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High blood pressure (BP) is the greatest single reversible cause of death and disability worldwide 1,2. Historically, a problem of higher income countries, over the last four decades, lower and middle-income countries have witnessed the largest increase in hypertension prevalence 1. The scientific evidence is undisputed – pharmacological lowering of BP significantly reduces cardiovascular events by 20–60% 3,4. However, despite the global availability of cheap, well tolerated and effective antihypertensive medications, half of those with hypertension remain unaware of their condition, and, of those who are aware, only half receive effective treatment 5. Whilst there are variations in the identification, treatment and control of high BP across the world, what is striking is that in every region, a large proportion of people with raised BP do not reach targets 5. The stark question is why is there not a public outcry for the failure to identify, treat and control hypertension – the consequences of which are placing a huge burden on global health services, global economy and, most importantly, people living with hypertension? Society seems happy to allow the food industry conglomerates (‘Big Food’) to fuel the BP and obesity epidemics via their relentless marketing of highly processed foods that are invariably high in both dietary salt and sugar. The low cost of such ‘foods’ also contributes to health inequities and hampers successful management of hypertension by healthcare providers. The association between salt and BP is undisputed 6. Although the WHO advises adults consume less than 5 g salt/day, global data estimates the average daily salt intake for adults is greater than 10 g, the majority of which comes from processed foods 7. Devolving responsibility for dietary salt reduction to the individual, who has no control over the ingredients in processed foods (note the salt content of some breakfast cereals is higher than seawater!) is absurd 8. We strongly support the view of the WHO and Action on Salt, that we must take a radical and systematic approach to reduce the salt content in processed food via co-ordinated government policies. The obesity pandemic is not only fuelling the rise in diabetes but also hypertension 9,10. This is particularly apparent in lower and middle-income countries where a ‘western diet’ promoted by ‘Big Food’ is responsible for the weight gain of the population and the increasing prevalence of obesity 1. Weight reduction is an effective method of BP lowering but is difficult to achieve and maintain 11. This is unsurprising given the biological basis to obesity and the ready availability of cheap, highly addictive, high-fat, high-sugar and high-salt processed foods 12. Clinical trials are currently in progress to evaluate the use of GLP-1 and SGLT2 inhibitors as adjuncts to antihypertensive therapy – but we question the ethics of relying on pharmaceuticals to counteract a problem largely driven by the food industry. In a misguided attempt to address these issues, National and International Hypertension Societies have produced countless guidelines on hypertension and its management 13–16. Guidelines started as a practical tool to support clinicians implement evidence-based medicine by providing clear rationales for treatment advice with a focus on implementation 17. Unfortunately, guideline development has evolved into a complex industry with convoluted systems of evidence grading and text of such verbosity that the result is both hard to read and implement 18,19. In our view, current guidelines do more for the H-index of the authors than improving the management of people living with high BP. We propose going back to basics and creating a guideline that supports clinicians improve outcomes for the vast majority of people living with high BP – and to kick start this process we offer the ‘4 S’ approach for successful blood pressure control (Fig. 1).FIGURE 1: The ‘4 S’ approach for successful blood pressure control. ABPM, ambulatory blood pressure monitoring; BIHS, British and Irish Hypertension Society; FBC, full blood count; HBPM, home blood pressure measurement; NICE, National Institute for Health and Care Excellence; TSH, thyroid-stimulating hormone; U&Es, urea and electrolytes.Salt and satiety: we recommend educating people about the hidden salt content of highly processed and preprepared foods such as bread, breakfast cereals, ‘ready meals’ and swapping domestic table salt for high potassium alternatives 20. We recommend supporting individuals to maintain a healthy weight by diet and appropriate exercise, acknowledging the biological basis to obesity and offering appropriate pharmacological and nonpharmacological therapies. Sensible drugs, sensible doses: we recommend the British and Irish Hypertension Society (BIHS-endorsed) four-step National Institute for Health and Care Excellence (NICE) hypertension treatment algorithm to achieve BP targets less than 130/80 mmHg in most people 21,22. Step 1 – initiate therapy with an ACE inhibitor/angiotensin II receptor blocker (A) or calcium channel blocker (C) – based on age and ethnicity. Step 2 – progress to combination therapy (A + C). Step 3 – add a thiazide-like diuretic (A + C + D) Step 4 – if BP remains above target, add a fourth-line agent 21,22. At each step, drugs and doses should be titrated every 4–6 weeks, wherever appropriate, to ensure BP targets are achieved within 6 months to minimize end-organ damage. We advise therapeutic agents are selected based on clinical efficacy supported by outcome trials demonstrating a reduction in major adverse cardiovascular events, long duration of action and a simple dosing schedule 23,24. Single-pill combinations have been shown to improve adherence and should be used wherever available 25. We recommend the following once-daily drugs: 1. A = Lisinopril 10–20 mg or Perindopril 4–8 mg 2. C = Amlodipine 2.5–10 mg 3. D = Chlorthalidone 25 mg or Indapamide SR 1.5 mg 4. Fourth line agent = Spironolactone 12.5–50 mg or Amiloride 10 mg 26–28 5. Alternative fourth line options = Bisoprolol 2.5–5 mg, Doxazosin XL 4–8 mg, Increase Chlorthalidone to 50 mg We strongly advise avoiding ramipril, felodipine, bendrofluazide, as these either lack outcome data on preventing cardiovascular events and/or are shorter acting than the alternatives in the same therapeutic class. pSeudo resistant hypertension: where BP remains above target, we recommend the following strategy: 1. Re-evaluate for white-coat hypertension, using ambulatory BP monitoring (ABPM) or repeat home blood pressure measurement (HBPM) 2. Objectively assess adherence using Direct Observed Therapy (DOT) and/or urine drug screen 3. Review concurrent medications, over-the-counter remedies and substances of abuse A study by Hayes et al. demonstrated that among 235 patients with apparent resistant hypertension, 25% were partially or totally noncompliant (evaluated by urinalysis) and 25% had normal ABPM 29. Nonadherence rates are consistent with observations from specialist hypertension clinics in Leicester 30 and Cambridge 31 that also indicate the number of prescribed antihypertensive medications is a strong predictor of adherence. Secondary hypertension: the prevalence of secondary hypertension in the adult hypertensive population is relatively low, with the notable exceptions being individuals with renal disease (50–90%) and hypertension in pregnancy (10%). Of the other secondary causes, hyperaldosteronism is probably the commonest – with an estimated prevalence of between 2 and 10% depending on the definitions used and clinical setting 32. We recommend a basic blood test including urea and electrolytes (U&Es), creatinine, calcium, phosphate, thyroid-stimulating hormone (TSH), full blood count (FBC) plus urine analysis and renal imaging. Wherever available, we also recommend checking plasma renin and aldosterone. These simple tests are sufficient to exclude most secondary causes of hypertension. For individuals in whom BP remains above target, despite taking at least three antihypertensive medications at maximum tolerated doses, with confirmed adherence and management of concurrent risk factors including dietary salt and weight management, referral to a hypertension specialist may be appropriate for further investigation 22. ACKNOWLEDGEMENTS Conflicts of interest I.B.W. has received research grants from AstraZeneca, GSK and scientific advisory board consultation fees for Viatris, Astra Zeneca and Roche. S.P. has no conflicts of interest to declare for this manuscript. P.S. has received renumeration for scientific advisory boards and lectures from Viatris.
Wilkinson et al. (Thu,) studied this question.