Revisiting Hypertension in Rural Areas: A New Approach Is Required

In this issue of the American Journal of Hypertension, Castro-Dominguez et al. reported an interesting work about the obstacles to hypertension control in rural communities in the Dominican Republic. In this study, hypertension prevalence, awareness, treatment, and control (<140/90 mmHg) in rural areas of Dominican Republic were investigated. Of note, nearly 60% of subjects had hypertension. Of concern, less than two-thirds of them were aware about their condition, 60% were receiving antihypertensive drugs, and only 35% were adequately controlled.1 This work is important, as it analyzes a specific population that has not been well characterized in previous studies. A recent cross-sectional study that determined hypertension prevalence, awareness, treatment, and control (<140/90 mmHg) of 33,276 individuals from urban and rural communities in Latin America (Argentina, Brazil, Chile, Colombia, Peru, and Uruguay) showed that overall, prevalence of hypertension was 44%, but with great variability between countries (from 18% in Peru to 53% in Brazil). Among hypertensive patients, nearly 60% were aware about the hypertension diagnosis, and around half of hypertensives were receiving treatment. Remarkably, the prevalence of hypertension was higher in urban (45%) than rural (42%) communities. In addition, blood pressure control rates were poorly controlled in all countries, particularly in rural areas (40% in urban vs. 32% in rural communities).2 Another study that analyzed a total of 30 peer-reviewed publications about the prevalence of hypertension in rural populations from Ibero-America and the Caribbean reported that the prevalence of hypertension was around 33%, awareness 54%, treatment 57%, and hypertension control rates 14%.3 PURE (Prospective Urban Rural Epidemiology) was a cross-sectional study performed in 628 communities from 3 high-income countries, 10 upper-middle-income and low-middle-income countries, and 4 low-income countries. Overall, the prevalence of hypertension was 41% and only 47% of patients were aware of the diagnosis and one-third achieved blood pressure recommended targets. The percentages of awareness and treatment were lower in low-income countries and awareness, treatment, and control of hypertension were higher in urban communities compared with rural ones in upper-middle-income and low-middle-income countries.4 In summary, hypertension is a very common condition worldwide, regardless urban or rural settings or countries’ incomes. However, the impact of hypertension on cardiovascular outcomes could be different, as blood pressure control rates seem lower in rural areas, as well as in moderate- and low-income countries. As stated by Castro-Dominguez et al., this could be related to the lack of insurance or health care visits in many patients that may occur more frequently in these countries and this translates into an underdiagnosis of hypertension, and among hypertensives, into a lower use of antihypertensive medication.1 These urban–rural differences regarding access to health care have also been described by other authors, leading to an increased risk of adverse outcomes.5 Hypertension is very common in Latin America and the Caribbean, as well as hypertension-related complications.2,3,6–8 Barriers to adequate hypertension care in these countries include lack of health insurance in the previous year, costs of medication, and also access to physicians and medications.9 As a result, in order to improve blood pressure control rates in this population, it is mandatory to increase public health interventions that facilitate the access to health care system, and also to affordable medications, particularly among most vulnerable patients, as well as non-office-based care models (i.e. pharmacists) that make therapeutic decisions independent of primary care clinic visits.1,9,10 This would translate into a better hypertension control, and likely to a reduction of hypertension-related outcomes and costs. Another important issue that was assessed in the study of Castro-Dominguez et al. was the role of clinical inertia on hypertension control. In this study, around two-thirds of patients with uncontrolled blood pressure, no therapeutic action was taken.1 Clinical inertia is a worldwide problem, regardless urban or rural environments that range from 50% to 90% of uncontrolled hypertensive patients.1,11–14 Different factors related to clinical inertia have been reported, including elderly, frailty, mild hypertension, blood pressure values close to the recommended target, multiple guidelines, waiting until next visit, or lack of time during office visit.13–16 To reduce the negative impact of clinical inertia on blood pressure control, not only more educational medical programs are mandatory in both urban and rural areas, but also simplification of treatment through the use of fixed-dose combinations. This is very relevant, as decreasing clinical inertia and improving medication adherence have been related to better blood pressure control and lower rates of hypertension-related outcomes and costs.14,17,18 In summary, the work of Castro-Dominguez et al. provides important information about hypertension and its management in rural areas that may be very helpful to understand the therapeutic approach of hypertension in this clinical setting, and consequently, it offers some key points about how physicians should act to improve blood pressure control. The authors declared no conflict of interest.