Hypertension in younger Asian population

The rate of hypertension is increasing among the young, but their awareness and treatment rates remain low, says a Korean cardiologist.

Dr Jinho Shin, a cardiologist at the Department of Internal Medicine, Hanyang University College of Medicine, South Korea, said hypertension among the younger population (those aged between 30 and 49 years) is an emerging problem in South Korea. The problem isn’t so much an increase in hypertension but the low awareness, treatment and control rates in this population.

To circumvent the lack of awareness in the younger population, Shin advocates an active screening programme targeted at them. For example, the May Measurement Month (MMM) programme and the Hypertension Awareness Week can be used for this endeavour. Shin was speaking to the participants at the 17^th Annual Congress of the Malaysian Society of Hypertension, held in Kuala Lumpur, recently. Shin, who presented via a recording due to his country’s travel restriction, said the awareness rate of younger patients is only half of the elderly (those aged 50 and above).    

Of the number who are aware of their hypertensive situation, only half are treated, with an overall control rate of less than 20 percent. Even in those who are aware of being hypertensive, about a quarter are still insufficiently treated. However, Shin noted that the control rate is similar to those in the older population. In light of these factors, Shin said a strategy to increase awareness among the younger population is needed.

Compounding the situation of low awareness among the younger group of patients about their hypertensive condition is their poor adherence to medication.

In the younger group of patients, lifestyle changes are essential and effective in lowering blood pressure (BP). In order to improve the treatment rate and adherence in younger patients, Shin said empathic and motivational strategies go a long way. By establishing a rapport with these patients, and expressing empathy to their situation, a doctor is more likely to get the patient to work towards an agreed target or behavioural change.

Hypertension and atrial fibrillation, the dreaded duo
In a separate lecture, Dr Suraya Hani Kamsani, cardiologist at the National Heart Institute (IJN), Kuala Lumpur, also spoke about the link between hypertension and atrial fibrillation (AF) in a relationship that can be described as a marriage of inconvenience. The two conditions are described as such because the two are incompatible and yet in many instances are welded indissolubly together.

The risk factors for both hypertension and AF are similar, including obesity and overweight, diabetes, sleep apnoea, and hyperlipidaemia, noted Suraya. “In hypertension, the heart becomes hypertrophic and endothelial dysfunction causes increased risk of heart failure with preserved ejection fraction (HFpEF), arterial stiffness and kidney dysfunction.” What follows is atrial stretch and fibrosis, leading to AF. Over time, with improper rhythm control therapy, permanent AF sets in.

The outcomes of this hypertension-AF combination are increased risk of stroke, congestive heart failure, major bleeding, cognitive decline, and subsequent death.   

Thus, it is imperative that hypertension should not be allowed to progress to AF. This would necessitate tighter BP control in those who are hypertensive without diabetes. Tight BP control, especially systolic BP, has been proven to reduce the incidence of new onset AF. The Malaysian Hypertension Guidelines recommend a BP of <140/90 mmHg with the elderly (aged >75 years of age) being placed on oral anticoagulants plus angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) to reduce mortality risk. Rate control should be done with beta-blockers or non-dihydropyridine calcium channel blockers.

Meanwhile, the 2018 ESC/ESH* guidelines for HTN patients with AF also recommend the same compounds for heart rate control as the Malaysian guidelines but recommend a lower systolic BP target at <130 mmHg.