The sorry state of Ireland’s patients with high blood pressure
A million people here have hypertension; almost 50% are unaware
It is now recommended that diagnosis and management of hypertension should be based on measurement of 24-hour ambulatory blood pressure rather than relying on so-called office blood pressure measurement. Photograph: iStock
Elevated blood pressure (known medically as hypertension) is now recognised as a major epidemic with nearly a billion people worldwide having high blood pressure that is accountable for about 17 million deaths a year, mainly from heart disease and stroke.
A study recently published by the Lancet issues a startling warning to the million people in this country with high blood pressure. In this massive study, data from more than 500,000 patients in the 12 high-income countries of Australia, Canada, Finland, Germany, Ireland, Italy, Japan, New Zealand, South Korea, Spain, the UK, and the US, were compared. Canada, Germany, South Korea and the US have the highest rates of awareness, treatment, and control of high blood pressure, whereas Ireland, Finland, Japan and Spain have the lowest.
In Canada and Germany, the number of people achieving blood pressure control (bringing elevated blood pressure down to normal levels) was up to four times greater than for patients in Ireland. In assessing these statistics, we should note that even in the best performing countries, the rates achieved fell short of what is recommended in international guidelines.
Moreover, the levels of blood pressure in the study were considerably higher than those being presently recommended which, if used, would make the comparison even worse for Ireland.
Most of the 10,000 strokes occurring each year at an annual cost of some €10 million could be prevented by a reduction of elevated blood pressure
These damning statistics should not come as a great surprise. We know from recent surveys that Ireland is faring badly compared with other countries. Of the million people with hypertension in Ireland, most of whom are over 60 years of age, nearly 50 per cent are unaware that they have the condition, and some 60 per cent are not on medication. Most worrying is the fact that of those on drug treatment, barely half have their blood pressure reduced to normal levels. We also know that most of the 10,000 strokes occurring each year at an annual cost of some €10 million could be prevented by a reduction of elevated blood pressure.
Bad as the situation may be, the alarming revelation from the Lancet study is that Ireland’s management of hypertension is shown to be all the more deplorable by being put into perspective by comparison with other countries. We can now clearly see that hypertension, an illness affecting more than 60 per cent of the elderly population, can, in fact, be managed much better by most other affluent countries, whereas previously, we were able to excuse our ineptitude by assuming that things were not much different elsewhere.
These revelations should now force us to consider how we can emulate the achievements of other countries to avert the consequence of uncontrolled hypertension which is the major cause of stroke, heart attack, kidney failure and a host of other cardiovascular diseases that now include cognitive impairment and dementia, all of which have grave societal and personal consequences.
So, what are the lessons to be learned?
Firstly, we do not have the concentrated awareness strategies of other countries, such as Canada, the US, Germany and South Korea. The Canadian Hypertension Education Program, for example, has demonstrated that it is feasible to achieve a high level of hypertension control by improving awareness of the illness, not only among the public, but also among healthcare providers, be they doctors, nurses or pharmacists.
There is at present a laissez-faire attitude to hypertension that leads to patients failing to appreciate the serious consequences of hypertension, most notably heart attack and stroke, and to doctors failing to achieve blood pressure control as soon as possible. The complications of high blood pressure, which can be prevented only if blood pressure control is achieved, are, therefore, mismanaged.
Secondly, patients with high blood pressure who are anxious to have access to further assessment, are faced with having to follow a circuitous, and often expensive, pathway to a general practitioner. It is now recommended that the diagnosis and management of hypertension should be based on measurement of 24-hour ambulatory blood pressure rather than relying on so-called office blood pressure measurement, which is often very misleading.
This measurement, and other cardiovascular tests, can be provided by pharmacists and there is growing evidence that involving pharmacists greatly improves blood pressure management. Indeed, such services, which are now being provided increasingly by pharmacists in Ireland, should be encouraged, to make it easier for patients to assess their cardiovascular status.
Single-pill combinations are now recommended by the World Health Organisation but their use in Ireland is the exception rather than the rule
Thirdly, suboptimal control of blood pressure is being achieved partly because many people with hypertension, even those with quite severe hypertension, are not being diagnosed and treated with adequate drugs to achieve control. Blood pressure lowering drugs have been shown unequivocally to reduce blood pressure and the risk of associated diseases. Current practice advocates the use of two or more drugs in low dosage rather than a single drug in high dose, in order to minimise any adverse effects and because drugs in combination tend to potentiate each other.
There are now single-pill combination preparations which allow for differing strengths of drugs to be administered in one tablet, thereby not only improving blood pressure control but also a patient’s adherence to treatment by simply having to take one tablet. These single-pill combinations are now recommended by the World Health Organisation but their use in Ireland is the exception rather than the rule.
Fourthly, the Lancet authors emphasise that in addition to incorporating the above strategies in any national effort to improve the management of hypertension, new approaches are urgently needed by using innovative methodologies to facilitate patients to improve patient participation in the management of the illness.
In this context it is pertinent to quote another editorial comment, which remarks on the inevitability of having to move from traditional forms of clinical practice: “From time immemorial, an invariable feature of doctor-patient interaction has been that it takes place in person. But the status quo is changing. A large portion of patient care might eventually be delivered via telemedicine by virtualists, physicians who treat patients they may never meet.”
If, by using online methodologies, patients with hypertension can be provided, firstly, with reliable expert information online, awareness will be improved; if, furthermore, they can be facilitated in having cardiovascular assessments performed in pharmacies, the adequacy, or otherwise, of blood pressure control can be assessed online and, finally, patients can be advised on the most appropriate treatment based on the information they provide.
Although many will deplore the replacement of the traditional personal interaction between patient and doctor, the reality is that without utilising such innovative strategies, the disturbing status of hypertensive patients in Ireland, as illustrated by the Lancet report, will only deteriorate with increasing incapacity for our ageing population.
Eoin O’Brien is professor of molecular pharmacology, Conway Institute, University College Dublin.