Around 50% people with hypertension are unaware of their condition. Of those who are aware, half do not take any action to control their blood pressure.

Adherence to treatment, following a diet, and making lifestyle changes are essential in treating hypertension.

Approximately 4 in 10 adults older than 25 have hypertension. This means that nearly 1 billion people have hypertension. Around 75% of the world’s hypertensive population are at risk and are potential candidates for heart disease, strokes, kidney disease or even sudden death. Raised blood pressure continues to be the biggest contributor to the global burden of disease and to global mortality, leading to 10.7 million deaths each year.


In South Africa, more than 1 in 3 adults live with high blood pressure and it is responsible for one in every two strokes and two in every five heart attacks. Risk factors for hypertension in South Africans include high salt intake, excessive alcohol abuse, overweight and obesity, sedentary lifestyles, genetic predisposition, physical inertia, poverty and tobacco use. Prof Neil Poulter, Professor of Preventive Cardiovascular Medicine at Imperial College of London was recently in Cape Town, presenting at the World Congress for Internal Medicine.


Worldwide guidelines recommend 2-drug combinations of antihypertensive drugs. Prof Poulter spoke about the core drug-treatment strategy for uncomplicated hypertension. Initial therapy (one pill) is a dual combination of ACEI or ARB + CCB or diuretic. Consider monotherapy in low-risk grade 1 hypertension or in very old (>80 years) or frailer patients. Step 2 is a triple combination (one pill) ACEI or ARB + CCB or diuretic. Step 3 (two pills) is a triple combination of spironolactone or other drug. For resistant hypertension, add spironolactone (25-50mg o.d.) or other diuretic, alpha blocker or beta-blocker.

Consider referral to specialist centre for further investigation. Consider beta blockers at any treatment step, when there is a specific indication for their use, e.g. heart failure, angina, post menopause, atrial fibrillation, or younger women with, or planning, pregnancy.


There is a controversy in the management of hypertension. Individual trial data and meta-analyses are relatively consistent in showing the superiority of ACE inhibitors. Recent hypertension guidelines do not reflect these data, suggesting equivalence. ARBs are better tolerated but do not reduce mortality. They should be used if patients cough on ACE inhibitors.


Adherence to treatment, following a diet, and making lifestyle changes are essential in treating hypertension. Reliable data shows that adherence to medication for chronic diseases is only about 50%. Several factors affect adherence, including social, economic, and therapy-related problems, as well as patients themselves. Improving adherence therefore needs to address each of these concerns, and not focus solely on or blame the patient. The relationship between the patient and the healthcare provider is also important. The most effective relationship is one where alternatives are explored, approaches negotiated, and adherence discussed, as a follow-up planned.


According to Prof Poulter, since most patients will need at least two hypertensive agents, why not start with them? There is more effective and rapid BP control than monotherapy and two ‘free’ drugs. They have reduced side effects, and enhanced adherence. As well as improved cardiovascular protection, they are more cost effective, he concluded.