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Pharmacotherapy for hypertension in Sub-Saharan Africa: a systematic review and network meta-analysis
Anna Seeley1,2, Josephine Prynn3, Rachel Perera4
1Medical Research Council Unit Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, University College London, London, UK. anna.seeley@nhs.net.
Insights
Hypertension management in Sub-Saharan Africa shows calcium channel blockers (CCBs) are effective first-line agents. Further research is needed to understand their impact on cardiovascular disease prevention in diverse African populations.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Sub-Saharan Africa (SSA) faces a high burden of hypertension, leading to increased mortality from stroke and related diseases.
- Ethnicity impacts antihypertensive drug response, particularly in black populations.
- This study focuses on the efficacy of common pharmacological agents for blood pressure reduction and cardiovascular outcomes in SSA.
Purpose of the Study:
- To evaluate the effectiveness of various antihypertensive medications in reducing blood pressure in Sub-Saharan African populations.
- To assess the impact of these agents on cardiovascular morbidity and mortality within the SSA region.
- To provide evidence-based recommendations for hypertension management in SSA.
Main Methods:
- A systematic review and network meta-analysis of randomized controlled trials were conducted, focusing on populations in SSA.
- Quality of evidence was assessed using a risk of bias tool.
- Random effects network meta-analysis and meta-regression were employed to compare interventions and explore heterogeneity.
Main Results:
- Thirty-two studies involving 2860 participants were analyzed.
- Any pharmacotherapy reduced systolic blood pressure (SBP) by 8.51 mmHg and diastolic blood pressure (DBP) by 8.04 mmHg compared to placebo.
- Calcium channel blockers (CCBs) demonstrated the greatest efficacy as first-line agents, reducing SBP/DBP by 18.46/11.6 mmHg. A trend favored CCBs combined with ACE inhibitors or diuretics.
Conclusions:
- Current evidence supports the use of CCBs as first-line agents and early combination therapy for hypertension in SSA.
- Significant gaps exist in research on the effects of antihypertensive therapy on cardiovascular disease prevention in diverse SSA populations.
- More extensive research is required to inform nuanced treatment strategies for stroke and cardiovascular disease prevention across the continent.
Background:
The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA.
Methods:
We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.
Results:
Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.
Conclusion:
Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.
Trial Registration:
PROSPERO, CRD42019122490. This review was registered in January 2019.
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