Dear Colleagues,
In this issue of the Newsletter, I want to comment on the “state of play” for high blood pressure (BP) treatment and control around the world. Obviously, we’ve made tremendous progress since diuretics were introduced as the first effective drugs for treatment of hypertension in the 1950s. Since then, efficacy trials have demonstrated the most effective nonpharmacological interventions for prevention and treatment of hypertension (weight loss, dietary sodium reduction and potassium supplementation, consumption of a heart healthy diet, physical activity, and abstinence or moderation in alcohol intake) as well as the efficacy of low-dose pharmacotherapy for prevention of hypertension and more intensive pharmacotherapy for treatment of high BP and prevention of cardiovascular disease (CVD).
This has translated into BP guideline recommendations to treat patients to an SBP of <120 to <140 mm Hg. The most recent BP guideline has been the European Society of Hypertension, which generally recommends an initial SBP goal of <140 mm Hg, with further reduction into the 130s if tolerated. Given the strength of the evidence and the consistency of guideline recommendations to treat adults with hypertension to at least <140 mm Hg one might reasonably expect a high and improving rate of SBP control to <140 mm Hg around the world1,2. Sadly, this is not happening in any country and in recent years control rates have deteriorated in the two countries (Canada and the United States) that have long had the best rates of treatment and control3. Unfortunately, there is a huge disconnect between demonstration of treatment efficacy and its incorporation into clinical practice. Most recently, this has been vividly demonstrated during long-term follow up of the SPRINT participants4 but we’ve “seen this picture” on many previous occasions. I recall the widespread failure to use β-blockers after an acute myocardial infarction despite abundant evidence of benefit in multiple clinical trials. This lack of translation from efficacy studies to clinical practice has important implications. First, it underscores the importance of taking advantage of implementation science to guide our treatment approaches. The extraordinary effectiveness of a simple but well-executed treatment strategy that incorporated major elements of implementation science was recently demonstrated in the China community health care workers led trial that resulted in a three-year SBP reduction >23 mm Hg and a correspondingly dramatic reduction in CVD and all-cause mortality5. The HEARTS initiative is also based on a strong science base for success in implementation and preliminary results are promising3. In all of this, there is a clear message that our guidelines need to pivot from a primary publication that is comprehensive and provides a strong science base for treatment recommendations to a much shorter and more focused primary communication that emphasizes implementation and is supported by secondary documents that provide greater detail and are more comprehensive. It will be interesting to see how the European Society of Cardiology, expected next year, and ACC/AHA BP guideline, expected circa 2025, will respond to this challenge.
As always, thanks to all of you for your continuing efforts to detect and treat high BP around the world.
Paul K. Whelton, MB, MD, MSc
President
1. Mancia Chairperson G, Kreutz Co-Chair R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, Muiesan ML, Tsioufis K, Agabiti-Rosei E, Algharably EAE, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension Endorsed by the European Renal Association (ERA) and the International Society of Hypertension (ISH). J Hypertens. 2023. doi: 10.1097/HJH.0000000000003480
2. Verdecchia P, Grossmann E, Whelton P. 2023 ESH Guidelines. What are the main recommendations? Eur J Intern Med. 2023. doi: 10.1016/j.ejim.2023.07.034
3. Whelton PK, Flack JM, Jennings G, Schutte A, Wang J, Touyz RM. Editors' Commentary on the 2023 ESH Management of Arterial Hypertension Guidelines. Hypertension. 2023;80:1795-1799. doi: 10.1161/HYPERTENSIONAHA.123.21592
4. Jaeger BC, Bress AP, Bundy JD, Cheung AK, Cushman WC, Drawz PE, Johnson KC, Lewis CE, Oparil S, Rocco MV, et al. Longer-Term All-Cause and Cardiovascular Mortality With Intensive Blood Pressure Control: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol. 2022;7:1138-1146. doi: 10.1001/jamacardio.2022.3345
5. He J, Ouyang N, Guo X, Sun G, Li Z, Mu J, Wang DW, Qiao L, Xing L, Ren G, et al. Effectiveness of a non-physician community health-care provider-led intensive blood pressure intervention versus usual care on cardiovascular disease (CRHCP): an open-label, blinded-endpoint, cluster-randomised trial. Lancet. 2023;401:928-938. doi: 10.1016/S0140-6736(22)02603-4
