Last week, during the scientific sessions of the International Society of Hypertension in Beijing, I had the privilege to chair a session where Professor Clara Chow, academic director of the Westmead Applied Research Centre in Australia, gave a lecture on important lessons practicing physicians could learn from the landmark PURE (Prospective Urban Rural Epidemiology) study. Professor Chow is one of the primary authors in the series of publications derived from the PURE study.
She and her colleagues looked at the prevalence, awareness, treatment and control of hypertension in participants coming from a multinational study population. The Philippines was represented in the study. Less than half of people with high blood pressure (BP), or 46.5 percent, are aware they have high BP. Of those who were treated, only a third, or 32.5 percent, had their BPs controlled.
That means only a little over 13 percent of the hypertensive population in the world have controlled BP, leaving eight to nine out of 10 hypertensive patients with uncontrolled BP, which can lead to heart attack, stroke, kidney failure and other potentially fatal complications of hypertension.
The stats from affluent countries is not that encouraging. At best, only one out of six hypertensive individuals in first-world or high-income countries have adequately controlled BP on the average.
This is quite a big irony because we have more than enough medicines now available, which should be able to control high BP in up to nine out of 10 hypertensive patients, if only physicians and healthcare givers can be more aggressive in treating their patients. Good patient adherence to treatment is also an important component.
Single pill combination
In the PURE study, less than 15 percent of patients are taking two or more drugs for their hypertension, despite the established knowledge that seven to eight out of 10 hypertensive patients need at least a two-drug regimen to achieve good control of their BP.
Sometimes, patients think taking too many drugs is not good for them, so even if their doctors prescribe two or three, they only take one, and believe they’re adequately protected from the serious complications of uncontrolled BP. They realize too late what their nonadherence to their doctor’s instructions has caused them when they’re rushed to the emergency room.
This is the reason why the recent European guidelines in the management of hypertension recommend single pill combinations (SPCs) as the preferred initial drug for most hypertensive patients. These pills, which are already available in the Philippines, contain two or even three drugs—all combined in one pill.
Except in the frail elderly and the low-risk hypertensive population, a two-drug SPC is now recommended as initial treatment. This minimizes the burden of having to take two or three pills instead of one. Studies show more prompt and ideal BP control, which has been shown by studies to translate to better long-term outcomes and life span.
I remember one of the editorial commentaries the late Professor Ramon Abarquez Jr. and I and several other colleagues coauthored in the 1990s, advocating the early use of drug-combination treatments for hypertensive patients. This was based on a long-term study of employees of a large beverage corporation, which showed that the BP can rapidly progress from mildly elevated to markedly high within a year or two if not adequately treated at the start, or if the employee is poorly compliant because of multiple pills.
There was not too much enthusiasm at that time for this recommendation. I wish Professor Abarquez were alive today so he’d know his recommendation is accepted now—it just came 20 years too early.
The bad news is that BP control worldwide is still dismally poor even in rich countries. The good news is that the new recommendation to use SPCs right at the start for most patients can dramatically improve BP control.
In the same session I chaired, renowned Chinese researcher Professor Zhaosu Wu also gave an excellent talk tracking how progressive development of the Chinese economy translated to the prevalence of cardiovascular disease (CVD) in China.
One would think that the improved healthcare system in China would have translated to better statistics as far as CVD is concerned. Unfortunately, this is not so.
The statistics Professor Wu’s group has been monitoring indicate an alarming trend—as the Chinese economy progresses, the number of cases of hypertension and CVD increases.
Professor Wu traces it to unhealthy lifestyle practices, which come with urbanization and economic progress. Fast-food chains have mushroomed in China, and coupled with the still high smoking rates, cases of high BP, heart diseases and stroke continue to increase.
Professor Wu exclaimed, “Wealth is not health!”
This is a grim reality of life. Sometimes, even the very rich realize this too late. In a deathbed essay credited to Steve Jobs, this sad lesson is highlighted.
“At this moment, lying on the sick bed and recalling my whole life, I realize that all the recognition and wealth that I took so much pride in, have paled and become meaningless in the face of impending death.
“… Now I know, when we have accumulated sufficient wealth to last our lifetime, we should pursue other matters that are unrelated to wealth … something that is more important: perhaps relationships, perhaps art, perhaps a dream from younger days.
“Nonstop pursuing of wealth will only turn a person into a twisted being, just like me.”