Inequities in hypertension: we can do better ... but how?

Stuart CG Rison; Rohini Mathur; Chris Carvalho; John P Robson

doi:10.3399/bjgp23X735261

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Inequities in hypertension management
Dr Maurice Carroll and Dr Emma O' Cinnéide

Published on: 13 November 2023

Published on: (13 November 2023)
Page navigation anchor for Inequities in hypertension management
Inequities in hypertension management
Dr Maurice Carroll, General practitioner, Edenderry Clinic
Other Contributors:
Dr Emma O' Cinnéide, General practitioner, Edenderry Clinic
Blood pressure (BP) control is an important public health issue. The GP has a unique and indispensable role in BP management and primary prevention of associated diseases.

The authors report that Black ethnicity and younger people have poorer control of BP compared with White and Asian ethnicity. Despite better control of hypertension in the Asian group, cardiovascular disease was higher.¹

Blood pressure measurement is central to this study, however, the authors fail to provide any detail on how BP was measured. We assume office BP readings were used. Current guidelines for the diagnosis and management of hypertension unanimously recommend the use of 24-hour ambulatory BP monitoring.²

It is well established that 24 hour ambulatory BP, and particularly night-time BP, are superior to office BP in predicting total and cardiovascular mortality and cause-specific cardiovascular complications in patients with hypertension, and in population cohorts. Ambulatory BP reveals both white coat and masked hypertension, and has been shown to be a cost effective intervention.²

Regarding ethnic variations described in the study, the lack of 24 hour ambulatory BP may explain some of the findings. Prevalence rates for masked hypertension, excessive morning BP surge and morning hypertension, and nocturnal hypertension are all higher in Asians than Westerners.³ Furthermore, sleep and 24-hour BP measures increase the pr...
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Blood pressure (BP) control is an important public health issue. The GP has a unique and indispensable role in BP management and primary prevention of associated diseases.

The authors report that Black ethnicity and younger people have poorer control of BP compared with White and Asian ethnicity. Despite better control of hypertension in the Asian group, cardiovascular disease was higher.¹

Blood pressure measurement is central to this study, however, the authors fail to provide any detail on how BP was measured. We assume office BP readings were used. Current guidelines for the diagnosis and management of hypertension unanimously recommend the use of 24-hour ambulatory BP monitoring.²

It is well established that 24 hour ambulatory BP, and particularly night-time BP, are superior to office BP in predicting total and cardiovascular mortality and cause-specific cardiovascular complications in patients with hypertension, and in population cohorts. Ambulatory BP reveals both white coat and masked hypertension, and has been shown to be a cost effective intervention.²

Regarding ethnic variations described in the study, the lack of 24 hour ambulatory BP may explain some of the findings. Prevalence rates for masked hypertension, excessive morning BP surge and morning hypertension, and nocturnal hypertension are all higher in Asians than Westerners.³ Furthermore, sleep and 24-hour BP measures increase the prevalence of masked hypertension, more among non-Hispanic Black compared with non-Hispanic White individuals.⁴

Ambulatory BP is the undeniable method of choice for the assessment of BP and for the rational use of antihypertensive drugs. Ambulatory BP measurement is standard of care in our practice. It is feasible to do in a primary care setting. We have found it to be highly informative and associated with high patient and doctor satisfaction.

Primary care presents exciting opportunities for augmentation of patient care with technology. We are entering an era of widespread use of wearable, cuff-less BP devices that provide more comfort and convenience. As primary care physicians we need to embrace these new technologies and the opportunities they present.

References

1. Rison S, Redfern O, Dostal I et al. Inequities in hypertension management: observational cross-sectional study in North East London using electronic health records. Br J Gen Pract. 2023;73(736): e798-e806.
2. Huang QF, Yang WY, Asayama K et al. Ambulatory Blood Pressure Monitoring to Diagnose and Manage Hypertension. Hypertension. 2021;77(2):254-64.
3. Kario K, Hoshide S, Chia YC et al. Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network. J Clin Hypertens (Greenwich). 2021;23(3):411-21.
4. Yano Y, Poudel B, Chen L et al. Impact of Asleep and 24-Hour Blood Pressure Data on the Prevalence of Masked Hypertension by Race/Ethnicity. Am J Hypertens. 2022;35(7):627-37.
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Competing Interests: None declared.