Hypertension

If there’s one ailment that most people in their 40s and 50s should think about but do not, it is hypertension.

Ask anyone above the age of 65 if they had been checked for blood pressure, and there’s a good chance a significant percentage of them would say “Yes” – and at least half of those who say yes will also have it.

Ask anyone in their 40s or 50s if they had tested for hypertension, and I would be surprised if even two out of five said they had.

Hypertension is the world’s most underrated ailment.

It is the leading controllable contributor to heart disease, heart failure, stroke, and end-stage renal disease, and it also contributes significantly to the death of people with diabetes.

Fig 22: Hypertension and rest of body: Hypertension can have an adverse effect on many critical parts of our body, leaving each with permanent damage that could last a lifetime.

Of specific importance is the significance of high blood pressure to cardiovascular diseases (diseases of the heart and blood vessels).

Every year, about 18 million people die from cardiovascular diseases, almost 50000 a day, one every two seconds. 18 million might not sound like a lot compared to the total world population of about 7.8 billion – only about 0.25%. But a different way of saying the same thing might make you sit up and take note – cardiovascular diseases contributed to about 31% of the total worldwide deaths of 58 million per year from any cause (this includes ALL deaths – even those from wars). 76 So, one in three all-cause deaths worldwide has a cardiovascular cause. That’s a stunning statistic!

If cardiovascular deaths are the leading contributor to world mortality, the #1 contributor to cardiovascular diseases is hypertension. 77

Fig 23: Hypertension: A dominant contributor to deaths globally: Cardiovascular diseases are the #1 contributor to worldwide deaths, and hypertension is the #1 contributor to cardiovascular diseases. Do I need to say any more for the need for hypertension control? 

Hypertension can hence be considered to be a top, if not the #1, contributor to deaths in the world. Given such a terrifying destructive potential, I feel that hypertension has not somehow grabbed the attention of the middle aged as much as the fear of cancer (10 million annual deaths), diabetes (1.5 million annual deaths) and even road accidents (1.35 million annual deaths).

But dying is only one tragic result of hypertension. For every one death, there are millions of people maimed in some way, their healthy, active lives cruelly constrained owing to a stroke, heart attack, acute heart failure, or if they are really unfortunate like amma, through aortic ailments that can turn your bodies into ticking time bombs.

Untreated hypertension can rob us of many years of life, or at least a healthy life. Given that the prevalence of hypertension increases significantly from the age of 40 and has a significant rate of increase until about 65, those in the age group 40-60 should be most concerned about both its identification and treatment.

If one were to go by the new norms brought in by American Heart Association and by WHO, almost a fourth of the world’s population above 20 years of age could have hypertension. 78 Some of them could end up like amma did for the final ten years of her life. And remember – amma was one of the luckier of this group.

Fig 24: Importance of hypertension control for those in the 40-60 age group. The probability of hypertension prevalence increases dramatically between the ages of 40 and 60., The probability of life-threatening emergencies from hypertension starts showing an increase from about 40 years of age too. Given these, people stand to lose the most years in their lives if hypertension does significant or fatal damage to them during the 40-60 ages. The takeaway? Start caring about hypertension when you are 40 years old – you may be able to buy a lot more years of your precious life.

Data suggest that the total number of people worldwide with hypertension increased from 594 million people in 1975 to over 1.1 billion in 2015 – that’s 15% of the total world population in 2015. Part of this increase has to do with population growth itself, and an aging population in many developed countries. But the main contributor to this increase has been the significant increase in hypertension in the developing and underdeveloped countries – mainly South Asia and parts of Africa. 79

While hypertension was earlier considered a rich man’s disease, it is no longer so. The rich countries have enhanced their awareness of the ailment and started seeing improvements in both blood pressure incidence and management, while many of the poor countries worldwide trying to emulate the lifestyles of the developed countries – albeit many times the wrong lifestyles – are seeing dramatic increases in hypertension. 80

Amma must have had hypertension for many years but I think the first time she came to know about it was when she had a minor stroke in 2002, when she was 62. Details of the stroke are patchy as I was not in the city at that time, but appa is said to have seen amma babbling incoherently in the night and she was taken to a nearby hospital. She survived and recovered completely with no adverse effects. Like many people in India, 81 amma also discovered that she had hypertension only in her early 60s, and in a way most people wouldn’t wish to discover.

But amma lived on for a further 18 years after her first light brush with death and after a remarkable recovery from aortic dissection, both caused by hypertension. Amma’s sister was not so lucky. She had hypertension too, but she had a sudden, massive cardiac arrest in 2004, when she was 68, and died instantaneously. She was the star of the family, a remarkable,  multi-talented lady who could have contributed a lot more to family and society had she lived an additional ten years – something that could have easily happened if only she had been more careful about her hypertension control.

This brings us to a critical aspect of non-adherence to blood pressure medications, something that is rampant worldwide. The reasons for non adherence differ based on regions, demographics and economic status. These vary all the way from lack of awareness of the criticality of these medications, negative perceptions about these drugs, poor doctor-patient interaction, forgetfulness, and for the economically weaker sections, lack of money needed to purchase the medication.

I think it is plain stupidity to be careless with hypertension medication. Except perhaps in cases where someone is so poor he or she cannot afford the medication (even though most blood pressure medications are not very expensive), what can be the justification for putting your life at serious risk and robbing yourself of 20 years of healthy life, when all that’s needed is to spend a minute every day to take two pills?

If there’s one activity in which I’m satisfied with my performance, in the context of amma’s health and survival, it was my focus on her blood pressure post 2015. I was just paranoid about her blood pressure not going above 120/80, and I don’t think it ever did between 2015 and her death.  Except for a couple of times when it hovered at 120/80, the levels were always around 110/70. Even if she had a minor headache, I checked her blood pressure to make sure it was under control. And when it came to medications, I let her in no doubt about the one pill she should never forget to take – the green and white pill as I called it to make it easier for her to understand. 82

All the same, I wish someone had provided me, 20 years back, all the above inputs about blood pressure. I wish that someone had given me a hard knock on the back of my head and said, “Dammit, just ensure that your parents take care of their blood pressure, and they will live a healthy life until 90”.

Putting in a system right then that would have kept amma’s blood pressure under control seems so utterly simple.

She would not have had the aortic dissections. Her life would have been less traumatic.

It might have been far less dramatic too, but she would still be here.

I can do without drama. But I’m finding it difficult to live without her.

The toy that kept falling <= Hypertension => AMMA AND ME

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Notes

76.  https://ourworldindata.org/causes-of-death

77. The others being high blood cholesterol, diabetes, obesity, smoking and inactivity

78. About 5 billion people worldwide are above 20 years of age, and 1 billion of these have hypertension with the earlier guidelines. With the 2017 guidelines by ACC/AHA, the number of people over 20 years having hypertension could be about 1.5 billion, or about 30% of the adult population. https://www.heart.org/en/news/2018/05/01/more-than-100-million-americans-have-high-blood-pressure-aha-says , https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017

79. http://www.bloodpressureuk.org/mediacentre/Newsreleases/1billionpeopleworldwidenowhavehighbloodpressure

80. The largest rises in high blood pressure were in South Asia, including in Bangladesh and Nepal, and Sub-Saharan Africa, including in Ethiopia and Malawi. On the other hand, Great Britain has the lowest rates of high blood pressure in Europe, with around 1 in 8 women and 1 in 5 men with high blood pressure, compared to more than a third of men in several central and eastern European countries. Worldwide, the lowest rates of high blood pressure were seen in Canada, UK, Australia, USA, Peru, South Korea, and Singapore. More than half of those with high blood pressure live in Asia, including 226 million people in China and 199 million in India.

81. In India, hypertension is prevalent only to a small extent in teengers (about 10%), but it grows gradually to a prevalence of about 20% by the age of 40 . The really significant jump happens in the 40-60 age group, when the prevalence almost doubles. And beyond 60 years, it is prevalent in about 50% of the population – https://www.sciencedirect.com/science/article/pii/S0019483219304201

82. She was taking a beta blocker tablet called metoprolol which comes in a green-white capsule.

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