parameters specific to India were obtained from large-scale surveys such as the Global Burden of Disease as well as local clinical trials. Input hypertensive medication cost parameters were based on government contracts. The model projected antihypertensive treatment costs, avoided CVD care costs, changes in disability-adjusted life year (DALYs) and incremental cost per DALY averted (represented as incremental cost-effectiveness ratio or ICER) over 20 years.Results:Over 20 years, at 70% coverage and adherence, the hypertension control intervention would avert 1.68% DALYs and be cost-saving overall. Increasing adherence (while keeping coverage constant) resulted in greater improvement in cost savings compared to increasing coverage (while keeping adherence constant). Results were most sensitive to the cost of antihypertensive medication, but the intervention remained highly cost-effective under all one-way sensitivity analyses.Conclusion:A national hypertension control intervention in India would most likely be budget neutral or cost-saving if the intervention can achieve and maintain high levels of both treatment coverage and adherence.

Inequalities and risk factors analysis in prevalence and management of hypertension in India and Nepal: a national and subnational study

BackgroundHypertension is one of the leading risk factors for cardiovascular diseases in India and Nepal. Socio-economic disparity in these two countries has created wide gap in management of hypertension. However, inequalities in prevalence and management (awareness, treatment, and control) of hypertension is poorly assessed. This study analyzes the risk factors associated with prevalence and management of hypertension in India and Nepal and assesses the wealth-and education-based inequalities in them.MethodsThis study used data from the Demographic and Health Survey; a cross-sectional survey conducted between January 2015 to December 2016 in India and June 2016 to January 2017 in Nepal. A total of 787,713 individuals in India and 14,454 individuals in Nepal aged between 15 and 49 years were included in the study. Respondents were classified as being hypertensive if their systolic blood pressure (SBP) readings were at least 140 mmHg or diastolic blood pressure (DBP) readings were at least 90 mmHg, or if they reported currently taking anti-hypertensive medication. Multilevel logistic regression models with random intercepts at household-and community-levels were used to identify the risk factors associated with prevalence and management of hypertension. For inequality assessment, slope index and relative index of inequalities in prevalence and management of hypertension were estimated.ResultsOverall prevalence of hypertension in India and Nepal were 11.4% (95% confidence interval (CI), 11.4–11.5) and 19.6% (95% CI, 18.9–20.2), respectively. Less than one-third of the hypertensive population received treatment and below 20% among them had their blood pressure controlled. In both countries, wealth-and education-based inequalities in awareness, treatment, and control of hypertension were significantly high in urban and rural areas.ConclusionWealth- and education-based inequalities in prevalence and management of hypertension were high among different socio-economic groups at national and sub-national levels. Tailored strategies are required to effectively manage hypertension in different regions by considering socio-economic and demographic factors.

Multidisciplinary Consensus Document on the Management of Uncontrolled Hypertension in India

Cardiovascular disease is predicted to be the largest cause of death and disability in India by 2020. Hypertension (HT), one of the main contributing factors, presents a significant public health burden. Inability to achieve adequate blood pressure (BP) control results in uncontrolled hypertension (UHT). The prevalence of UHT is high in India, with only about 9-20% of patients achieving target BP goals. Presently, there are no guidelines specific to UHT, which if left uncontrolled can lead to resistant HT, chronic kidney disease and other complications of HT. A multidisciplinary panel, comprising of specialists in cardiology, nephrology and internal medicine, was convened to address the diagnosis and management of UHT in the Indian population. The panel identified key points concerning UHT and discussed management recommendations in the Indian clinical setting.

P1945High levels of unawareness and suboptimal management of hypertension in India: data from a large community based study

Abstract Background Hypertension is the most common cause of the rising cardiovascular disease (CVD) epidemic in India. However, despite availability of proven therapies management remains sub-optimal. Purpose To determine the hypertension control rates and associated factors among adults with known hypertension in urban and rural India. Methods We conducted a representative population based cross-sectional survey among 12243 participants aged ≥30 years residing in rural and urban North and South India. Participants were selected using a multistage cluster random sampling technique. Trained personnel collected the data using an interviewer administered questionnaire, measured blood pressure, conducted anthropometry and collected bio-samples. Hypertension was defined as known hypertension (self-report of physician diagnosis) or systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Control was defined as SBP &lt;140 mmHg and DBP &lt;90 mmHg among those with known hypertension. The associations were measured using logistic regression. Results The mean (±SD) age of participants was 47.7 (±12.5) years, women comprised 54%. The age-standardized prevalence of hypertension was 29.0% (95% CI: 28.2- 29.8) and known hypertension was 14.0% (13.4- 14.6). Among all hypertensives 38.6% (37.0–40.2) were on treatment and 26.2% (24.6–28.0) had their blood pressure controlled, while among known hypertensives 79.8% (77.8–81.7) were on treatment and 55.7% (53.3–58.1) had their blood pressure controlled. In multivariate analysis, participants from North Indian site [OR: 1.9 (1.6–2.3)], urban residents [1.3 (1.1–1.6)], younger participants [1.5 (1.2–1.8)], men [2.0 (1.5–2.6)], those with low socio-economic status [1.6 (1.1–2.3)], without comorbidities and those without a family history hypertension were more likely to be unaware about their hypertensive status and less likely to take treatment. Hypertension control was significantly higher in participants from South Indian site [1.5 (1.2–1.0)], the highly educated [1.6 (1.1–2.4)], those without heart diseases [1.8 (1.1–3.1)], those without central obesity [1.4 (1.1–1.9)], physically active individuals [1.5 (1.1–2.0)] and current non-alcohol users [1.9 (1.3–2.6)]. Conclusions Many individuals with hypertension remain unaware and sub-optimally managed. This warrants the implementation of tailored public education to raise awareness, complemented by active screening for the early detection and effective management of hypertension, in order to stem the rising tide of preventable CVD in India. Acknowledgement/Funding Unrestricted educational grant from Eli Lilly under the Lilly NCD Partnership

Usefulness of ambulatory blood pressure measurement for hypertension management in India: the India ABPM study

The present paper reports differences between office blood pressure (BP) measurement (OBPM) and ambulatory blood pressure measurement (ABPM) in a large multi-centre Indian all comers’ population visiting primary care physicians. ABPM and OBPM data from 27,472 subjects (aged 51 ± 14 years, males 68.2%, treated 45.5%) were analysed and compared. Patients were classified based on the following hypertension thresholds: systolic BP (SBP) ≥ 140 and/or diastolic BP (DBP) ≥90 mmHg for OBPM, and SBP ≥ 130 and/or DBP ≥ 80 mmHg for 24-h ABPM, and SBP ≥ 120 and/or DBP ≥ 70 mmHg for night-time ABPM and SBP ≥ 135 and/or DBP ≥ 85 mmHg for daytime ABPM, all together. White coat hypertension (WCH) was seen in 12.0% (n = 3304), masked hypertension (MH) in 19.3% (n = 5293) and 55.5% (n = 15,246) had sustained hypertension. Isolated night-time hypertension (INH) was diagnosed in 11.9% (n = 3256). Untreated subjects had MH relatively more often than treated subjects (23.0% vs. 14.8%, p < 0.0001; respectively). Females had higher relative risk (RR) of having WCH than males (RR 1.16 [CI 95, 1.07–1.25], p < 0.0001). Whereas, males had higher RR of MH than females (RR 1.09 [CI 95, 1.02–1.17] p < 0.01). INH subjects had lower average systolic and diastolic dipping percentages (0.7 ± 6.6/ 2.2 ± 7.9 vs. 9.0 ± 7.3/11.9 ± 8.5, p < 0.001) than those without INH. In conclusion, for diagnosis of hypertension there was a contradiction between OBPM and ABPM in approximately one-third of all patients, and a substantial number of patients had INH. Using ABPM in routine hypertension management can lead to a reduction in burden and associated costs for Indian healthcare.

A collaborative model for capacity building of primary care physicians in the management of Hypertension in India.

A collaborative model for capacity building of primary care physicians in the management of Hypertension in India.

Process evaluation protocol for a cluster randomised trial of a complex, nurse-led intervention to improve hypertension management in India

IntroductionIndia has high prevalence of hypertension but low awareness, treatment and control rate. A cluster randomised trial entitled ‘m-Power Heart Project’ is being implemented to test the effectiveness of a...

M-Power Heart Project - a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial

BackgroundThe proportion of patients with controlled hypertension (< 140/90 mmHg) is very low in India. Thus, there is a need to improve blood pressure management among patients with uncontrolled hypertension through innovative strategies directed at health system strengthening.MethodsWe designed an intervention consisting of two important components – an electronic decision support system (EDSS) used by a trained nurse care coordinator (NCC). Based on preliminary data, we hypothesized that this intervention will be able to reduce mean systolic blood pressure by 6.5 mmHg among those with uncontrolled blood pressure in the intervention arm compared to the standard treatment arm (paper-based hypertension treatment guidelines). The study will adopt a cluster randomized trial design with the community health center (CHC) as the unit of randomization. The trial will be conducted in Visakhapatnam district (southern India). A total of 1876 participants aged ≥30 years with high blood pressure – systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg will be enrolled from 12 CHCs. The intervention consists of trained NCCs equipped with an evidence-based hypertension treatment algorithm in the form of the EDSS with regular SMSs to patients with hypertension to promote hypertension treatment and blood pressure control for 12 months. The primary outcome will be difference in the mean change of SBP, from baseline to 12 months, between the intervention and the standard treatment arm. The secondary outcomes are the difference in mean change of DBP; difference in the proportion of patients with controlled blood pressure (< 140/90 mmHg); difference in mean change of fasting blood sugar, HbA1C, eGFR, and albumin to creatinine ratio; difference in the proportion of patients visiting the CHC regularly (number of actual visits to the CHC/number of visits suggested by the EDSS > 80%); difference in proportion of patients compliant to anti-hypertensive medication/s; cost-effectiveness of intervention versus enhanced care. All the outcomes will be assessed at 12 months.DiscussionThe study is expected to provide evidence on the effectiveness of NCC-led, EDSS-based hypertension management in India and can likely offer an exemplar for improving cardiovascular disease (CVD) management in India within the resource-constrained public healthcare system.Trial registrationClinicalTrials.gov, ID: NCT03164317). Registered retrospectively on 23 May 2017 (first patient enrolled on 6 April 2017) because the authors did not receive a response to their original registration submission (5 January 2017) to the Clinical Trial Registry – India (CTRI).

Socio-demographic inequalities in the prevalence, diagnosis and management of hypertension in India: analysis of nationally-representative survey data.

BackgroundHypertension is a major contributing factor to the current epidemic of cardiovascular disease in India. Small studies suggest high, and increasing, prevalence especially in urban areas, with poor detection and management, but national data has been lacking. The aim of the current study was to use nationally-representative survey data to examine socio-demographic inequalities in the prevalence, diagnosis and management of hypertension in Indian adults.MethodsUsing data on self-reported diagnosis and treatment, and blood pressure measurement, collected from 12,198 respondents aged 18+ in the 2007 WHO Study on Global Ageing and Adult Health in India, factors associated with prevalence, diagnosis and treatment of hypertension were investigated.Results22% men and 26% women had hypertension; prevalence increased steeply with body mass index (<18.5 kg/m2: 18% men, 21% women; 25-29.9 kg/m2: 35% men, 35% women), was higher in the least poor vs. poorest (men: odds ratio (95%CI) 1.82 (1.20 to 2.76); women: 1.40 (1.08 to 1.81)), urban vs. rural men (1.64 (1.19 to 2.25)), and men recently vs. never using alcohol (1.96 (1.40 to 2.76)). Over half the hypertension in women, and 70% in men, was undetected with particularly poor detection rates in young urban men, and in poorer households. Two-thirds of men and women with detected hypertension were treated. Two-thirds of women treated had their hypertension controlled, irrespective of urban/rural setting or wealth. Adequate blood pressure control was sub-optimal in urban men.ConclusionHypertension is very common in India, even among underweight adults and those of lower socioeconomic position. Improved detection is needed to reduce the burden of disease attributable to hypertension. Levels of treatment and control are relatively good, particularly in women, although urban men require more careful attention.

Medication adherence and associated barriers in hypertension management in India

Summary Hypertension is inadequately controlled in most patients due to poor adherence to treatment. Not much is known about the underlying reasons for poor adherence. The main objective of this study was to assess medication adherence in hypertensive patients and to identify the main barriers associated with medication adherence. A questionnaire-based survey was conducted in the medicine outpatient department of Kempe Gowda Institute of Medical Sciences and Research Centre, Bangalore, India. Self reported adherence was measured by using a short validated questionnaire and detailed patient interviews. Of the 608 patients participated, non-adherence was found in 49.67% of patients. Belief barrier was reported in 39.14% patients. Access barrier and recall barrier were reported by 82.57% and 62.17%, respectively. 78.62% of patients reported that it is difficult to pay for the medication and 54.93% indicated that it is difficult to get a refill on time. It was concluded that about half of the Indian patients studied were not adherent to their antihypertensive regimen and this might result in poor blood pressure control. Non-adherence to hypertension management remains a major limiting factor among Indians in the effective control of hypertension and in the prevention of cardiovascular diseases.

BPTRU — An automated blood pressure monitoring device in the physician's office — A useful alternative to 24 h ambulatory blood pressure monitoring in the evaluation and management of hypertension in India

Objective The purpose of this pilot study is to determine to what degree BPTRU monitoring correlates with 24 h ambulatory blood pressure monitoring (ABPM) in comparison to routine clinic BP measurement in hypertensive patients in India. Methods 20 patients who were referred for 24 h ABPM for the evaluation of suspected white coat hypertension or to assess control of blood pressure underwent routine clinic BP measurement by physician by sphygmomanometer as well as by oscillometric method using the automated device called BPTRU (made by VSM Tech, Vancouver, Canada).