Imagine a silent killer lurking in the shadows, threatening the lives of millions of Nigerians – a ticking time bomb that can strike at any moment, leaving devastation in its wake, yet it’s still being handled with so much levity. Recent studies show that among Nigerians living with hypertension, only 29% are aware of their diagnosis. This lack of awareness is a major concern, as it means many individuals aren’t receiving the treatment they need to manage their condition. The situation worsens when it comes to treatment: a mere 12% of Nigerians with hypertension receive treatment, a tiny fraction of those who need it. Furthermore, control rates are even more dismal, with only 3% of individuals achieving blood pressure control. This puts the vast majority of Nigerians with hypertension at risk of developing life-threatening complications. The consequences of poor hypertension control are severe: individuals with uncontrolled hypertension are at a significantly higher risk of myocardial infarction, strokes, heart failure, and kidney disease.. These complications can devastate individuals, families, and communities and burden the healthcare system.

Hypertension, or high blood pressure, has been extensively discussed, but preventive measures and early detection strategies remain underutilised, particularly in Nigeria and other African countries. Recent studies indicate that hypertension prevalence in Nigeria ranges from 22-44%. Landmark studies have consistently shown that high blood pressure significantly contributes to the global burden of cardiovascular diseases, independent of other risk factors. In 2017, the American College of Cardiology (ACC) and American Heart Association (AHA) lowered the hypertension threshold to 130/80 mmHg from >140/90. This change was informed by evidence that patients can develop target organ damage even with seemingly normal blood pressure. This fact challenges the long-held notion that blood pressure levels below 140/90 are entirely safe. Instead, it highlights the complexity of hypertension and the need for a more nuanced approach to its management. The reality is that even mildly elevated blood pressure can cause damage to vital organs over time. For instance, the kidneys can suffer damage, leading to chronic kidney disease, while the heart may experience strain, resulting in left ventricular hypertrophy or heart failure, and vascular damage from catastrophic acute vascular events like dissection. Similarly, the brain and eyes can also be affected, increasing the risk of transient ischemic attacks (TIAs), stroke, cognitive decline, and vision loss. All these instances are possible causes of sudden death. In our environment, many of these deaths are attributed to a lot of misconceptions as well as spiritual attacks or ‘village people’, but in fact, most cases of sudden death can be attributable to a significant elevation in blood pressure. Given this understanding, it’s clear that relying solely on a specific blood pressure threshold may not be sufficient for preventing long-term complications. Instead, a proactive approach that includes regular monitoring, lifestyle modifications, and, when necessary, medication can help mitigate the risks associated with hypertension. By acknowledging the potential for end-organ damage even at lower blood pressure levels, healthcare providers can work towards more personalised and effective treatment strategies that prioritise long-term health outcomes. Early identification is likely to improve outcomes and reduce disease-related morbidity and mortality. Implementing this new guideline in Nigeria will create opportunities for early intervention and better management, although it will also lead to a significant increase in the number of individuals diagnosed with hypertension.

To corroborate this, take the instance of the SPRINT trial, which backs the concept of “the lower the better” in blood pressure management, an approach that has gained significant attention in recent years. The SPRINT (Systolic Blood Pressure Intervention Trial) study demonstrated that intensive blood pressure control, targeting a systolic blood pressure of less than 120 mmHg, resulted in improved cardiovascular outcomes compared to standard treatment targeting a systolic blood pressure of less than 140 mmHg. The trial showed significant reductions in major cardiovascular events, including heart attacks, strokes, and heart failure, as well as a decrease in all-cause mortality. The SPRINT trial’s findings suggest that lower blood pressure targets can lead to better health outcomes, supporting the idea that the “the lower the better” approach may be beneficial for certain patients. However, it’s essential to note that individual tolerance and circumstances may vary, and healthcare providers should work closely with patients to determine the most appropriate blood pressure targets based on their unique needs and health status.

Some individuals may have normal blood pressure readings in a clinical setting, but experience elevated pressures during their daily activities. This phenomenon is known as masked hypertension. Despite normal hospital readings, these individuals may still be at risk for target organ damage. Hence, routine examination and screening can help identify signs of target organ damage, even in individuals with seemingly normal blood pressure readings. This highlights the importance of regular monitoring and potentially using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring to capture a more accurate picture of an individual’s blood pressure patterns.

A major setback in managing hypertension is that most guidelines for diagnosing hypertension originate from developed countries, limiting their applicability to Black Africans. People of African descent tend to have higher blood pressure and worse cardiovascular outcomes compared to Caucasians, as shown in epidemiological and genetic studies. This disparity should serve as a wake-up call for healthcare professionals and organisations to develop tailored guidelines for Nigerian patients, ensuring more effective care and improved health outcomes.

A recent initiative which has become the beacon of hope for Nigeria is the Nigeria Hypertension Treatment Program (HTN), a groundbreaking initiative that aims to tackle the growing burden of hypertension in the country. By adapting, implementing, and evaluating the WHO HEARTS package in 60 primary healthcare centres in the Federal Capital Territory, the program addresses gaps in hypertension evaluation and management. This comprehensive approach includes standard treatment protocols, fixed-dose combination therapy, patient registration and empanelment, incentivised team-based care, and home blood pressure monitoring with health coaching. The program’s results are impressive, with over 90% of registered patients receiving treatment and over 50% achieving hypertension control. Between January 2020 and December 2023, more than 21,000 patients benefited from the program. These outcomes demonstrate the effectiveness of the HTN Program in managing hypertension at the primary healthcare level. More so, the program implemented a drug-revolving fund, which has improved access to blood pressure-lowering medications for patients.

If sustained and scaled up in other state in the country, the HTN Program could serve as a template for delivering integrated non-communicable disease care in primary care settings across Nigeria. By adopting and implementing this program in routine public health policies and practices, Nigeria could significantly reduce its hypertension disease burden and improve the health and well-being of its citizens. The program’s success highlights the importance of strengthening primary healthcare services to alleviate the burden on secondary and tertiary care centres, ultimately improving patient outcomes and reducing healthcare costs.

Additionally, annual physical examinations are crucial, even for individuals who appear to be in good health. These check-ups can help identify potential health issues before symptoms arise, allowing for early intervention and treatment. Regular health screenings can detect conditions like hypertension, diabetes, and high cholesterol, which often don’t exhibit noticeable symptoms until they have caused significant damage. It’s time for Nigeria to take a closer look at its own hypertension landscape. By adopting the new guidelines or developing our own, as well as scaling up the HTN programme and screening, by then we can take the step towards reducing the burden of hypertension and cardiovascular diseases. The question is: are we ready to take on the challenge?

Dr Aiwuyo is a Nigerian-trained Cardiologist currently a Resident physician in Internal Medicine who works at One Brooklyn Health/Brookdale Hospital Medical Center, Brooklyn, New York, USA (Email: [email protected])

Dr Echofa is a clinical researcher and also a Resident Physician at the Department of Anaesthesia and Intensive Care unit at Delta State University teaching hospital, Oghara, Delta state, Nigeria (Email: [email protected])