Raised blood pressure is the number one cause of preventable death worldwide, and more than half of people who are hypertensive don’t know they have the condition. Over a billion people worldwide have hypertension, with most (two-thirds) living in low- and middle-income countries. Fewer than one in five people with hypertension have the problem under control, including many in countries with a mature and well-developed healthcare system.
May Measurement Month (MMM) is a global awareness campaign started in 2017 by the International Society of Hypertension (ISH) and is the largest free blood screening program in the world. Each May, volunteers measure the blood pressure of people in cities, towns, and villages around the world as part of MMM. All participants leave knowing their blood pressure and anyone who is found to have hypertension is given advice about what they need to do next.
Before this years’ campaign, almost five million people in 100 countries have been screened for MMM, and over one million of those have been identified with untreated or inadequately treated hypertension, enabling them to take action to improve their health. Following the growth and success of the MMM campaign since 2017, MMM is now an independent charity which is currently running the 2022 campaign.
To learn more about the urgency of getting people’s blood pressure measured, George Medicines spoke with Professor Neil Poulter, Professor of Preventative Cardiovascular Medicine at Imperial College London and Director of the Imperial Clinical Trials Unit, the Chief Investigator for MMM and a former President of the International Society of Hypertension.
How did this initiative come about?
I was President of the International Society of Hypertension from 2016 to 2018. During the process of becoming president, I had to propose what I would do over the next two years in the role. At the time, I had just seen the data from the PURE (Prospective Urban Rural Epidemiology) study, which showed that around the world only 46.5% of people with hypertension were aware they had it. As clinicians, we always worry about getting the treatment right, but actually even if you did it perfectly for those 46.5% aware of their problem, the remainder (the majority) of hypertensive patients remain untouched by human hands. We clearly have a problem around the world of inadequate blood pressure control, and the big gateway for opening that up is awareness.
Raised blood pressure kills around 10.8 million per year, working out at 30,000 deaths per day. To put that in perspective, COVID-19 has never killed 30,000 per day around the world. So, hypertension is a massive killer – the biggest single killer and contributor to the global burden of disease. May 17th is World Hypertension Day, but I felt that something that kills that many people deserved more than one day’s recognition. We needed a World Hypertension Month. This became May Measurement Month, and our objective is to really fly the flag for blood pressure testing with a view, ultimately, of making May the month where everyone gets measured. That’s the objective, but we are still a long way off that.
Why are so many people unaware they have hypertension?
It’s called a silent killer, and that’s because most people don’t know they’ve got it and have no symptoms. It’s only when you measure it that you find out, or when you have a serious complication such as a stroke. We’re aware of patients ending up in a wheelchair due to stroke, which was caused by chronically raised blood pressure undiagnosed and/or untreated for many years often decades. Generally, women tend to be more aware of raised blood pressure than men because during contraceptive treatments and pregnancy it is often picked up.
What treatment options do people have and why do so many not have their condition under control?
Firstly, there is the non-drug stuff, which is all the things nobody wants to hear about, such as cutting down body weight, cutting down on alcohol and salt intake, eating more fresh fruit and vegetables and exercising more. These can be difficult for a lot of people to do. It works if people do it, but people just don’t. Historically, doctors haven’t really been taught about nutrition, and if they have it will perhaps only include one hour about diseases from being undernourished rather than being overweight – which is the bigger problem. So doctors in general, are not good at advising on diets!
If the standard lifestyle things aren’t enough to get your blood pressure to a reasonable level, then you have to add in the drugs. There are four or five good standard drugs that are in use. The recommendation is to use two drugs at once at low-ish doses as initial therapy, ideally as a single pill – the single pill combination approach, like George Medicines is pursuing. This is because single pills improve adherence, which is a huge problem. People aren’t achieving sufficient control even when they are being treated, because they are not being given the right drugs at the right doses.
The majority of people who are treated around the world get one drug, but you should be on at least two. In order to get to our current targets, many patients will need to be on three different drug classes, however over 50% are only on one drug. There is a good quote from the British Hypertension Society from 2004, “monotherapy is usually inadequate therapy”, and that’s true. However, the first hurdle to controlling hypertension is getting diagnosed. Then, the doctor’s got to actually say, ‘I think you should be treated’, which some doctors are reluctant to do. Once the doctor has decided to proceed with treatment, if the patient agrees, they have to give you the right combination of drugs at the right dose. There is also a tendency to ignore what is optimal therapy for different ages and ethnicities, but some of the drugs are more suitable for younger vs. older patients and so on. So, the right drug, the right number and the right dose will make all the difference.
It’s also hard for patients to manage taking multiple pills, especially as hypertension is more common as you get older. These patients often have other ailments too which require medication such as diabetes or arthritis. If they are taking so many different tablets, how can they possibly remember? Some people are on 20 different pills that must be taken at different times of day. It’s just very difficult.
How does hypertension affect patients and their families?
The initial diagnosis does not usually affect patients at all, apart from the worry of the potential dangers of heart attack or stroke. In terms of the disorder itself, for many years it may make no difference to a person, and they won’t notice it. It could affect the family by proxy – a worried spouse for example. However, if you are in a developing country such as India, the cost of treating hypertension could be one quarter of a family’s income, which patients often cannot afford, with huge implications.
In terms of physical effects, it’s only when you have the serious complications like a heart attack that it becomes clinically obvious. Raised blood pressure can also lead to all sorts of nasty chronic illnesses such as strokes, heart failure, dementia and kidney failure.
Why is May Measurement Month so important?
The current death toll due to raised blood pressure is the equivalent of 70 jumbo jets fully laden with passengers crashing every day. Today, if one jumbo jet crashes, the whole world would be up in arms and demanding to know what had gone wrong. Yet here we have the equivalent of 70 a day, and we are just used to it and don’t do anything about it. So that’s why it’s important, it kills more people than anything else, it’s easily measured, it’s relatively easily treated, and reasonably cheap to treat – although not cheap everywhere. This is something that can be dealt with and should be dealt with. Prevention would be the starting point, but assuming we aren’t going to solve the world’s lifestyle ailments, the priority is to detect those with raised blood pressure. Only then can you do something about it.
Although regular cardiovascular check-ups may happen in the UK, systematic blood pressure screening is not carried out in many countries. That’s why May Measurement Month is so important. It gets into the press, people learn how to measure blood pressure, nurses and medical students get trained up, and it raises the profile of the whole condition. Hopefully with the data that we generate, we can persuade governments, and those who make healthcare decisions, to improve screening and management of raised blood pressure, and ultimately to prevent it.