Implications of the New American College of Cardiology Guidelines for Hypertension Prevalence in India | Cardiology | JAMA Internal Medicine | JAMA Network
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Table 1.  Prevalence of Blood Pressure Thresholds and Cardiovascular Disease Risk Among Participants Aged 30 to 74 Years in the District-Level Household Survey-4 (DLHS4) and the Annual Health Survey (AHS) in Indiaa
Prevalence of Blood Pressure Thresholds and Cardiovascular Disease Risk Among Participants Aged 30 to 74 Years in the District-Level Household Survey-4 (DLHS4) and the Annual Health Survey (AHS) in Indiaa
Table 2.  Comparison of Age-Standardized Prevalence of Hypertension in India Among 1 387 680 Adults Aged 18 Years and Older
Comparison of Age-Standardized Prevalence of Hypertension in India Among 1 387 680 Adults Aged 18 Years and Older
1.
GBD 2016 Risk Factors Collaborators.  Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.  Lancet. 2017;390(10100):1345-1422. doi:10.1016/S0140-6736(17)32366-8PubMedGoogle ScholarCrossref
2.
Geldsetzer  P, Manne-Goehler  J, Theilmann  M,  et al.  Diabetes and hypertension in India: a nationally representative study of 1.3 million adults.  JAMA Intern Med. 2018;178(3):363-372. doi:10.1001/jamainternmed.2017.8094PubMedGoogle ScholarCrossref
3.
Chobanian  AV, Bakris  GL, Black  HR,  et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee.  Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.  Hypertension. 2003;42(6):1206-1252. doi:10.1161/01.HYP.0000107251.49515.c2PubMedGoogle ScholarCrossref
4.
Whelton  PK, Carey  RM, Aronow  WS,  et al.  2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.  Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065PubMedGoogle Scholar
5.
Muntner  P, Carey  RM, Gidding  S,  et al.  Potential US population impact of the 2017 ACC/AHA High Blood Pressure Guideline.  Circulation. 2018;137(2):109-118. doi:10.1161/CIRCULATIONAHA.117.032582PubMedGoogle ScholarCrossref
6.
Anchala  R, Kannuri  NK, Pant  H,  et al.  Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension.  J Hypertens. 2014;32(6):1170-1177. doi:10.1097/HJH.0000000000000146PubMedGoogle ScholarCrossref
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    Research Letter
    October 2018

    Implications of the New American College of Cardiology Guidelines for Hypertension Prevalence in India

    Author Affiliations
    • 1Public Health Foundation of India, Gurgaon, India
    • 2Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    JAMA Intern Med. 2018;178(10):1416-1418. doi:10.1001/jamainternmed.2018.3511

    In India, ischemic heart disease is the leading cause of death and premature death, and high blood pressure (BP) is the fourth leading risk factor of death and disability.1 In a recent study in JAMA Internal Medicine, Geldsetzer et al2 reported the first national prevalence rate of hypertension in India to be 25%, based on a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher, as defined in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines (JNC7).3 In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Clinical Practice Guidelines reduced the systolic BP and diastolic BP threshold for stage 1 hypertension to 130/80 mm Hg and recommended the initiation of BP-lowering medication if the patient’s 10-year risk for cardiovascular disease (CVD) is 10% or greater or if the patient has known clinical CVD, diabetes, or chronic kidney disease.4 The objective of the present study was to estimate the difference in hypertension prevalence in India depending on whether the JNC7 or the ACC/AHA guidelines were applied.

    Methods

    This study was exempt from review by the institutional review board of the Harvard T.H. Chan School of Public Health and the institutional ethics committee of the Public Health Foundation of India, as the study was a secondary analysis of data available in the public domain. Data analysis was conducted from February 4, 2018, to February 14, 2018.

    We used data from the District-Level Household Survey-4 (DLHS4) and the Annual Health Survey (AHS) carried out between 2012 and 2014 in all of the 29 states, except Jammu, Kashmir, and Gujarat, and 5 of the 7 union territories in India. During the surveys, each household member aged 18 years or older, excluding pregnant women, underwent 2 BP measurements while seated; an electronic sphygmomanometer was used on the left arm, and the 2 readings were taken at least 3 minutes apart. Hypertension was determined using the mean of the 2 readings, according to JNC7 or ACC/AHA guidelines. Hypertension prevalence was weighted to the age structure of India’s population in 2013. The difference in hypertension prevalence, overall and by demographic and socioeconomic subgroups, was estimated. The 10-year risk for CVD was calculated using the Framingham office-based CVD risk score among those aged 30 to 74 years with ACC/AHA stage 1 hypertension. The details of this analysis are published elsewhere.2

    Results

    A total of 1 387 680 (85.7%) of the 1 619 230 adults interviewed (733 617 [52.9%] were female and 654 063 [47.1%] were male, with a mean [SD] age of 41 [15.9] years) had nonmissing systolic and diastolic BP values. The overall hypertension prevalence increased from 302 514 (21.8%; 95% CI, 21.5%-22.1%) following the JNC7 guidelines to 725 756 (52.3%; 95% CI, 51.9%-52.8%) following the ACC/AHA guidelines, resulting in a relative increase of 140%. Among those aged 30 to 74 years with ACC/AHA stage 1 hypertension, 181 792 of 321 584 (56.5%) participants had a 10-year CVD risk score of 10% or higher and thus would qualify for antihypertensive medication (Table 1). The new BP threshold showed the greatest increase in prevalence of hypertension in the youngest age group (aged 18 to 25 years) and resulted in slightly greater increases in prevalence among those living in rural compared with urban areas (146.4% vs 130.0%) and those in the poorest compared with the richest households (160.5% vs 119.3%) (Table 2).

    Discussion

    The lowered BP threshold in the new ACC/AHA guidelines resulted in a 140% relative increase in the hypertension prevalence in India. This increase was 3 times higher than the 43% relative increase reported in the United States.5 The prevalence reported in our analysis is likely an underestimate, given that the DLHS4 and the AHS did not collect information on antihypertensive medication use; thus, this study considered those individuals who achieved BP control with medication to not have hypertension.

    Such an increase in the hypertension prevalence in India is likely to have significant implications for the Indian health system. Greater increases among younger patients and those from rural and poorest households may exacerbate the existing access-to-care issues in these high-risk subgroups. Hypertension treatment and control rates are already very low in India.6 The current health system, beset with an irregular supply of drugs and high load of patients, is unlikely to have the capacity to absorb such a significant surge in new patients. In our view, adoption of the new ACC/AHA guidelines in India is not advised. Instead, measures to strengthen the health system to manage existing cases as well as primary prevention efforts that target high dietary salt intake, low fruit and vegetable intake, excessive alcohol intake, physical inactivity, tobacco use, and air pollution should be encouraged.

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    Article Information

    Accepted for Publication: June 4, 2018.

    Corresponding Author: Nikhil Srinivasapura Venkateshmurthy, MD, Public Health Foundation of India, Plot no. 47, Sector 44, Institutional Area Gurgaon– 122002, India (nikhil.sv@phfi.org).

    Published Online: August 6, 2018. doi:10.1001/jamainternmed.2018.3511

    Author Contributions: Dr Jaacks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Srinivasapura Venkateshmurthy, Geldsetzer, Jaacks.

    Drafting of the manuscript: Srinivasapura Venkateshmurthy.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Geldsetzer.

    Obtained funding: Jaacks.

    Study supervision: Jaacks.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    GBD 2016 Risk Factors Collaborators.  Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.  Lancet. 2017;390(10100):1345-1422. doi:10.1016/S0140-6736(17)32366-8PubMedGoogle ScholarCrossref
    2.
    Geldsetzer  P, Manne-Goehler  J, Theilmann  M,  et al.  Diabetes and hypertension in India: a nationally representative study of 1.3 million adults.  JAMA Intern Med. 2018;178(3):363-372. doi:10.1001/jamainternmed.2017.8094PubMedGoogle ScholarCrossref
    3.
    Chobanian  AV, Bakris  GL, Black  HR,  et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee.  Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.  Hypertension. 2003;42(6):1206-1252. doi:10.1161/01.HYP.0000107251.49515.c2PubMedGoogle ScholarCrossref
    4.
    Whelton  PK, Carey  RM, Aronow  WS,  et al.  2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.  Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065PubMedGoogle Scholar
    5.
    Muntner  P, Carey  RM, Gidding  S,  et al.  Potential US population impact of the 2017 ACC/AHA High Blood Pressure Guideline.  Circulation. 2018;137(2):109-118. doi:10.1161/CIRCULATIONAHA.117.032582PubMedGoogle ScholarCrossref
    6.
    Anchala  R, Kannuri  NK, Pant  H,  et al.  Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension.  J Hypertens. 2014;32(6):1170-1177. doi:10.1097/HJH.0000000000000146PubMedGoogle ScholarCrossref
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