Gauri Healthy Heart Project – Pulwama | Managing High Blood Pressure: A Challenge for the Clinicians

In our Healthy Heart project in district Pulwama, we started with a symposium on High blood pressure (Hypertension). The meeting was organized by Dr Haseena Mir, the CMO and her team from Pulwama and all the doctors working in the subdistricts and blocks participated. It was a very interactive event including a lecture from me, which was chaired by her. The event was held in the General Nursing midwifery (GNM) hall of the district Hospital on 26th November.

Importance of High BP:

   

High Blood Pressure (Hypertension) is the most important cause of death world-wide. Contrary to popular belief it exceeds cigarette smoking, diabetes, high cholesterol, obesity and physical inactivity etc. One out of 5 young adults in India has high BP and the estimated number according to a recent Indian study there are an estimated 234 million adults with hypertension in India. More than 3.5 million persons may be suffering from hypertension in Kashmir and at least 2.2 lac persons in district Pulwama.  Unfortunately, only 25% in rural and 40% people in urban milieu are aware that they have high BP. Complications of untreated or under-treated hypertension lead to serious damage to the muscles of the heart because of more force needed to pump blood. It also leads to hardening of the arteries of the body including those supplying blood to heart, brain, kidneys and eyes. This can lead to heart attacks, brain strokes, blindness and kidney failure. In addition, it can lead to heart failure, impotence, irregularity of heart beat and even sudden death. It is very important for everybody to know his/her BP, because hypertension is very often asymptomatic (Silent Killer).

Diagnosis of High BP:

Measuring BP is easy. These days preference is given to well calibrated instruments made by a number of reliable companies. The digital instruments using an oscillometer method are the preferred ones over the dial type or manometric instruments. Mercury manometers which are still used in many places have been completely banned all over the world because of the toxicity of mercury. It has also been recognized that self-measured home recording is the best way to record the BP. It obviates the problem of white coat hypertension (high BP only in clinic and not at home) seen in about 25% of our population, in a very large “India Heart Study” The other finding from this study was that the evening BP in our population was higher than the morning recordings which was believed to be higher as a customary belief. These findings can have some bearing on the time of drug administration for treating high BP in our patients. 24 hours ambulatory BP monitoring is also a very useful way of finding the average BP before initiating treatment in persons with wide fluctuations or in those with difficult to control BP by office and home recordings.

Dr U Kaul with his team at Pulwama. Photo Credit: Team GHHP

Managing a patient with high BP:

Managing hypertension is a long-term affair for the physicians, often lifelong. All patients with hypertension need a full evaluation once the diagnosis is made. This evaluation includes at least measuring, blood sugar, serum lipid profile, kidney function tests and urine examination for proteins. An ECG and in individuals with BP more than 160/100 mms Hg an echocardiogram is recommended to see the effects on the heart. This helps to optimize the final medical treatment in order to prevent vascular events like heart attacks, stroke, chronic kidney disease and blindness.

Life style measures are a very important measure for BP reduction and if carried out meticulously can be as effective as 2 drugs and should always be an integral part of the holistic treatment. These basically consist of weight loss by 10 kgs ( in obese and overweight people ) which can result in up to 10-20  mms Hg reduction, reducing the salt intake to minimum can reduce BP by up to 5 mms Hg, eating plenty of  fruits and vegetables along with reduction of dairy products by up to 10 mms Hg, Regular exercise helps in reduction up to 5 mms Hg.

Drugs for treating high BP:

It should be remembered that patients who need drug therapy often need multiple drugs (at least 2). These are best prescribed in a single tablet combination for purposes of compliance and ease of administration. Those needing a third drug again should best be given a triple drug combination. The drugs are usually belonging to the group of renin angiotensin system blockers (Enalapril, Losartan, Telmisartan, etc), Calcium channel blockers (amlodipine, cilnidipine, benidipine etc), diuretics (chlorthiazide, chlorthalidone, indapamide). If the BP is not controlled with even 3 drugs it is called “Resistant Hypertension. These patients need addition of a fourth drug which is another agent working on the RAAS system, spironolactone or eplerenone. In cases where 4 drugs also are not enough addition of another drug is required, this can be individualized but is usually a beta blocker (Metoprolol, bisoprolol or nebivolol). There is a group of patients where even 5 drugs are not enough and is termed as “Refractory Hypertension”. Chronic kidney disease patients with abnormally high serum creatinine levels often belong to this category.

Before labelling a patient Resistant and Refractory hypertension it is always important to rule out non-adherence to medication, improper cuff size of the BP instrument, simultaneous and regular intake of pain killers or anti-depressants, excessive salt intake sometimes in the form of too much of pickles, chutneys and preserved foods and white coat hypertension. In elderly people blockages in the kidney arteries on both sides needs to be ruled out by appropriate investigations like a doppler study and confirmed by a CT angiogram. Non adherence of medication should be confirmed by asking a family member to keep a record of the medications consumed vs those prescribed and keeping a pill count. In case no other cause is found the patient needs a specialized attention to diagnose rarer causes.

If all these causes have been excluded then one needs to add specialized drugs like; alpha blockers (prazosin), centrally acting drugs like clonidine, methyldopa and direct vasodilators like hydralazine and Minoxidil. All these drugs are available in India but have several side effects that is why these are reserved for only selected cases.

Targets to Achieve: In general, it is now generally agreed that the target should be 130/80 or below if tolerated but not less than 120/80 in all persons below 65 years of age. These include subjects with diabetes, chronic kidney disease, patients with heart disease and strokes. In patients between 65 and 79 years and also those more than 80 years, the target is below 140/90 and if tolerated up to 130 mms Hg. The concept that elderly patients do not need a tight control is wrong. It is these patients who are most prone to strokes. Only care to be taken is to add drugs slowly and carefully, because some of them develop severe fall in BP when standing and can have a fall leading to injuries including hip fractures and head injuries.

Conclusion:

Managing High BP is a challenge for the doctors especially those working in districts, subdistricts and peripheral health centres. Before starting treatment, doctor needs to counsel them for the need of long-term treatment. Life style changes always need to be strongly emphasized. Drug treatment should always be a single tablet combination even if 3 drugs are needed. Home BP measurement with a calibrated instrument should always be strongly recommended. It also allows the BP recordings in other family members who often also have high BP. Adequate control to targets in our population is a burning need and is the most economical way of reducing the increasing burden of heart diseases and strokes and reducing hospitalizations.

Dr U Koul, a Cardiologist, is Founder Director Gauri Healthy Heart Project. He is recipient of Padma shri and Dr B C Roy Award.

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