The Hypertension Pandemic: Need for a Strategic Evidence-based Response

Hypertension has long been recognized as a major population health risks for all people and ages.^1-3 While not an infectious or communicable consideration, hypertension does meet the dynamics and dogma of a ‘pandemic’ with a major population mortality and morbidity impact consistent with many historical epidemics.^4,5 As such, it is critical that high blood pressure be addressed with the same rigor, level of intensity and priority as other pandemics, such as smallpox and currently COVID19.^6-8 In fact, hypertension detection, awareness, treatment and control has been highlighted with the structured evidence-based guidelines implemented since the 1970’s.^9-15 These guidelines and population-based programs have coincided with significant reductions in blood pressure, improvements in hypertension control, and reduction in high blood pressure related conditions including stroke.¹⁶ It is important to note that each rendition of the guidelines and reports includes new evidence-based detail and refined recommendations such as target blood pressure levels.¹⁷ This staged approach was associated with the nearly eradication of the severe systolic blood pressure levels common in the first half of the 20^th century.¹⁸ The strategic approach for hypertension control continues with the current 2017 recommendations based on the latest evidence.^19,20 With rigorous implementation, it would be expected that these guidelines would be associated with improvement in hypertension control.²¹ However, guidelines for high blood pressure management, control and prevention are not ‘one size fits all’, and successful implementation requires a detailed targeted approach.

In this Issue, Jones and colleagues provide a well written report addressing the management of stage 1 hypertension with the purpose to complement the 2017 American College of Cardiology/American Heart Association Blood Pressure Management Guidelines.²² While the statement identifies key evidence-based considerations for high blood pressure and provides detailed strategies for a specific group of hypertensive patients, the implications for prevention, management and control go beyond the mere reporting of the facts. Specifically, patients with “untreated stage 1 hypertension (systolic blood pressure /diastolic BP [DBP] 130-139/80-89 mmHg) with a ten-year risk for atherosclerotic cardiovascular disease lower than 10% who fail to meet the SBP/DBP goal (<130/80 15 mmHg) after 6 months of guideline recommended lifestyle therapy” represent a group that till current was poorly understood .²² Nonetheless, a substantial portion of the hypertensive population are in this category and developing suggestions specific to the risks in this group. These specific targeted guidelines are consistent with the earlier statements focused on higher hypertension categories that were associated with the lowering of blood pressure distributions and substantial reduction of the most elevated levels.^16-18 With implementation, such an approach of targeted hypertensive patients should contribute to the continued lowering of population blood pressure levels and subsequent adverse outcomes.

The statement also recognizes the racial and ethnic disparities in hypertension and blood pressure levels. In addition to the differences in blood pressure distributions, racial differences in changes should be considered. From 1960 to 2005, population blood pressure levels were lowered for all adults and ages.^16.18 However, the magnitude of the reductions was greater for Black women and men compared to White emphasizing the implications for the importance of the consideration of race and ethnicity with the implementation of the guidelines.¹⁸

Recognizing high blood pressure with the implications of a global pandemic must be considered a top priority in order to reduce the disease burden for the population.^23,24 Jones, et.al. are to be commended for providing another critical piece of the evidence-based response. As the statement authors indicate, continued research is needed to refine the clinical considerations for hypertension treatment and management. And the guidelines do not circumvent individual clinical judgement. But clinicians should remain confident that the proposed clinical management suggestions and considerations, as well as the primordial and primary preventions strategies, are based on strong evidence.