Challenges for the management of hypertension in low-resource settings

Cardiovascular diseases (CVD) account for one third of the global mortality and one tenth of the global disease burden; however, if rates of hypertension, a cardiovascular risk factor, were controlled, the reduction of the CVD burden would follow. One of the major constraints for controlling hypertension is the limitation of resources for health care, particularly in low- and middle-income countries, which contribute to 80% of the global CVD burden. Hence, it is vital to use the scarce resources with maximum efficiency. In this context, it is important to note that the benefits and cost-effectiveness of managing hypertension are determined by the overall risk of CVD and not by blood pressure level alone. Using this concept demands a paradigm shift from a "single risk" factor to an "absolute risk" approach. Unfortunately, the weak infrastructure of low-resource settings does not allow cardiovascular risk assessment using such variables as blood lipid measurements for risk stratification. Feasible risk assessment methods are needed and should use simple variables such as age, sex, smoking habits, history of premature cardiovascular disease in the family, and rates of diabetes and hypertension. To meet this need, a pragmatic CVD-Risk Management package has been developed by the World Health Organization (WHO) to facilitate cardiovascular risk assessment and management in low-resource settings. Cost-effective healthcare interventions to reduce the cardiovascular burden can only be implemented if the health services policy environment and financing enable implementation. The success of this approach will also depend on the capacity of primary heathcare systems to deliver these interventions and serve the long-term needs of high-risk CVD patients. For many countries, the individual management of large numbers of patients with low CVD risk will not be affordable. Yet, individuals at low risk, and not those at high risk, account for a greater share of the overall disease burden. Therefore, we must shift the distribution of CVD through population-wide strategies that address all major CVD risk factors, including hypertension.