Addressing Failures in Achieving Hypertension Control in Low- and Middle-Income Settings through Simplified Treatment Algorithms

Improving Implementation of NCD Care in Low- and Middle-Income Countries: The Case of Fixed Dose Combinations for Hypertension in Kenya

Health systems in low- and middle-income countries face the challenge of addressing the growing burden of non-communicable diseases (NCDs) with scarce resources to do so. There are cost-effective interventions that can improve management of the most common NCDs, but many remain poorly implemented. One example is fixed dose combinations (FDCs) of medications for hypertension. Included in WHO's Essential Medicines List, FDCs combine two or more blood pressure lowering agents into one pill and can reduce burden on patients and the health system. However, implementation of FDCs globally is poor. We aimed to identify health systems factors affecting implementation of evidence-based interventions for NCDs, and opportunities to address these, using the case study of FDCs in Kenya. We conducted semi-structured interviews with 39 policy-makers and healthcare workers involved in hypertension treatment policy and identified through snowball sampling. Interview data were analyzed thematically, using the Access Framework to categorize themes. Our interviews identified factors operating at the global, national, county, and provider levels. These include lack of global implementation guidance, context specific cost-effectiveness data, or prioritization by procurement agencies and clinical guidelines; perceived high cost; poor data for demand forecasting; insufficient budget for procurement of NCD medications; absence of prescriber training and awareness of clinical guidelines; and habitual prescribing behavior and understaffing limiting capacity for change. We propose specific strategies to address these. The findings of this work can inform efforts to improve implementation of other evidence-based interventions for NCDs in low-income settings.

HEARTS Pharmacy: A framework for integrating pharmacists in hypertension and cardiovascular disease risk management in primary care

HEARTS Pharmacy, a project within the HEARTS in the Americas Initiative, provides a framework to integrate pharmacists into primary health care. Pharmacists are highly respected in health care but face challenges, such as limited scope of practice, regulatory barriers, and insufficient recognition, compounded by social norms that hinder their full potential. This paper presents compelling evidence that pharmacist-led interventions improve blood pressure control, lower cardiovascular risk, and reduce health care costs. It underscores the role of national pharmacy systems in ensuring access to high-quality medications. HEARTS Pharmacy emphasizes the role pharmacists play in team-based care, highlighting their expertise in medication management, patient education, and adherence. This paper advocates policy changes that empower pharmacists with greater responsibility, enabling them to play an active role in patient care. It also recommends actions to fully integrate pharmacists into care teams, positioning them as key players in hypertension control and cardio-vascular disease risk management within primary health care.

Stroke Outcomes in a Population-Focused Urban Hypertension Program in Brazil and Senegal

BACKGROUND

Stroke is one of the major causes of death worldwide, mainly in low- and middle-income countries. The implementation of multifaceted strategies aiming at blood pressure control may change the global burden of stroke.

METHODS AND RESULTS

We evaluated the impact of a multisector urban cardiovascular health initiative (CARDIO4Cities) on stroke outcomes in Dakar, Senegal, and São Paulo, Brazil. Data covered preintervention, intervention, and follow-up periods with ongoing intervention from 2016 to 2021. An interrupted time series analysis and a segmented regression approach were used to evaluate temporal trends. The relative risk of stroke hospitalization was analyzed with a generalized linear model. In São Paulo, data could also be compared between intervention and control districts. A total of 3445 stroke hospitalizations were analyzed in Dakar and 4491 in São Paulo. In both cities, age-standardized stroke hospitalization rates (Dakar: -26%; São Paulo: -54% on average across 2 districts) and the risk of death from stroke declined over the intervention period. In São Paulo, the baseline risk of stroke hospitalization was comparable across the city. In the follow-up period, the risk was 24.5% lower in the intervention districts compared with the rest of the city (P<0.05). The COVID-19 situation did not change this dynamic.

CONCLUSION

The implementation of the multisectoral CARDIO4Cities initiative correlated with positive trends in stroke outcomes. Interventions to reduce cardiovascular risk and improve hypertension management at population level appear to rapidly translate into reduced stroke-related hospitalizations and mortality.

Acceptability of fixed-dose combination treatments for hypertension in Kenya: A qualitative study using the Theoretical Framework of Acceptability

Fixed-dose combinations (FDCs) - 2-3 anti-hypertensive medications in a single pill - have the potential to improve hypertension treatment and outcomes. Yet, they are not widely implemented. Factors undermining implementation remain unknown, particularly in sub-Saharan Africa, where hypertension is a major cause of disease burden and is poorly controlled. This study explored the acceptability of FDCs among patients, caregivers, and healthcare workers. We conducted semi-structured in-depth interviews with 58 participants from four purposively selected health facilities in Kiambu county, Kenya. Data were analyzed using an iterative thematic analysis approach, guided by the Theoretical Framework of Acceptability. Our findings indicate that FDCs are potentially acceptable to all participant groups. Acceptability is supported by the perception of FDCs as a means of reducing treatment burden (for patients and healthcare workers) and improving treatment adherence, and by patients' deferral to and trust in healthcare workers. However, acceptability among healthcare workers may be undermined by variable levels of knowledge about FDCs, concerns about FDCs as an "inflexible" treatment that does not allow dose titration or identifying causes of side effects, and concerns about inconsistent availability and affordability of FDCs in Kenya. To enhance acceptability and implementation of FDCs for hypertension treatment in Kenya, it is crucial to strengthen the capacity of all healthcare worker cadres to appropriately prescribe, inform patients about, and support adherence to FDCs. These efforts must align with broader initiatives to address upstream health system factors such as poor availability and affordability.

Cardiovascular disease in the Americas: optimizing primary and secondary prevention of cardiovascular disease series: cardiovascular disease in the Americas

While, many interventions can prevent cardiovascular disease (CVD), and its resulting morbidity or mortality, these are used sub-optimally in most countries. Therefore, health systems need to develop new approaches to ensure that proven CVD therapies are delivered widely. In this review, we describe five impactful implementation strategies which include: (1) Task shifting, (2) Use of mobile-Health (mHealth) support and virtual access to care, (3) simplified diagnostic and management algorithms for the prevention of CVD, (4) improving the use of combinations of medicines (i.e., polypill), and (5) patient engagement and role of patient-nominated peer support (i.e., treatment supporters). Adapting and tailoring these strategies to the local context in different settings in various countries in the Americas and the Caribbean can reduce the morbidity and mortality of CVD substantially.

Effectiveness and Safety of Using Standardized Treatment Protocols for Hypertension Compared to Usual Care: A Meta-Analysis of Randomized Clinical Trials

Large gaps persist in the diagnosis, awareness, treatment, and control of hypertension globally. Standardized treatment protocols (STPs) have been widely proposed to guide hypertension treatment, particularly in primary healthcare settings. However, there has been no review that quantifies the effects of hypertension STPs on blood pressure (BP) reduction and control. We conducted a systematic review of randomized clinical trials (RCTs) among adults with hypertension, comparing hypertension STPs (intervention) with usual care (comparator) for effects on BP. Relevant RCTs were identified by searching multiple electronic databases. Random-effects meta-analyses were conducted to evaluate between-group differences in systolic BP reduction (primary outcome), diastolic BP reduction, BP control, and adverse events (AEs). Sixteen RCTs involving 59,945 participants (baseline mean BP: 149/91 mmHg) were included. Reductions in systolic and diastolic BP with STPs compared to usual care were 6.7 (95% CI 3.7-9.8) mmHg and 2.6 (1.2-4.1) mmHg, respectively (p < 0.001 for both). BP control achieved was 57% in the STP group compared to 24% in the usual care group (p < 0.001). The overall incidence of any AEs was 14.5% versus 13.5% (RR 1.27 [0.88-1.82]) with STPs and usual care, respectively. In summary, interventions involving hypertension STPs significantly reduce systolic and diastolic BP and improve BP control compared to usual care. STPs can, therefore, be an efficient strategy to implement evidence-based treatments and upscale treatment coverage, given the large untreated and uncontrolled hypertension burdens globally.

Standardized treatment protocols for hypertension: global availability, characteristics, and alignment with the hypertension guideline recommendations

BACKGROUND

Hypertension control is suboptimal globally. Implementing evidence-based, simple, standardized treatment protocols (STPs) has been instrumental in effectively and efficiently improving treatment and control of hypertension. We aimed to identify, characterize, and critically appraise hypertension STPs.

METHODS

We defined STP as a series of steps for the pharmacological treatment of primary hypertension, with information on target population, BP threshold for treatment initiation, target BP, specific drugs/classes/doses, and follow-up frequency. STPs for adult patients were identified from the websites of relevant health organizations, Google search, and through expert consultations (until July 2023). STPs for secondary, gestational, or malignant hypertension or those that were templates/samples were excluded. Included STPs were critically appraised using HEARTS in the Americas Checklist for hypertension management in primary care and compared with the 2021 WHO hypertension management guideline recommendations.

RESULTS

Fifty STPs were identified. All STPs had a stepwise treatment approach, involved guideline-recommended first-line drugs, and 98% consisted of at least four steps. Majority (54%) recommended monotherapy with calcium channel blockers as first-line treatment. Only 44% STPs recommended treatment initiation with combination therapy, and 16% recommended single-pill combinations. Most (62%) had dose-intensification as the second step. Most (74%) STPs did not provide complete dosing information. Only one STP mentioned a target time for achieving BP control. On average, STPs scored a performance of 68% on the HEARTS Checklist.

CONCLUSION

Several STPs are available globally; however, most of them have enormous scope for improvement through interventions aimed at alignment with the latest evidence-based guidelines and multistakeholder engagement.

HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control

PURPOSE OF REVIEW

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

RECENT FINDINGS

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

[HEARTS in the Americas: targeting health system change to improve population hypertension controlHEARTS nas Américas: impulsionar mudanças no sistema de saúde para melhorar o controle da hipertensão arterial na população]

Purpose of review

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

Recent findings

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation.

Summary

Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

Real-World Prescribing Patterns for Hypertensive Children in China from 2018 to 2021: A Cross-Sectional Multicenter Study

Background

Pediatric hypertension become an early marker of cardiovascular diseases, but their antihypertensive drug use patterns are rarely known.

Purpose

To investigate the epidemiological characteristics of pediatric hypertension and the use of antihypertensive drugs in the real world in China.

Methods

In this study, the demographic, diagnosis, and medication prescription data including the antihypertensive drug types and comorbidities, were analyzed. The antihypertensive drugs use were evaluated according to the Chinese guidelines for hypertension.

Results

1301 prescriptions (number of visits) containing 1880 antihypertensive medical orders were collected. The average number of antihypertensive drugs per prescription was 1.45 (±0.75). The patients aged 16 to 18 (70.18%) accounted for the highest proportion. Kidney diseases (33.28%) were the most common comorbidities. Calcium channel blocker (CCB), angiotensin II receptor blocker (ARB), and β receptor blocker (BB) were the most used antihypertensive drugs. The most frequent monotherapy was CCB, while that of two and three drugs combination were ARB+CCB and ARB+BB+CCB, respectively. Metoprolol (11.44%), nifedipine (10.64%), amlodipine (10.59%), valsartan (6.12%) were the most commonly used antihypertensive drugs. The utilization rate of fixed compound preparations was 7.34%. However, the percentage of recommended antihypertensive drugs was just 14.20%, while the recommended drug combination was 84.93% according to the guidelines.

Conclusion

For the first time ever we reported the antihypertensive prescription analysis in children in a large area of China. Our data provided new insights into the epidemiological characteristics and drug use in hypertensive children. We found that the guidelines for medication management in hypertensive children were not routinely followed. The wide use of antihypertensive drugs in children and those with weak clinical evidence raised concerns regarding its rational use. The findings could lead to more effective management of hypertension in children.

Most Recent Trials and Advances in Hypertension

Hypertension is one of the most prevalent cardiovascular risk factors and blood pressure control remains a clinical challenge, especially for patients with established cardiovascular disease. Late-breaking clinical trials and other evidence in hypertension have evolved to assess the most accurate ways to measure blood pressure, the use of combination therapies, considerations in special populations and evaluation of new techniques. Recent evidence supports the superiority of ambulatory or 24-hour blood pressure measurements, rather than office blood pressure measurements, for the assessment of cardiovascular risk. The use of fixed-dose combinations and polypills has been demonstrated to be valid and to provide clinical benefits beyond blood pressure control. There have also been advances in new approaches such as telemedicine, devices and the use of algorithms. Clinical trials have provided valuable data on blood pressure control in primary prevention, during pregnancy and in the elderly. The role of renal denervation remains unsolved but innovative techniques using ultrasound or alcohol injections are being explored. Current evidence and results of latest trials are summarised in this review.

[HEARTS in the Americas: innovations for improving hypertension and cardiovascular disease risk management in primary careHEARTS nas Américas: inovações para melhorar a gestão do risco de hipertensão e de doenças cardiovasculares na atenção primária]

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.

HEARTS in the Americas: innovations for improving hypertension and cardiovascular disease risk management in primary care

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.