Management Practices in Indian Patients with Uncontrolled Hypertension.

INTRODUCTION: Hypertension (HTN), being a major risk factor for cardiovascular diseases (CVDs), is an important issue of medical and public health. High blood pressure (BP) is ranked as the third most important risk factor for attributable burden of disease in south Asia (2010). Hypertension (HTN) exerts a substantial public health burden on cardiovascular health status and healthcare systems in India. Uncontrolled hypertension among adults with hypertension is associated with increased mortality. An inadequate data is available in India on uncontrolled hypertension.

OBJECTIVES: The present study was planned to evaluate the patient profile, co-morbidities, management in uncontrolled hypertensive patients and also to determine the number of patients with resistant hypertension across India.

METHODS: A total of 4725 uncontrolled hypertensive patients who were on anti-hypertensive medications were evaluated in this cross-sectional and observational study. The observed patterns were recorded with respect to the prevalence of uncontrolled hypertension and evaluate the socio-demographic, medical history, anthropometric variables and treatment preferences in Indian patients with uncontrolled hypertension.

RESULTS: Majority of the patients with uncontrolled hypertension were males (71.4%) and aged 46-65 years. Most of the study population were pre-obese (males: 35.7%; females: 27.4%). Higher proportion of patients with uncontrolled hypertension were residents of Maharashtra (25.6%) and Gujarat (11.6%). Antihypertensive monotherapy was used by 45.4% and 54.6% patients used combination therapy (≥ 2 categories of anti-hypertensive medications). Angiotensin receptor blockers (ARBs) were the most preferred agent as monotherapy (70.6%) and also the most common component of dual and triple combination anti-hypertensive agent. 19.5% (922/4725) patients had resistant hypertension and 80% of the patients were aged 46-65 years. Higher proportion of patients were males (67.2%; 620/922) and higher proportion of patients were to residents of Andhra Pradesh (21.4% patients) and Maharashtra (19.3% patients). All 922 resistant hypertensive patients were on ≥ 3 anti-hypertensive medications and received ARB + CCB + Diuretics as the most preferred anti-hypertensive combination therapy. Diabetes and dyslipidaemia were the major comorbidities reported in patients with uncontrolled and resistant hypertension. Lipid lowering agents followed by oral hypoglycaemic agents and antiplatelet medications were the common concomitant medications used. Various factor responsible for not achieving the desired blood pressure goals may be the physician's lack of awareness about recent hypertensive treatment guidelines that might contribute to patient's poor adherence due to not explaining adequately the benefit and risks of a medication, not giving consideration to the patient's life style, the cost of medication, and inadequate dose titration.

CONCLUSIONS: Uncontrolled hypertension is a major problem in India. It is prudent to focus on multiple risk factors while treating hypertension. A combination therapy with multiple blood pressure lowering drugs are important and concerns should be identified while selecting the appropriate dosage of combinations of anti-hypertensive therapy and adherence to the therapy. The preferred choices for mono, dual combination and triple combination anti-hypertensive regimens are ARBs; ARB + CCB; ARB + CCB + Diuretics, respectively. In this study, most of the patients were on monotherapy; however a rationale combination therapy or dose adjustment is required for the effective management of hypertension. The protective measures to be taken to control hypertension includes reduction of physicians inertia, diet and physical activity, regular patient follow-up with BP measurements and counselling, and the improvement in patient adherence.