Colombia is an upper-middle income country in South America. |
Despite affordable healthcare, high rates of hypertension awareness, and promising regional initiatives, blood pressure control in Colombia is suboptimal, resulting in a high cardiovascular death rate. |
More widespread use of antihypertensive single-pill combinations may assist in improving adherence, therapeutic inertia, and blood pressure control in Colombia. |
1 Introduction
2 Literature Search
3 Epidemiology of Hypertension in Colombia
Study | Population | N | Prevalence (%) | Awareness (%) | Treatment, % of aware patients | Control, % of treated patients |
---|---|---|---|---|---|---|
Camacho (2016) [17] | Urban and rural residents aged 35–70 years | 7444 | 37.5 | 51.9 | 77.5 | 37.1 |
Barrera (2019) [19] | Community-dwelling adults aged ≥ 60 years (SABE population) | 23,694 | 57.7 | 93.9 | 88.8 | 50.1 |
Barrera (2020) [44] | Primary care patients with hypertension aged > 18 years | 1358 | – | – | – | 38.4 |
Hessel (2020) [18] | Community-dwelling adults aged ≥ 60 years (SABE population) | 3984 | 32.4 | – | – | – |
Londoño Agudelo (2021) [10] | Low-income urban residents of Medellin aged ≥ 35 years | 1873 | 43.5 | 64.9 | 93.4 | 66.4 |
Lopez-Jaramillo (2021) [11] | Individuals assessed during May Measurement Month 2019 | 48,324 | 27.9 | 63.7 | 60.0 | 64.0 |
García (2022) [14] | Individuals aged ≥ 60 years participating in the SABE project | 5228 | – | 82 | – | 35a |
Lopez-Lopez (2022) [15] | Urban and rural residents aged 35–70 years participating in the PURE study | 3745 | 39.1 | – | – | – |
Smith (2022) [16] | Insured individuals aged 18–74 years living in Northern Colombia | 2613 | 30.2 | – | – | – |
Mendivil (2023) [21] | Individuals with diabetes on the NRCKD | 1,352,846 | 66.6 | – | – | 57.3b |
4 Issues in Hypertension Management
4.1 Treatment Initiation
Guideline | Recommendation | COR | LOE |
---|---|---|---|
Colombian guidelines 2017 [36] | Initiate combination antihypertensive therapy in patients with BP > 160/100 mmHg or with BP > 140/90 mmHg plus risk factors | NR | NR |
It is recommended that patients with hypertension undergoing pharmacological treatment who require combined therapy receive single daily doses and fixed combinations to increase adherence to antihypertensive treatment | NR | NR | |
Latin American guidelines 2017 [34] | Initiate combination therapy for individuals with grade 1 hypertension and high or very high cardiovascular risk, and in patients with grade 2 or 3 hypertension, independently of risk stratification | NR | NR |
When combination therapy is chosen, fixed-dose combination preparations should be used whenever possible as they are associated with higher adherence to treatment | NR | NR | |
For patients with grade 2 hypertension (any level of cardiovascular risk) or grade 3 hypertension (moderate or high cardiovascular risk), start with SPC therapy at standard doses of ACE inhibitor or ARB + CCB or diuretic | NR | NR | |
US (ACC/AHA) guidelines 2017a [30] | Initiation of antihypertensive drug therapy with two first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mmHg above their BP target | I | C-EO |
Use of combination pills rather than free individual components can be useful to improve adherence to antihypertensive therapy | IIa | B-NR | |
For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs | I | ASR | |
For secondary stroke prevention, treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor, is useful | I | A | |
European (ESC/ESH) guidelines 2018 [31] | Combination treatment is recommended for most patients with hypertension as initial therapy. Preferred combinations should comprise a RAAS blocker (either an ACE inhibitor or an ARB) with a CCB or diuretic. Other combinations of the five major classes can be used | I | A |
It is recommended that β-blockers are combined with any of the other major drug classes when there are specific clinical situations, e.g., angina, post-myocardial infarction, heart failure, or heart rate control | I | A | |
It is recommended to initiate an antihypertensive treatment with a two-drug combination, preferably in a SPC. Exceptions are frail older patients and those at low risk and with grade 1 hypertension (particularly if SBP is < 150 mmHg) | I | A | |
Interamerican Society of Cardiology (IASC) guidelines 2020 [35] | For patients with grade 1 hypertension and low cardiovascular risk, low-dose fixed-dose combination therapy is an option (along with monotherapy) as initial therapy, with ACE inhibitor or ARB + CCB or diuretic; combination therapy at standard doses can also be considered | NR | NR |
For patients with grade 2 hypertension (any level of cardiovascular risk) or grade 3 hypertension (moderate or high cardiovascular risk), start with SPC therapy at standard doses of ACE inhibitor or ARB + CCB or diuretic | NR | NR | |
International (ISH) guidelines 2020 [29] | Step 1 treatment is a dual low-dose combination, ideally SPC therapy; consider monotherapy in low-risk grade 1 hypertension or in very old (≥ 80 years) or frail patients | Optimal b | |
Step 1 treatment should be a RAAS blocker (ACE inhibitor or ARB) + CCB; consider RAAS blocker + diuretic in post-stroke, very elderly or Black patients, or those with incipient heart failure or CCB intolerance; consider CCB + diuretic in Black patients | Optimal b | ||
Use free combinations if SPCs are not available or unaffordable | Essential b | ||
WHO guidelines 2021 [28] | For adults with hypertension requiring pharmacologic treatment, the WHO suggests combination therapy preferably with a SPC (to improve adherence and persistence) as an initial treatment. Antihypertensive medications used in combination therapy should be chosen from the following three drug classes: diuretics (thiazide or thiazide-like), ACE inhibitor/ARB, and long-acting dihydropyridine CCBs | Strong | High |
For adults with hypertension requiring pharmacologic treatment, the WHO recommends the use of drugs from any of the following three classes of pharmacologic antihypertensive medications as initial treatment: (1) thiazide and thiazide-like agents, (2) ACE inhibitors/ARBs, (3) long-acting dihydropyridine CCBs | Strong | High | |
Panamerican guidelines 2022 [33] | In adults with hypertension that require pharmacological treatment, it is recommended that patients are given a fixed combination in a single tablet (to improve compliance and therapeutic persistence) as initial treatment | Conditional | Moderate |
Antihypertensive medications administered in combination treatments must have a prolonged duration of effect that allows for once-daily administration and must be chosen from the following classes of medications: diuretics (thiazides or thiazide-like agents), ACE inhibitors or ARBs, and dihydropyridine CCBs | Conditional | Moderate | |
Combination treatment may be especially valuable when baseline BP values are ≥ 20/10 mmHg higher than target values | Good practice | NR | |
Combination treatment in a single tablet improves adherence and persistence and BP control | Good practice | NR | |
European (ESH) guidelines 2023 [32] | Initiation of therapy with a two-drug combination is recommended for most patients with hypertension. Preferred combinations should comprise a RAAS blocker (ACE inhibitor or ARB) with a CCB or thiazide/thiazide-like diuretic. Other combinations of the five major drug classes can be used | I | A |
The use of SPCs should be preferred at any treatment step, i.e., during initiation of therapy with a two-drug combination and at any other step of treatment | I | B | |
β-blockers should be used at initiation of therapy or at any treatment step in specific clinical situations (e.g., HFrEF), anti-ischemic therapy in chronic coronary syndromes, heart rate control in atrial fibrillation, and younger hypertensive women of child-bearing potential or planning pregnancy | I | A |
Characteristic | First-line recommendations |
---|---|
General population | ACE inhibitor or ARB |
CAD | ACE inhibitor or ARB + β-blocker (irrespective of BP) or CCB |
Post-MI | ACE inhibitor + β-blocker |
Prior stroke | ACE inhibitor or ARB + CCB or diuretic |
Heart failure (HFpEF) | ACE inhibitor or ARB or ARNI + β-blocker + MRA ± diuretic Add SGLT2 inhibitor |
Chronic kidney disease | ACE inhibitor or ARB + CCB or diuretic |
COPD | ACE inhibitor or ARB + CCB and/or diuretic β1-selective β-blockers in selected patients (e.g., with CAD or heart failure) |
Diabetes | ACE inhibitor or ARB + CCB and/or thiazide-like diuretic |
Psychiatric disorders | ACE inhibitor or ARB and diuretic β-blocker (not metoprolol) if drug-induced tachycardia |
Aortic valve stenosis | ACE inhibitor (+ β-blocker) |
Atrial fibrillation | ACE inhibitor or ARB + β-blocker or non-dihydropyridine CCBa or ACE inhibitor or ARB + β-blocker + CCB or diuretic |
Pregnant women | Methyldopa, β-blocker (labetalol), dihydropyridine CCB |
HIV/AIDS | As per general population Consider drug interactions with CCBs |
Lipid disorders | As per general population Add appropriate lipid-lowering therapy |
Metabolic syndrome | As per general population Add appropriate additional therapy considering additional risk factors and overall cardiovascular risk |
Inflammatory rheumatic disorders | As per general population (preferentially with RAAS blocker and CCB) Treat underlying inflammation effectively and avoid high doses of NSAIDs |
4.2 Treatment Adherence
Asymptomatic nature of hypertension |
Lack of information about hypertension |
Lack of knowledge about healthy lifestyles |
Economic difficulties limiting access to medical center (e.g., transportation costs), drugs, tests, and healthy food |
Lack of time and money for self-care |
Lack of a support network for disease and treatment |
Presence of comorbidities or other factors (e.g., age and obesity) that limits ability/motivation to undertake healthier lifestyles and habits |
Poor doctor-patient relationship |
Polypharmacy |