High blood pressure or hypertension is a huge problem both in the world and India. The prevalence of hypertension has shown some decline in high income countries but continues its ascent in low and medium income nations. At least a third of worlds population above 18 years has hypertension; the prevalence in India is staggering, with more than a quarter of the adult population suffering from hypertension. Worse, apparently less than 50% of people in India are aware that they have hypertension. Moreover less than 13% are on antihypertensive medication and less than 10% have their blood pressure under control. Hypertension is an important risk factor for heart attacks and stroke, the first is he largest killer on the planet while stroke is the third leading cause of death. In India, the prevalence is high, but awareness by subjects or adequate control low. This grim situation persist despite anti hypertensive pills being reasonably inexpensive. The prevalence of hypertension in people as young as 18 to 25 years is around 12%. Systolic and diastolic blood pressure was measured 3 times using an Omron device, with at least 5 minutes difference between each reading. Crucially the definition of blood pressure was 140/90 mm Hg. The new American College of Cardiology /American Heart Association definition of stage 1 hypertension is systolic 130 mm Hg (or more) or diastolic 80 mm Hg (or more) ! One can safely presume that the prevalence of hypertension with the latest definition would exceed 35% of adult population. I still consider hypertension as blood pressure exceeding 140/90 mm Hg. Anything below this level or around this level should be best managed by life style modification; I have discussed these changes extensively in the past. Interestingly Chhatisgarh and Nagaland had high prevalence go hypertension, whereas Jammu and Kashmir and Kerala were considered “role models” by the researchers. So must for Article 370. Uttar Pradesh had a prevalence of 14.4% but in absolute numbers it had 14,267,516 hypertensives. India currently has 18% of the worlds population but in the next 5 years will haver the largest number of people on the plant.(PLoS Med 16(5): e1002801. https://doi.org/10.1371/journal. pmed.1002801).
So we now know that a very large number of people have hypertension in thIs country; but less than 10% are getting optimal treatment; despite reasonably cheap blood pressure pills freely being available in the market. The next important question is when should these pills be taken? There is scant data on the timing of taking these pills. Generally, because cardiac events take place in the early morning hours, advice has been that blood pressure pills be taken first thing in the morning. We now have a large randomised trial including 19,000 people with high blood pressure that assessed whether pills should be taken in the morning or at night. The conclusion is that blood pressure pills work much better if taken at night, rather than when consumed in the morning. Cardiovascular events such as heart and attack and stroke were almost reduced by a half by the night time dose. The reasoning is that the same medic at the same dose works differently in the body depending upon the time of the day or the night. The ability of the drug to be absorbed and then circulate within the human body apparently is superior at night. 19000 patients were divided into 2 groups, one group got the pills in the morning while the second group took them at night. Patients who took night pills had a 56% lower risk of cardiovascular death; 49% reduced risk of stroke and a 44% lore risk of heart attack, after adjusting for age, sex, diabetes, kidney disease or smoking. Importantly people who took their pills at night had better kidney function and lipid profile. Median follow up was for 6.3 years. The researchers of the Hygia Chronotheraspy Trial concluded that the modestly reduced systolic sleep blood pressure was the most important marker for reduced clinical events, far more important than diabetes, male sex, advanced age, low HDL cholesterol, smoking and kidney disease (European Heart Journal (2019) 0, 1–12 doi:10.1093/eurheartj/ehz754). The big limitation of this study is data restricted to people between 15 and 49 years, most people with high blood pressure are their 50′ to 70’s.
About 25% of patients were on ACE inhibitors, 30% were on calcium channel blockers, 20% were on beta blockers and 45% were on a diuretic. The most commonly dual therapy was a combination of an ARB/ACEi with a diuretic (hydrochlorthiazide) at 43% or ARB/ACEi with a calcium channel blocker at 26%. There was no significant difference in intake of low dose aspirin or a statin.Crucially, more than 50% of patients in this trial were on angiotensin receptor blockers or ARB’s. The reader must be informed that a small storm has been brewing the last almost 12 months. Three ARB’s ( valsartan, irebsratan and losartan) have been found to be contaminated by nitrate salts that are potentially precancerous. There have been therefore massive recalls of these pills. Unacceptable levels of N-Nitrosodimethylamine (NDMA) were first found in valsartan tablets. Most of these ARB’s are manufactured in China and India; it is feared that these precancerous molecules develop during the manufacturing process. There is no direct link of ARB’s with cancer. The risk of developing cancer is minute but the danger however small is there. Industry claims that the risk is as low as 1 in 100,000 cancer cases over 70 years. But the reality is that voluntary recall has been demanded by FDA, which has issued a warning letter to the India based Torrent pharmaceutical company. Torent manufactures losartan potassium tablets ; one of the 3 ARB’s facing recalls since last December.
The purpose of mentioning potential carcinogens in ARB’s is certainly NOT to advise against blood pressure pills. Blood pressure pills, on the contrary ,are mandatory if one has high blood pressure apart from life style alterations. Do NOT stop taking your blood pressure pill under any circumstance; consult your treating physician to prescribe an alternative. Controlling blood pressure is crucial, keeping in mind the scandalously high prevalence of hypertension in Indians, and the fact that very few take optimal treatment for the problem. There are a variety of effective blood pressure pills available; also there are other effective ARB’s without NDMA.