Rédaction Africa Links 24 with Arthur L. Kellermann
Published on 2024-02-14 09:30:37
The scale of the problem is staggering. Every year, hypertension, or high blood pressure, claims the lives of more than 10 million people worldwide, making it the leading killer. This “silent killer” lurks in the background, often undetected until it’s too late. Unfortunately, it is also one of the most neglected and widespread pandemics of our time. Former CDC Director Tom Frieden aptly describes it as such, calling for a global focus on this deadly condition in a recent op-ed for the Washington Post titled, “It’s the world’s leading killer. Make it the focus of the next breakthrough.”
While I agree with Frieden’s call to action, the policy prescription he advocates for leaves me perplexed. He suggests spending substantial resources on a mix of prevention and treatment strategies that have historically fallen short. The reality is, we need a different approach if we are to successfully reduce the immense toll of hypertension. The “next breakthrough” Frieden seeks doesn’t need to be discovered; it already exists and has been proven to work. It is a private service offered in the United Kingdom, and the World Health Organization endorsed the concept in July. Regrettably, this approach is not available in the United States, where heart disease alone claims the lives of 695,000 people annually and incurs $240 billion in costs. Strokes claim a further 150,000 lives, generating an additional $56 billion in costs.
Though preventive measures accounted for nearly half of the reduction in U.S. cardiovascular mortality during the 20th century, modern medicine has not continued to build on this success. In a 2015 essay, Frieden noted that “Blood-pressure control, which can save more lives than any other clinical intervention, is successful in only about half of Americans.” Shockingly, nearly half of people with hypertension globally are unaware that they have the condition, as reported by the World Health Organization.
It is clear that the current approach is not yielding the desired results. The U.S. is falling behind when it comes to blood pressure control. A study of cardiovascular health in middle-aged U.S. adults found that between 1999 and 2020, rates of hypertension did not improve among higher-income adults and worsened among low-income adults. Moreover, between 2000 and 2019, blood pressure-related deaths of Americans aged 35 and older have increased across the board.
While it might seem like we’re not trying hard enough, the reality is that we might be trying in the wrong way. Currently, we promote blood pressure screening and make testing stations and low-cost monitors widely available. Individuals identified as hypertensive are promptly referred for treatment. However, Frieden and others propose a radically different strategy, one that has shown impressive results.
Twenty years ago, U.K. preventive medicine experts Nicholas Wald and Malcolm Law proposed a new approach. Instead of measuring blood pressure in everyone and reducing it in some, they advised lowering blood pressure in everyone older than 50 and measuring it in some. Their idea is based on the fact that age is the strongest risk factor for heart attack or stroke, other than already having had one. A person’s risk of heart attack or stroke roughly doubles every seven years, making this a crucial risk factor to address. By focusing on this age group, they believe that over 90% of the people who, in the absence of preventive medication, would experience a first heart attack or stroke would be identified. Moreover, their proposal includes the use of a daily “polypill” composed of three low-dose generic blood pressure medicines, a generic statin to lower cholesterol, and low-dose aspirin, among other medications as needed. Numerous studies have found that the polypill can safely and reliably lower blood pressure and serum cholesterol, regardless of the patient’s starting level, making it an effective strategy for reducing hypertension.
It’s essential to note that the polypill’s impact on outcomes is impressive, as a 2021 meta-analysis of three large international studies involving over 18,000 participants found that a daily polypill decreased heart attacks, strokes, and cardiovascular deaths by 38%, compared to usual care. Additionally, a large U.S.-based study in 2022 found that among 2,500 patients followed for a median of three years, those who were prescribed a daily polypill had substantially fewer cardiovascular events than those in the usual care group.
Despite such compelling results, there seems to be reluctance to embrace this approach from prominent doctors, the pharmaceutical industry, and key decision-makers at federal regulatory and research agencies. This hesitation might be associated with a radical departure from the way medicine has typically been practiced, as well as potential economic repercussions. The implementation of the polypill strategy could lead to financial winners and losers within the healthcare system.
However, to move forward, it is crucial to conduct a large U.S.-based clinical trial of the polypill versus usual care for primary prevention of heart attacks, strokes, and sudden cardiac death. This trial should ideally enroll a diverse population of women and men aged 50 to 59 and follow them for three to five years. Unfortunately, since the polypill contains inexpensive generic medicines, no pharmaceutical company will sponsor the trial. Instead, a federal research agency or philanthropy will need to sponsor it. If the trial confirms prior findings, the polypill should be accepted by America’s doctors, offering a cost-effective and impactful solution to reducing the burden of hypertension and cardiovascular disease.
With the U.S. health care system annually consuming $4.5 trillion and the country’s adult life expectancy lagging behind that of 56 other countries, it is evident that a better strategy for preventing cardiovascular disease must be found. By embracing the polypill approach, not only can millions of lives be saved in the U.S., but the rest of the world could follow suit, offering a promising and impactful solution to this global problem. As we look to the future, it’s essential that we adapt and embrace innovative strategies that have been proven to be effective, providing hope for a healthier future for all.
