In the case of high blood pressure, doctors say people ought to “know their number”. In India, though, even a cursory glance at the numbers on hypertension can send anxiety levels soaring.
According to the National Family Health Survey-IV, 207 million people in India have high BP. About one-third of urban Indians are hypertensive; less than 15 per cent of those suffering from high BP are able to control it, and the prevalence of the disease, also known as the silent killer, is increasing in India, as compared to other countries.
Dr Naveen Bhamri, director, cardiology, Max Super Speciality Hospital, Delhi, said that the “rule of half” best explains the current situation of hypertension in India. “Only half of those who have high BP are aware of it. Of these, only half are receiving treatment. Out of these, only half are getting adequate treatment. So, only 12.5 per cent of those suffering from high BP are actually getting adequate treatment,” he said. Besides, the numbers in India could cause greater distress if they were considered in light of the recently lowered threshold for high BP. While the NFHS data considered 140/90 as the cut-off mark for high BP, in 2017, the guidelines issued by American College of Cardiologists stated that BP was normal only if it was under 120/80, and elevated if it was 120-129/less than 80. The ACC said that a person would be stage I hypertensive if his BP fell between 130-139/80-89.
Though the ACC lowered the threshold to less than 130/80, the European guidelines have retained the previous definition of hypertension as higher than 140/90. Both sets of guidelines, however, recommend the same therapeutic goal of BP to be kept under 130/80.
Even as doctors debate over whether to follow the Americans or the Europeans, this month the Association of Physicians of India released the latest edition of the Indian Guidelines on Hypertension (the last guidelines came out in 2013). The Indian guidelines, based on work by around 150 experts, are closer to the European guidelines and suggest that hypertension is diagnosed when BP is greater than, or equal to, 140/90.
The authors do caution that starting at 115/75 mmHg, cardiovascular disease risk “doubles with each increment of 20/10 mmHg” throughout the BP range. The risk of cardio-vascular death increases “two-fold” if the BP “rises to 135/85”, “four-fold if BP rises to 155/95”, and “eight-fold at 175/105”.
“However, the complications show a marked jump after the 140/90 mark. Besides, in India, if the threshold is lowered, we will only end up labelling more people as sick, and spread panic,” said Dr Y.P. Munjal, one of the authors.
Authors of the Indian guidelines also said that “all definitions of hypertension issued by various international bodies are arbitrary”. “There is some evidence that the risk of cardiovascular events in Asian Indians is higher at relatively lower levels of BP. Recently, the ACC/AHA guidelines have changed the definition of hypertension to 130/80. However, the European guidelines and many others maintain the earlier definition of 140/90. The Indian guidelines IV will continue with the previous definition,” the authors state. “Each country has its own local variations when it comes to high BP. In India, the difference is that high BP starts at least 15-20 years earlier, fluctuates considerably according to seasons (higher in winter, lower in summers), and salt intake of Indians is significantly higher,” said Munjal.
Bhamri, however, said that a large section of cardiologists (about 75 per cent) such as him were following the American guidelines. “Studies have shown that the lower the BP, the better it is,” he said. “More than 25 per cent of our population is hypertensive. So, we consider 130-139/80-89 as stage I hypertension.”
Another doctor with a premier hospital, who did not want to be identified, said that the medical fraternity in India was “divided” on the issue of BP threshold and there was “no consensus” on the subject due to “different state and pharma influence” at work.
“I don’t think it is prudent to fight on which guidelines are correct,” said Dr H.K. Chopra, senior consultant, cardiology, Moolchand Hospital, Delhi. “Indians need to keep their BP under 130/80. Studies have found that the rate of events (chest pain, stroke, kidney disease) are reduced if the BP is less than that. Most people are diabetic in India, and so, the symptoms are silent for them,” he said. A study done among 600 patients of stroke at Apollo Hospital, Hyderabad, found that 75 per cent of them had uncontrolled hypertension, he added.
“Hypertension is a real problem in India, and it is best for us to keep it lower than 130/80,” said Chopra, who is the former president of Cardiological Society of India. The need of the hour with a country of 1.3 billion, and over 25 per cent with high BP, he said, was to reduce the numbers, as concurred by authors of “various Indian guidelines”.
Both Chopra and Bhamri said that an ambulatory monitor helps measure BP through the day, and night. At night, BP dips by at least 10 mm of mercury. But some among us are “non-dippers”, for whom BP won't come down at that time, too.
Bhamri also points to the fact that hypertension is mostly asymptomatic, and there is a misconception that headaches are a common symptom. He said it is important that BP is monitored as often as possible—once every few months. Doctors also advise that the BP monitoring instrument is calibrated every 3-6 months to ensure an accurate reading.
Given India’s precarious situation on hypertension and heart disease, Chopra said that it is time the country had kiosks at public places to measure BP, and people had home BP monitor.
At times, patients of hypertension also tend to delay medication in the morning, when BP peaks. “Most heart attacks, strokes occur in early morning because that is when BP shoots up. So patients ought to have their medication first thing after waking up,” said Bhamri. According to Munjal, some low-cost medicines for high BP were as good as the high priced ones, and doctors needn’t go for expensive medication. “Combination of two drugs is better because the dosage can be kept low, and side-effects can be avoided. New diabetic drugs such as SGLT2 inhibitors can also be used to lower BP and sugar levels, and stem kidney disease to some extent, too,” he said.
To counter the confusion over which guidelines to follow, Munjal said that the government ought to take the lead by initiating funding for the process of setting guidelines—as was the process in other countries—and bringing together a diverse group of experts such as physicians, cardiologists, nephrologists, and diabetologists to work on building consensus. For a country with mind-boggling numbers of high BP, stroke, and heart disease, that is an initiative waiting to be taken.