Viewpoints

Recent Guidelines for Hypertension

A Clarion Call for Blood Pressure Control in India
H.K. Chopra, C. Venkata S. Ram

S ystemic hypertension is the leading cause of global car-

diovascular mortality and morbidity. Yet, it is a con-
dition which can be diagnosed easily and without much
<130/80 mm Hg (Figure 1A and Table 2). What would be the
overtones of the aggressive BP goals for India with a popu-
lation of 1.3 billion and an estimated average prevalence of
costs. Uncontrolled hypertension promotes target organ hypertension of 25% or higher?5,6 In the elderly (>70 years),
damage and significant disease burden on the community. the incidence of hypertension is nearly 60%. India is under
Therefore, aggressive control of hypertension is manda- a long stretch of escalating incidence of hypertension medi-
tory to preserve and protect public health in India. ated disease which is battering and destroying the health of
its citizens (Figure 1B). Unless this incontrovertible track is
Cardiovascular disease (CVD) causes nearly 18 million
dismantled, India is marching towards a cardiovascular calam-
deaths annually. Despite the phenomenal progress in disease
ity of startling proportions never witnessed.
management, 30% of global deaths are attributable to CVD.1
India should no longer tolerate the current dismal rates
A number of genetic and acquired risk factors for the devel-
of BP control of <15%!6 This frightful status quo should be
opment of CVD are identified. Amongst the CVD risk fac-
renounced in favor of healthy BP levels for the country. There
tors, systemic hypertension remains as the leading root cause
is a seeming argument that the newer (lower) thresholds for
of excessive premature mortality and morbidity.2 The conse-
goal BP levels are unattainable particularly if the country
quences of any level of elevated blood pressure (BP) are of
adopts American definition of hypertension. There is enough
momentous impact on the public health. Since hypertension
evidence to prove that BP levels between 130 to 139/80 to
is a common disorder in the community, guidelines on its
89 mm Hg in the Indian population cause substantial CVD,
management are issued periodically by the experts in the field
stroke, and premature mortality7 (Figure 2). A large number
and advocacy professional organizations. It is estimated that
of Indians have prehypertension, which embraces the new
nearly 1.5 billion adults in the world will have hypertension
stage-I hypertension per American guidelines. Although se-
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in the decade ahead. If this trend is not reversed, the ramifica-

vere hypertension is identified and managed in a specialist
tions do not bode well for the pandemic of CVD. It has thus
care setting, considerable percentage of Indians have stage-I
become a transcendental priority to lower the prevailing BP
hypertension by any definition. And if you add to this pro-
levels across the world.
digious number, the previous category of prehypertension,
The latest European guidelines3 retain the previous defi-
the absolute numbers of people at risk is a mind-boggling
nition of hypertension (ie, BP >140/90 mm Hg) whereas the
figure. Given this fact and confronting the storm of hyper-
American guidelines4 lowered the threshold to define hyper-
tension driven scourge, it is germane for India to endorse the
tension to <130/80 mm Hg (Tables 1 and 2). The American
newer (lower) thresholds for target BP levels.8 It is indeed a
guidelines (proposing new definition of hypertension) are
challenge but to turn deaf ear is not justified. Embracing and
driven largely by meta-analyses of important outcome tri-
als including SPRINT (Systolic Blood Pressure Intervention
Trial). And the European guidelines are assembled largely
on the basis of population attributable risk. Yet, both the sets Table 1.  Comparison of the Latest ACC/AHA and ESC/ESH Hypertension
of guidelines recommend the same therapeutic BP goal of Guidelines

Parameter ACC/AHA ESC/ESH

The opinions expressed in this article are not necessarily those of the Definition of >130/80 >140/90
editors or of the American Heart Association. hypertension,
From the Department of Cardiology, Moolchand Hospital, New Delhi, mm Hg
India (H.K.C.); World Hypertension League/South Asia Office, Apollo
Hospitals, and Apollo Medical College, Hyderabad, India (C.V.S.R.); Grading of Normal <120/80 Optimal <120/80
Texas Blood Pressure Institute, University of Texas Southwestern normal pressure,
Medical School, American Society of Hypertension, Dallas (C.V.S.R.); Elevated 120–129/<80 Normal 120–129/80–84
mm Hg
and Faculty of Medicine and Health Sciences, Macquarie University, High normal 130–139/85–89
Medical School Sydney, Australia (C.V.S.R.).
Correspondence to C. Venkata S. Ram, MD, MACP, World Grading of Grade 1, 130–139/80–89 Grade 1 140–159/90–99
Hypertension League/South Asia Office, Apollo Hospitals, and Apollo hypertension,
Medical College, Hyderabad, India. Email ramv@dneph.com Grade 2, ≥140/90 Grade 2, 160–179/100–109
mm Hg
(Circ Res. 2019;124:00-00. Grade 3, ≥180/110
DOI: 10.1161/CIRCRESAHA.119.314789.)
© 2019 American Heart Association, Inc. Target blood ≤65 y, <130/80 <65 y, <130/80
pressure in
Circulation Research is available at https://www.ahajournals.org/ ≥65 y, <130/80 ≥65 y, <140/80
various subsets
journal/res
DOI: 10.1161/CIRCRESAHA.119.314789 Data derived from Williams et al3 and Whelton et al.4

984
 Chopra and Ram   Guidelines for Hypertension in India   985

Table 2.  Office BP Treatment Goals

Office Systolic Blood Pressure Treatment Target Ranges (mm Hg) Diastolic

Treatment Target
Age Group Hypertension + Diabetes Mellitus + CKD + CAD + Stroke/TIA Range (mm Hg)
18−65 y Target to 130 Target to 130 Target to <140 to 130 Target to 130 Target to 130 <80 to 70
or lower if tolerated or lower if tolerated if tolerated or lower if tolerated or lower if tolerated
Not <120 Not <120 Not <120 Not <120
65−79 y Target to <140 to 130 Target to <140 to 130 Target to <140 to 130 Target to <140 to 130 Target to <140 to 130 <80 to 70
if tolerated if tolerated if tolerated if tolerated if tolerated
≥ 80 y Target to <140 to 130 Target to <140 to 130 Target to <140 to 130 Target to <140 to 130 Target to <140 to 130 <80 to 70
if tolerated if tolerated if tolerated if tolerated if tolerated
Diastolic treatment <80 to 70 <80 to 70 < 80 to 70 <80 to 70 <80 to 70
target range (mmHg)
Data derived from Williams et al.3 BP indicates blood pressure.

acknowledging the need for aggressive BP goals will provide
enormous public health benefits paving the way for a healthy
India. Of course, the ambitious BP target will invite some
dissidence. But the denial of insurmountable documentation
will take us nowhere and is a dangerous attitude. Any day,
prevention is better than roadside assistance!
The European hypertension guidelines identify South
Asians as the highest risk category and most vulnerable to the
consequences of elevated BP. Coupled with this blaring sound
is the growing incidence of diabetes mellitus and prediabe-
tes mellitus in India which further exasperates the prospect
of already worsening chronic disease burden.9 Furthermore,
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Hypertension awareness in the country is low with urban-rural
differences in health care access12 and because of fragmenta-
tion of disease prevention pathways. Health systems enhance-
ment and standardized access of medical care and medicines
should be developed with some power of enforcement at the
local level. Any broad national policy towards noncommuni-
cable disease (NCD) has to percolate to the grassroots.
CVD and stroke rates in India have escalated rapidly and
upward in the last decade. This direction, if not reversed, will
impact the human resource pool in the country and will be
an instant setback to the economy and national productivity.
NCDs account for more than 54% of total deaths in India,

European guidelines have identified high uric acid level as an
additional risk factor in patients with hypertension; hyperuri-
cemia is common in Indian patients with hypertension.10 What
is the pertinency of new guidelines to control hypertension in
India? Because of its vast number of people with hyperten-
sion, lower BP thresholds will be difficult to accomplish but of
far-reaching beneficial consequence. There is enough affirma-
tion that BP levels between 130 to 139/80 to 89 mm Hg cause
substantial CVD complications and hence, we should advocate
a goal BP of <130/80 mm Hg for most patients with hyperten-
sion.11 It is unwise to question whether India should espouse
aggressive BP control targets. Instead, the country should
lead the way in advocating healthy BP levels for its citizens.
Signing up for the revised goals will face tenacious obstacles.
out of which CVDs contribute a share of 25%! A worrisome
trend is relentless occurrence of NCDs in the ages <50 years,
an alarming situation.13 The loss of productivity (from NCDs)
is highest in the age group 35 to 64 years, much higher than
comparable countries like China and Brazil. Public education
about hypertension and NCDs has to be stepped up by all the
available forums.14,15
Patient empowerment using information technology (mo-
bile phone apps and understandable educational tools) should
be activated to overcome the regional, cultural, economic, and
cultural barriers. None of these avenues can be traversed with-
out professional education in the arena of NCD prevention.
Over decades, the country has been witnessing a steady rise in
BP levels, cholesterol levels, glucose levels, body weight, sed-
entary life-styles, and unhealthy nutrition which calls for mul-
tidimensional comprehensive preventive measures. Lifestyle

Figure 1. A, Latest hypertension guidelines 2017/2018. B, Financial Figure 2. Deaths from ischemic heart disease and blood pressure
burden from CVD-INDIA. CVD indicates cardiovascular disease; and levels from Mumbai/India cohort study. SBP indicates systolic blood
HTN, hypertension. Data derived from Gupta.6 pressure.
 986  Circulation Research  March 29, 2019
changes have to be enforced to prevent NCDs. National poli-
cies and objectives are often discussed, cited, and promoted
but not implemented.
Indians develop coronary heart disease at younger age
(<40 years) irrespective of their geographic or expatriate
status. Ironically, the worst affected are those who can-
not afford medical expenses. This situation requires im-
mediate implementation of changes in health care delivery
access to the entire population. The Indian hypertension
guidelines16 should be revised to advocate more aggres-
sive BP reduction as mandated by the current unfavora-
ble trends in CVD driven by uncontrolled hypertension.6
Massive screening check-ups for hypertension should be
undertaken but with a guaranteed follow-up and evalua-
tion. BP measurements (preferably with a Kiosk) should
be made available at public places like airports, railway
stations, shopping malls, hospital lobbies, bank lobbies,
and at the workplace to promote awareness about hyper-
tension and its sequelae.
To meet the objective of decreasing the CVD mortality by
25% by 2025, the prevalence of hypertension in India has to
be reduced by 25% and secondary prevention by 50%. These
ambitious but necessary aims cannot move forward by mean-
ingless arguments, and by measureless silly debates by so-
cial engineers, eloquent savants, and self-appointed pontiffs.
Lack of urgency is a huge obstacle to prevent NCDs. Chronic
disease burden from NCDs does not elicit panic like a flu
epidemic or Zika and Ebola infections. For politicians and
illiterate arm chair commentators, preventive medicine is dis-
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tant and only an abstract. Fortunately, in the long road lead-
ing to CVD, opportunities exist for prevention at every step.
India stands to benefit immensely if it seizes every moment
to disarm the onset and progression of hypertension medi-
ated CVD. It is essential for the practitioners to recognize
that initiating BP control is only the first step and they should
monitor the patients closely to ensure that the recommended
therapeutic goals are maintained without interruption. India
has vastly succeeded in containing communicable diseases;
it can repeat the same logic and magic in curbing NCDs as
well!
In collective wisdom, India is likely the ultimate recepta-
cle for the challenges, solutions, and benefits from tighter BP
goals for its vast population.
Disclosures
None.
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Key Words: blood pressure ◼ cholesterol ◼ glucose ◼ hypertension
◼ hyperuricemia