Blood Pressure Control—Many Paths, 1 Goal

Blood pressure control among individuals with hypertension in both high-income and in low-income and middle-income countries (LMICs) is low, resulting in avoidable and expensive strokes, heart attacks, kidney failure, dementia, and other negative health outcomes. Among individuals with hypertension in the US, less than half (45%) have a blood pressure less than 140/90 mm Hg; in LMICs, control rates are as low as 6% to 8%. The reasons for uncontrolled hypertension are complex, including patient factors (eg, the asymptomatic nature of hypertension, the direct and indirect costs of treatment, medication adverse effects), clinician factors (eg, clinical inertia, poor uptake of guideline-based care), health system factors (eg, cost of medications, distance and timing barriers to access care), and the exposome (eg, unhealthy nutrition and built environment, air pollution). The World Health Organization (WHO) HEARTS strategy includes blood pressure monitoring and medication treatment protocols and is the recommended central strategy to manage hypertension in LMICs. Multiple medication regimens are suggested, recognizing that the ideal treatment approach is one that is not only effective, but also meets local implementation challenges, such as cost, accessibility, health system capacity, and burden to patients. In many LMICs, medication stockouts in public sector health facilities are commonplace, antihypertensive medication is unaffordable for most people in the private sector, and provision of medication for chronic conditions is stymied by insufficient health care delivery infrastructure.