to

HYPERTENSION IN INDIA

Dr. A. Muruganathan Dr. M. Chenniappan

President - API Trichy
Medical Writer
 On the Occasion of
World Hypertension Day...

An API Initiative to upgrade knowledge of Practising

physicians throughout India
Why ?
 Educate
Empower
Easy learning
Enjoyable learning
Evaluate ownself
9912064435
 The theme for World Hypertension Day 2013 is Healthy
Heart Beat - Healthy Blood Pressure.
Considering the fact that atrial fibrillation arrhythmias is
very common in people with hypertension, especially
among older patients, the WHL executive board felt that it
is important to improve the public awareness about atrial
fibrillation arrhythmias. In order to make it easier for the
public to understand they have used the simple
terminology Heart Beat.
 The objectives of the World Hypertension League are to
promote the detection, control and prevention of arterial
hypertension in populations.
The World Hypertension League is a federation of leagues,
societies, and other national bodies devoted to this goal.
Bringing together and stimulating organizations committed
to the control of hypertension is the goal of the WHL.
The WHL is a division of the International Society of
Hypertension (ISH), and is in official relations with the World
Health Organization (WHO).
Benefit of Interventions Over 5 Years
Lowering systolic BP 4 mm Hg:
-12.5 cardiovascular events / 200 patients
Lowering LDL cholesterol 1 mmol/L
-8.2 cardiovascular events / 200 patients
Lowering HbA1c 0.9 %
-2.9 cardiovascular events / 200 patients
Prevalence1
Nearly 1 billion adults (more than a quarter of the worlds
population) had hypertension in 2000, and this is predicted
to increase to 1.56 billion by 2025.
The prevalence of hypertension varies considerably from
one region of India to another.
In India, 23.10% men and 22.60% women over 25 years old
suffer from hypertension, says the World Health
Organizations global health statistics 2012 released in May,
2012.

1. Indian J Med Res 128, December 2008, pp 688-690

Prevalence
Recent (2012) studies show that for every known person
with hypertension in India, there may possibly be 2 persons
with either undiagnosed hypertension or prehypertension.
With over 139 million patients, India accounts for 15% of
worlds uncontrolled hypertension patients.
Prevalence
In terms of attributable deaths, the leading behavioral and
physiological risk factors globally are raised blood pressure
(to which 13% of global deaths are attributed), followed by
tobacco use (9%), raised blood glucose (6%), physical
inactivity (6%) and being overweight or obese (5%).
It has been estimated that raised blood pressure causes 51%
of stroke deaths and 45% of coronary heart disease deaths.
 Global Mortality 2000: Impact of
Hypertension and Other Health Risk Factors

High mortality, developing region

Lower mortality, developing region
Developed region

0 1000 2000 3000 4000 5000 6000 7000 8000

Attributable Mortality
(In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:1347-1360.
Prevalence
Only 1 in 5 hypertensive women were on treatment and less
than 4% are controlled.
Majority of hypertensive still remain undetected & the
control of hypertension is also inadequate.
But, despite all this, the good news is that the prevalence of
hypertension in India is low as compared to world figures
and India fares better than other countries in the South-East
Asia Region (SEAR).
SEARs average is
- 25.40% in men & 24.20 in women.
 Among the High Blood Pressure patients only one third are
aware of the disease.
Out of this only one third come for treatment.
Out of this only one third of patients are under control.
An Analysis of NHANES III
Blood Pressure Data Summary:
Hypertensives fall into one of two categories:
1. A smaller (26%), younger (age < 50 years), predominantly
male (63%) with diastolic hypertension out of proportion to
systolic hypertension (primarily IDH and SDH)
2. A larger (74%), older (age 50 years), predominantly female
(58%) with systolic hypertension out of proportion to
diastolic hypertension (primarily ISH).

Franklin et al. Hypertension 2001;37: 869-874

Pre-hypertension
Pre-hypertension is defined as a systolic blood pressure reading
between 120 and 139 and a diastolic blood pressure of 80 to 89.
Nearly 50 % people have Pre Hypertension, accordingly to one
study, 50 % of people above 50 years have high blood pressure.
The category of pre-hypertension, was introduced to emphasize
that persons whose blood pressure is >120/80 mm Hg are likely
to progress to definite hypertension.
It was also hoped that doctors will encourage persons with pre-
hypertension to begin lifestyle modifications to prevent its
progression to hypertension.
 Members of the Association of Physicians of India (API) are
planning to conduct screening camps and patient education
regarding hypertension, complications and management with the
help of IMA throughout the country.
API is also interested to conduct updates for practicing
physicians regarding the newer methods and updates about
hypertension throughout the country directly and through
web.
 The Medical content of all 3 Modules has been written by
Dr.M.Chenniappan (Trichy)
The Panelist representing respective Regions and Key Members
of API will review & give their suggestions on the Modules before
it is uploaded in the www.apiindia.org site.
Sessions on Modules 2 & 3 will be facilitated by respective
Panelist/KOLs in respective Bimonthly period
A book on Diabetic Hypertension will be released with the input
& support of API Key Members & Panelists and will be presented
to registered Drs for E-Hypertension Academy
 MODULE-1
Basics, Diagnosis and
Lifestyle Modification
1: INTRODUCTION AND BASICS
Introduction to hypertension e academics
Epidemiology of hypertension in India Incidence,
Awareness , Control
Etiopathogenesis of hypertension
Classification
2: DIAGNOSIS OF HYPERTENSION
Clinical examination in hypertension
Measurement of blood pressure
Ambulatory BP monitoring
Laboratory investigation in hypertension
Imaging in hypertension
3: NONPHARMACOLOGICAL APPROACH
TO HYPERTENSION
Goals and risk stratification
Diet and hypertension
Salt and hypertension
Exercise and other lifestyle modifications
MODULE-2
Management of
Hypertension
1: PHARMACOLOGICAL TREATMENT OF
HYPERTENSION (Part 1)
Classification of antihypertensive and their mechanism of
action
Selection of initial drugs in uncomplicated hypertension
Selection of drugs according to compelling indications
2: PHARMACOLOGICAL TREATMENT OF
HYPERTENSION (Part 2)
Combination therapy
Difficult to control hypertension and resistant hypertension
Approach
Treatment of acute severe hypertension
3: INTERVENTIONAL THERAPY IN
HYPERTENSION
Renal artery Angioplasty
Renal sympathetic denervation
Baroreceptor stimulation
Surgical approach to hypertension
MODULE-3
Target Organs and
Special Situations
1: HYPERTENSION AND HEART
Various cardiovascular changes in hypertension
Hypertension and CAD
Hypertension and HF (REF, PEF)
Hypertension and atherosclerosis vascular aging
Cardiovascular emergencies in hypertension.
2: HYPERTENSION IN SPECIAL SITUATION
Hypertension in extremes of age
Hypertension and kidney
Hypertension and lung disease
Hypertension and CVA
Pregnancy and Hypertension
3: EVIDENCE
Important trials in Hypertension
Meta analysis in Hypertension
API Indian hypertension guidelines
 MODULE-4
(Optional)
Patient Based Interactive Module
THE GOOD NEWS
 There is considerable
reduction in cardiovascular risk
with effective lowering of blood
pressure with therapy.
 Long-Term Antihypertensive Therapy
Significantly Reduces CV Events
Myocardial
Average reduction in events (%)

Stroke infarction Heart failure

0

10
20

30 20%-25%
40
35%-40%
50
>50%
60

Blood Pressure Lowering Treatment Trialists Collaboration.

Lancet. 2000;355:1955-1964.
On Completion of all 3 Module Test, Practising Physician will be given
Certificate of Participation from the house of API
 MODULE-1
1B
Hypertension in India
 Diseases Attributable to Hypertension
Left Ventricular
Gangrene of the Heart
Hypertrophy Myocardial
Lower Extremities Failure Infarction

Aortic Hypertensive
Aneurysm Encephalopathy

HYPERTENSION
Coronary Heart
Blindness Disease
Chronic Cerebral
Kidney Stroke Preeclampsia/E Hemorrhage
Failure clampsia

Adapted from Dustan HP et al. Arch Intern

Med. 1996; 156: 1926-1935
Global Mortality 2000: Impact of
Hypertension and Other Health Risk Factors

High mortality, developing region

Lower mortality, developing region
Developed region

0 1000 2000 3000 4000 5000 6000 7000 8000

Attributable Mortality
(In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:1347-1360.
Hypertension in India (1/2)
Cardiovascular diseases caused 2.3 million deaths in India in
the year 1990; Projected to double by the year 2020
Hypertension directly responsible for 57% of all stroke
deaths and 24% of all coronary heart disease deaths in India
Strong correlation between changing lifestyle factors and
increase in hypertension in India
The nature of genetic contribution and gene-environment
interaction in accelerating the hypertension epidemic in
India needs more studies

Gupta R. J Hum Hypertens 2004;18:73-78

Hypertension in India (2/2)
In India, hypertension is present in 25% urban and 10% rural
subjects
At an underestimate, there are 31.5 million hypertensives in
rural and 34 million in urban populations
A total of 70% of these would be Stage I hypertension
(systolic BP 140-159 and/or diastolic BP 90-99 mmHg)
Recent reports show that borderline hypertension (systolic
BP 130-139 and/or diastolic BP 85-89 mmHg) and Stage I
hypertension carry a significant cardiovascular risk

Gupta R. J Hum Hypertens 2004;18:73-78

Risk Attributable due to Hypertension
in India

http://www.whoindia.org/SCN/AssBOD/08-
Hypertension.pdf Accessed on 27th May 2010
Prevalence studies in India

R Gupta :Journal of Human Hypertension (2004)

18, 7378
Recent studies

R Gupta :Journal of Human Hypertension (2004)

18, 7378
R Gupta :Journal of Human Hypertension (2004)
18, 7378
TRENDS IN AWARENESS, TREATMENT AND
CONTROL OF HIGH BLOOD PRESSURE 1976-2000
National Heath and Nutrition Survey, Percent
1976-80 1988-91 1991-94 1999-2000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34

In India and surrounding countries, awareness level is 45%.

Only 50% of these are on treatment and BP control rates are
very poor.
Trends in BP Control in India (1/2)
100
81.1
76.2
hypertensive patients

80 70.5
% of uncontrolled

60
36.9
40

20

0
Hypertension (n=3402) Diabetic Hypertension
(n=1435)

Uncontrolled Systolic BP Uncontrolled Diastolic BP

Only 27.3% patients had both SBP and DBP under control
Survey in hypertensive patients (n=3402) receiving antihypertensive medications

Hathial M. J Indian Med Assoc. 2007; 105 (7): 401-

2, 404, 410.
Trends in BP Control in India (2/2)
55
patients achieving BP goal
% of hypertensive

51.1
50

45.9
45

40
Hypertension (n=154) Diabetic Hypertension
(n=149)
Study conducted in Chennai, of the treated hypertensive patients (n=154), only
45.9% of patients had their BP under control (i.e. <140/90 mm Hg).
Similar analysis done in diabetic hypertension patients (n=149) showed that of the
patients that were treated for hypertension, only 51.1% had their blood pressure
under control.

Mohan V et al. JAPI 2007; 55: 326-32.

 Control of Hypertension in Indian population
Controlled hypertension
Treated hypertension 29.2%
Diagnosed hypertension
29.2%
32.8%
Normotensive
80% Hypertensive
20%

Untreated hypertension
70.8% Uncontrolled hypertension
70.8%

Undiagnosed hypertension
67.2%

only 15.4% of total hypertensive group have blood pressure controlled

Mohan:J Assoc Physicians India, 2007

May;55:326-32
END OF MODULE-1
1B