Compliance With Guidelines of Hypertension Management, and Associated Factors Among the Health Practitioners.

The consequences of uncontrolled hypertension such as stroke, myocardial infarction, retinal damage and others are significantly affecting individual and the community in large. The patients are suffering from compromised quality of life, permanent disability, and premature death in developing countries. The reason for the existence of the gap hasn't been clear yet. An institutional-based retrospective cross-sectional study designed from patient medical record data was used to assess compliance with the federal democratic and republic of Ethiopia ministry of health hypertension management guideline. Medical records of adult Patients treated for hypertension from March 2019 to March 2020 were reviewed. Systematic sampling technique from patients' medical records every 10th interval was taken to reach the total sample size. The collected data were checked for completeness, consistency, and accuracy before analysis. Data were coded, entered, and cleaned using Epi-data 7 and exported to SPSS version 25 for analysis. Overall compliance with the hypertension guideline was found to be poor; only 75 (19.5%) patients managed according to the guideline in these institutions. The majority of health practitioners complied with the pharmacological Antihypertensive treatment protocols for 238 (62.0%) patients, while for 146 (38.0%) of the patients the guideline was not followed. Combining the lifestyle modification recommendations and pharmacological antihypertensive treatment to assess compliance with the hypertension management guideline, only 75 (19.5%) patients managed as per the guideline, while 309 (80.5%) did not. Nearly more than two-thirds of the patients were not managed following the national hypertension guideline, and health practitioners are failed to recommend lifestyle modifications for most of the patients, as a result, the majority of the hypertensive patients are being exposed to complications and urgent intervention is demanded against the gap.

Change in blood pressure status defined by 2017 ACC/AHA hypertension guideline and risk of cardiovascular disease: results of over a decade of follow-up of the Iranian population.

Background: Hypertension (HTN) is known to be the leading cause of cardiovascular disease (CVD) and mortality. We aimed to assess the impact of changes in 3 years in different blood pressure (BP) categories on incident CVD. Methods: In this study, 3,685 Tehranians aged ≥30 years (42.2% men) free of prevalent CVD with BP level <140/90 mmHg and not on BP-lowering medications were enrolled. Participants were grouped according to baseline BP category using the 2017 ACC/AHA hypertension guideline definition: normal BP (<120/80 mmHg), elevated BP (120-129/<80), and stage 1 HTN (130-139 and/or 80-89). The hazard ratio of incident CVD by changes in the BP category was estimated after adjustment for traditional risk factors using Cox's proportional hazard model, with stable normotension as a reference. Results: During a median follow-up of 11.7 years, 346 CVD events (men = 208) occurred. Compared to the reference group, among participants with normal BP at baseline, only those with BP rising to stage 1 HTN [1.47 (0.99-2.16)], and among those with stage 1 HTN at baseline, regression to elevated BP [1.80 (1.11-2.91)], remaining at stage 1 [1.80 (1.29-2.52)], and progression to stage 2 HTN [1.81 (1.25-2.61)] had a higher risk for CVD; however, regression to normal BP attenuated this risk [1.36 (0.88-2.12)]. Conversion from elevated BP to any other categories had no significant association with CVD risk. Conclusions: Generally, prevalent stage 1 HTN (regardless of changing category) and incident stage 1 HTN were significantly associated with a higher risk of CVD; even regression to elevated BP did not attenuate the risk. Accordingly, these populations are potential candidates for antihypertensive management.

Hypertension Subtypes, Mortality Risk, and Differential Effects Between Two Hypertension Guidelines.

Aim: To examine which hypertension subtypes are primarily responsible for the difference in the hypertension prevalence and treatment recommendations, and to assess their mortality risk if 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline were adopted among Chinese adults. Methods: We used the nationally representative data of China Health and Retirement Longitudinal Study (CHARLS) to estimate the differences in the prevalence of isolated systolic hypertension (ISH), systolic diastolic hypertension (SDH) and isolated diastolic hypertension (IDH) between the 2017 ACC/AHA and the 2018 China Hypertension League (CHL) guidelines. We further assessed their mortality risk using follow-up data from the China Health and Nutrition Survey (CHNS) by the Cox model. Results: The increase from the 2017 ACC/AHA guideline on hypertension prevalence was mostly from SDH (8.64% by CHL to 25.59% by ACC/AHA), followed by IDH (2.42 to 6.93%). However, the difference was minuscule in the proportion of people recommended for antihypertensive treatment among people with IDH (2.42 to 3.34%) or ISH (12.00 to 12.73%). Among 22,184 participants with a median follow-up of 6.14 years from CHNS, attenuated but significant associations were observed between all-cause mortality and SDH (hazard ratio 1.56; 95% CI: 1.36,1.79) and ISH (1.29; 1.03,1.61) by ACC/AHA but null association for IDH (1.15; 0.98,1.35). Conclusion: Adoption of the 2017 ACC/AHA may be applicable to improve the unacceptable hypertension control rate among Chinese adults but with cautions for the drug therapy among millions of subjects with IDH.

Impact of 2017 ACC/AHA guideline on prevalence, awareness, treatment, control, and determinants of hypertension: a population-based cross-sectional study in southwest of Iran.

BACKGROUND: In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) provided a new guideline for hypertension prevention and management. We aimed to update the prevalence, awareness, control, and determinants of hypertension based on this guideline in Khuzestan province, southwest of Iran, and to estimate the number of people who are eligible for non-pharmacologic and pharmacologic intervention. METHODS: This population-based cross-sectional study was conducted in Khuzestan, a large province in the southwest of Iran. Comprehensive information about the potential relating factors of hypertension was collected, blood pressure was measured, and anthropometric measurements were obtained. Moreover, the dietary pattern was evaluated in 2830 individuals, using a qualitative food frequency questionnaire. RESULTS: Among 30,506 participants, 30,424 individuals aged 20-65 years were eligible for the study. In comparison with the previous guideline released by the Joint National Committee (JNC8), the prevalence of hypertension in Khuzestan dramatically increased from 15.81 to 42.85% after implementation of the ACC/AHA guideline, which was more dominant in the male population and the 45-54 age group. The sex and age adjustment of the hypertension prevalence was estimated to be 39.40%. The percentage of hypertension awareness, treatment, and control were 45.85%, 35.42%, and 59.63%, which dropped to 22.72%, 26.37%, and 28.94% after implementation of new guideline, respectively. CONCLUSIONS: In the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition were shifted into the hypertension category and the level of awareness, treatment, and control were dramatically decreased, which highlight a great need to expand the public health infrastructure for further managing the substantial increased burden on healthcare system. However, further studies with population over 65 years are required to estimate the eligibility for antihypertensive treatment in this province after implementation of new guideline.

Changes in the prevalence of measures associated with hypertension among Iranian adults according to classification by ACC/AHA guideline 2017.

BACKGROUND: Different definitions have been proposed to categorize hypertension. We aimed to investigate the difference in prevalence of measures associated with hypertension according to the American College of Cardiology/American Heart Association (ACC/AHA) criteria versus Joint National Committee 7 (JNC7) criteria. METHODS: We analyzed the data of 10,000 participants of Yazd Health Study (YaHS) aged 20-69 years. Blood pressure was measured three times with standard protocol defined by ACC/AHA. Prevalence of high blood pressure measure was compared in both definitions and absolute differences reported. RESULTS: The prevalence of high blood pressure in our measurement was 61.0% according to ACC/AHA, and 28.9% according to JNC 7. The prevalence of self-reported hypertension was 18.6%. Age and sex standardized prevalence rates of high blood pressure measure indicates a 2.4-fold increase in the prevalence rate (30.1% absolute difference) by the ACC/AHA guideline. While the prevalence increased in all age groups, the age group of 20-29 showed the highest relative increase by 3.6 times (10.6% vs. 38.1%). High blood pressure measure among people with diabetes increased from 45.8 to 75.3% with the ACC/AHA guideline. Of the people who had no past history of diagnosed hypertension (n = 7887), 55.1 and 22.7% had high blood pressure measure by ACC/AHA and JNC-7 guidelines, respectively. From JNC7 to ACC/AHA, the overall difference in unawareness about HTN increased by 32.4%. CONCLUSION: Prevalence of hypertension associated measures increased over two folds by using the ACC/AHA criteria compared to JNC 7. Also, change in the criteria, reduces awareness of the disease and increases uncontrolled hypertension respectively. More research is needed to determine if the new definitions can affect management of hypertension in societies. Considering local priorities and implication of cost effective may improve implementation of new definitions for hypertension in different countries.

Insight into blood pressure targets for universal coverage of hypertension services in Iran: the 2017 ACC/AHA versus JNC 8 hypertension guidelines.

BACKGROUND: We compared the prevalence, awareness, treatment, and control of hypertension in Iran based on two hypertension guidelines; the 2017 ACC/AHA -with an aggressive blood pressure target of 130/80 mmHg- and the commonly used JNC8 guideline cut-off of 140/90 mmHg. We shed light on the implications of the 2017 ACC/AHA for population subgroups and high-risk individuals who were eligible for non-pharmacologic and pharmacologic therapies. METHODS: Data was obtained from the Iran national STEPS 2016 study. Participants included 27,738 adults aged ≥25 years as a representative sample of Iranians. Regression models of survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension. RESULTS: The prevalence of hypertension based on JNC8 was 29.9% (95% CI: 29.2-30.6), which soared to 53.7% (52.9-54.4) based on the 2017 ACC/AHA. The percentage of awareness, treatment, and control were 59.2% (58.0-60.3), 80.2% (78.9-81.4), and 39.1% (37.4-40.7) based on JNC8, which dropped to 37.1% (36.2-38.0), 71.3% (69.9-72.7), and 19.6% (18.3-21.0), respectively, by applying the 2017 ACC/AHA. Based on the new guideline, adults aged 25-34 years had the largest increase in prevalence (from 7.3 to 30.7%). They also had the lowest awareness and treatment rate, contrary to the highest control rate (36.5%) between age groups. Compared with JNC8, based on the 2017 ACC/AHA, 24, 15, 17, and 11% more individuals with dyslipidaemia, high triglycerides, diabetes, and cardiovascular disease events, respectively, fell into the hypertensive category. Yet, based on the 2017 ACC/AHA, 68.2% of individuals falling into the hypertensive category were eligible for receiving pharmacologic therapy (versus 95.7% in JNC8). LDL cholesterol< 130 mg/dL, sufficient physical activity (Metabolic Equivalents≥600/week), and Body Mass Index were found to change blood pressure by - 3.56(- 4.38, - 2.74), - 2.04(- 2.58, - 1.50), and 0.48(0.42, 0.53) mmHg, respectively. CONCLUSIONS: Switching from JNC8 to 2017 ACC/AHA sharply increased the prevalence and drastically decreased the awareness, treatment, and control in Iran. Based on the 2017 ACC/AHA, more young adults and those with chronic comorbidities fell into the hypertensive category; these individuals might benefit from earlier interventions such as lifestyle modifications. The low control rate among individuals receiving treatment warrants a critical review of hypertension services.

Blood pressure and the new ACC/AHA hypertension guidelines.

The ACC/AHA hypertension guidelines cover virtually all aspects of the diagnosis, evaluation, monitoring, secondary causes as well as drug and non-drug treatment of hypertension. Substantial and appropriate emphasis has been given to the strategies necessary for accurate measurement of blood pressure in any setting where valid blood pressure measurements are desired. Most "errors" made during blood pressure measurement bias readings upwards resulting in over-diagnosis of hypertension and, amongst those already on drug therapy, underestimating the true magnitude of blood pressure lowering resulting in over-treatment. Hypertension is diagnosed when blood pressure is consistently ≥130 and/or ≥80 mm Hg. However, the majority of patients with hypertension between 130-139/80-89 mm Hg (stage 1 hypertension) do not qualify for immediate drug therapy. The guideline breaks new ground with some of its recommendations. Absolute cardiovascular risk is utilized, for the first time, to determine high-risk status when BP 130-139/80-89 mm Hg (Stage 1 hypertension) and high-risk patient characteristics/co-morbidities are absent including age 65 and older, diabetes, chronic kidney disease, known cardiovascular disease; high-risk individuals initiate drug therapy when BP ≥ 130/80 mm Hg. The exception amongst high-risk individuals is for secondary stroke prevention in drug naïve individuals as drug therapy is initiated when blood pressure ≥140/90 mm Hg. Non-high risk individuals will initiate drug therapy when BP is ≥140/90 mm Hg. Irrespective of blood pressure threshold for initiation of drug therapy, the target BP is minimally <130/80 mm Hg in most. However, target BP is <130 systolic amongst those 65 and older as the committee made no recommendation for a DBP target. Treatment should be initiated with two drugs having complementary mechanisms of action when blood pressure is >20/10 mm Hg above goal.

Gene and environmental interactions according to the components of lifestyle modifications in hypertension guidelines.

Risk factors for hypertension consist of lifestyle and genetic factors. Family history and twin studies have yielded heritability estimates of BP in the range of 34-67%. The most recent paper of BP GWAS has explained about 20% of the population variation of BP. An overestimation of heritability may have occurred in twin studies due to violations of shared environment assumptions, poor phenotyping practices in control cohorts, failure to account for epistasis, gene-gene and gene-environment interactions, and other non-genetic sources of phenotype modulation that are suspected to lead to underestimations of heritability in GWAS. The recommendations of hypertension guidelines in major countries consist of the following elements: weight reduction, a healthy diet, dietary sodium reduction, increasing physical activity, quitting smoking, and moderate alcohol consumption. The hypertension guidelines are mostly the same for each country or region, beyond race and culture. In this review, we summarize gene-environmental interactions associated with hypertension by describing lifestyle modifications according to the hypertension guidelines. In the era of precision medicine, clinicians who are responsible for hypertension management should consider the gene-environment interactions along with the appropriate lifestyle components toward the prevention and treatment of hypertension. We briefly reviewed the interaction of genetic and environmental factors along the constituent elements of hypertension guidelines, but a sufficient amount of evidence has not yet accumulated, and the results of genetic factors often differed in each study.

Increased Risk of Hypertension in Young Adults in Southwest China: Impact of the 2017 ACC/AHA High Blood Pressure Guideline.

PURPOSE OF REVIEW: To examine the impact of the new 2017 ACC/AHA hypertension guideline on the prevalence of hypertension, its constituent ratio, and their associated factors in southwest China. RECENT FINDINGS: A total of 14,220 permanent residents ≥ 18 years were enrolled in this survey. According to the 2017 ACC/AHA hypertension guideline, the hypertension prevalence was substantially increased (46.9% vs. 24.5%); consistent across different age and gender groups, while the hypertension awareness (23.8% vs. 45.6%); treatment (18.6% vs. 35.5%); control (2.3% vs. 11.2%); and control among treatment (9.6% vs. 24.0%) patients were decreased in southwest of China. In our cohort, 31.1% participants were newly diagnosed as hypertension. Young adults accounted considerable proportion in this newly diagnosed hypertension population. The proportion of young hypertensive individuals substantially increased, whereas those of the older hypertensive subjects decreased. Among the hypertensive subjects aged ≥ 65 years undergoing treatment, 90% of the elderly subjects were not eligible for hypertension control and 32.5% have systolic blood pressure control at 130-149 mmHg, and thus need to intensify antihypertensive treatment according to 2017 ACC/AHA hypertension guideline. Smoking, drinking, body fat percentage, and body mass index were considered the factors associated with hypertension according to the Chinese hypertension guideline but not in the 2017 ACC/AHA hypertension guideline. The adoption of the 2017 ACC/AHA hypertension guideline will substantially increase hypertension prevalence in southwest of China. The new definition of hypertension implies that more young adults will likely suffer from high cardiovascular risks, while additional one third of elder hypertensive subjects will likely need intensified antihypertension treatments.

Difference in evening home blood pressure between before dinner and at bedtime in Japanese elderly hypertensive patients.

The authors evaluated the differences between evening home blood pressure (HBP) readings taken before dinner and those taken at bedtime, which were documented in a European and a Japanese guideline, respectively. Forty-eight patients (mean age, 76.4 years) measured their evening HBP twice each day (two measurements both before dinner and at bedtime) for 14 days. The authors defined the at-bedtime (B) minus the before-dinner (D) systolic HBP as the B-D difference. The mean B-D difference was -8.7 mm Hg (P<.001). The depressor effect of bathing was significantly prolonged for 120 minutes. The B-D difference with alcohol consumption was significantly greater than that without alcohol. In the linear mixed model analysis, time after bathing ≤120 minutes and alcohol consumption were significantly associated with the B-D difference after adjustment with covariates. There was a marked difference between evening HBP values. When patients' evening HBP is measured according to the guidelines, their daily activities should be considered.

Chinese Hypertension Guidelines.

According to the 4th National Nutrition and Health Survey in 2002, the prevalence of hypertension in China was 18.8%. Although there are no recent updated nationwide data, it is believed that the prevalence of hypertension has increased substantially in the past decade up to more than 200 million hypertensive patients in the populous country of China. To fight against the growing risk of hypertension, three Chinese hypertension guidelines were compiled in the past two decades, in 1999, 2005, and 2011. The current guidance document for the management of hypertension was named '2010 Chinese hypertension guideline', but it was actually published in 2011. In this guideline, all five classes of antihypertensive drugs were recommended as possible initial and maintenance therapy. The goal of treatment was a systolic/diastolic blood pressure below 140/90 mm Hg in general, 130/80 mm Hg in various groups of high-risk patients, and 150/90 mm Hg in the elderly (≥65 years). With the recent publication of several national and international hypertension guidelines, the Chinese guideline is now under discussion for updating.