MODULE #I.   CIC/WHAG: THE WHY QUESTIONS  

IA. WHY DID WE DO THIS?

A TALE OF TWO COUNTRIES: 

THE COMMON BOND OF FAMILY SUFFERING  

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In the Boston (U.S.)  area, the father of the primary author was working at his computer when noticed difficulty moving his hand.  He then fell when trying to stand up, and was unable to speak.  Fortunately, his wife heard the fall, rapidly identified it as a stroke, and called 911.  Emergency Medical Services (EMS) responded immediately and he was quickly transported to the Emergency Room of a local hospital where he was identified as high risk for Large Vessel Occlusion (LVO) of the Middle Cerebral Artery (MCA), and was transported by helicopter to a world-renowned Boston hospital high level stroke center.  Mistakenly, completely out of protocol, he received heparin in the ER at time of transport, so that was deemed not to be a candidate for either “clot-busting” fibrinolytic (rtPA) Rx or an attempt at thrombectomy or direct removal of clot.  Fortunately, the weakness did improve but the dense aphasia (inability to speak) as a silver bullet in one so articulate was devastating and permanent.  While technology and higher-income in the developed world has obvious benefits, one of the costs is the geographic dispersion of the nuclear family where a simple telephone (before facetime) was insufficient form of communication for those who could not physically be there.  There was suffering. 

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At the local hospital outpatient clinic in Belladere Haiti, there seemed to be an endless parade of people being brought in by family members after change in status at home, many without a clear understanding that the change was due to a recent stroke.  One memorable male patient was brought in relatively early by his son (that is 24-48 hours) with a clear understanding that there was a stroke with new and dense hemiparesis (one sided weakness) and difficulty speaking.

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Blood Pressure (BP) was on the relatively low side of normal, with counselling that the BP be followed closely in follow-up.  As a physician, all one could do is make best judgement that the deficit had stabilized over 48 hours and maybe not hemorrhagic, and maybe evidence might suggest that giving aspirin in another day might not be completely outrageous.  

Almost there...

While seemingly trivial acute phase intervention, it might at least alleviate the guilt that otherwise there was absolutely nothing to do beyond the empathetic statement that you understand and are really sorry, and in the difficult days of recovery ahead “take care of your dad”.  There was suffering, and it was palpable, and it was bilaterally shared. That therapeutic quandary and desire to go beyond nihilism has led to the CIC/WHAG approach.  

Just about finished...

Our experience in urban hospitals in Port au Prince Haitiobserving many acute stroke related deaths, especially in young people, was a very different experience from the rural areas where hearing about stroke related death was often anecdotal after the event.  We discuss the connection of passion and suffering, independent of statistics.  We do not know how many of these mostly anonymous deaths of the rural destitute poor souls even had the basic human dignity of being recognized as a hypertension/stroke statistic.    

You did it...

These personal stories represent our motivation, and why we are so passionate about what we do, especially focused on hypertension, stroke and families. Our efforts are dedicated to our families, those families in Haiti, and their affected brothers and sisters worldwide.  It is all with the recognition that though the burden of grief for stroke mortality is a family and community experience, the major burden of stroke morbidity is borne by families and caregivers, as well as the stroke survivor.  This is especially the case in areas of low-resource without rehabilitation services.  Hypertension is described as the silent killer.  In reality, it is so much more, and the carnage is very real.  

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We have all heard the sometimes incessant “why” questions of an inquisitive child.  It is a binding and shared universal experience.  Children tend to reduce complexity to the basics, and reflect the immediate world around them.  

 

So, in the gradient from high to low income countries the corollary questions might range from the simple “why bother?” reflective of contentment, to the more profound “why doesn’t anybody care enough to do anything to help me and my family?” reflective of loss.   Family and community suffering due to hypertension related catastrophic illness, especially from cardiovascular disease and stroke, is also a binding and shared universal experience.  

As we triangulate from the extremes of the spectrum, the answer to the basic questions of “why hypertension” and “why focus on low resource venues” will become fairly self-evident to the inquiring mind.  A simplistic question for highly complex systems might be Why is it that successful programs in highincome countries do not work in low-income countries?”  and “What are the most important components of success that are able to be translated?   

 

Is it just a matter of insufficient money for implementation of the blueprint?  Or, is it due to fundamental differences that require very different innovative and flexible approaches? 

 CIC/WHAG has obviously decided on the inevitability of the latter approach, asking the challenging status quo questions of “Why does it have to be that way?”, “Why not try something different?”, “Why not here?”, and “Why not now?” 

The quest to develop answers to these basic questions, has coalesced to the simple CIC /WHAG MISSION STATEMENT:  BRINGING TOGETHER THOSE UNITED IN THE PASSION TO ALLEVIATE INDIVIDUAL, FAMILY, AND COMMUNITY SUFFERING DUE TO THE RAVAGES OF UNCONTROLLED HYPERTENSION IN LOW RESOURCE VENUES.  

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It is our passion to alleviate suffering from stroke by controlling hypertension in the community, and supporting healthy families.  That is what this whole comprehensive effort is about, and we hope you will share that passion.  We hope you will share our optimism and enthusiasm for the large effort to have a positive impact on families worldwide, manifest as the avoidance of preventable suffering.  

This is also why we continue to tell the family story using coloring books for children.  It is factual family folklore in areas with high levels of illiteracy, because that is where the real prevention intervention will take place for future generations!  The data has clearly shown that knowledge of stroke risk factors and warning signs are most limited in older adults (>65 years), with low levels of education, and people living in rural areas.  Culturally appropriate learning about hypertension and stroke is a game the whole family can play!   

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We have all heard the sometimes incessant “why” questions of an inquisitive child.  It is a binding and shared universal experience.  Children tend to reduce complexity to the basics, and reflect the immediate world around them.  So, in the gradient from high to low income countries the corollary questions might range from the simple “why bother?” reflective of contentment, to the more profound “why doesn’t anybody care enough to do anything to help me and my family?” reflective of loss.   Family and community suffering due to hypertension related catastrophic illness, especially from cardiovascular disease and stroke, is also a binding and shared universal experience.  

 

Good work, you've completed IA!

As we triangulate from the extremes of the spectrum, the answer to the basic questions of “why hypertension” and “why focus on low resource venues” will become fairly self-evident to the inquiring mind.  A simplistic question for highly complex systems might be Why is it that successful programs in highincome countries do not work in low-income countries?”  and “What are the most important components of success that are able to be translated?   Is it just a matter of insufficient money for implementation of the blueprint?  Or, is it due to fundamental differences that require very different innovative and flexible approaches?  CIC/WHAG has obviously decided on the inevitability of the latter approach, asking the challenging status quo questions of “Why does it have to be that way?”, “Why not try something different?”, “Why not here?”, and “Why not now?” 

The quest to develop answers to these basic questions, has coalesced to the simple CIC /WHAG MISSION STATEMENT:  BRINGING TOGETHER THOSE UNITED IN THE PASSION TO ALLEVIATE INDIVIDUAL, FAMILY, AND COMMUNITY SUFFERING DUE TO THE RAVAGES OF UNCONTROLLED HYPERTENSION IN LOW RESOURCE VENUES.  

IB. WHY DID WE DO THIS THE WAY WE DID?

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You might also think of this conceptually as the intersection of two FBOs, reflecting both Faith-Based Organizational and Fact-Based Organizational mindsets, both focused on having an impact in the battle against global hypertension. 

Bringing these diverse mindsets together is the challenge.  It is a balancing act.  We are essentially trying to serve at least two masters in order to make it simply educational and even task oriented for entry level volunteers and some Community Health Workers.  On the other end of the spectrum, we must make it factually correct and comprehensive as a defensible reference for teachers, leaders, and program developers.  The most impactful fulcrum in the middle are dedicated nurse and physician practitioners 

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Our Haitian colleague nurses and physicians historically have told us not to “dumb things down”, and to let them find their level of comfort with knowledge acquisition and not make the decisions externally for them as to what level is appropriate.  After nearly twenty years of experience, we understand the wisdom of that advice.  We have seen this play out with multiple evolving superb physician leaders who have absorbed what was offered, and then built on the knowledge base foundation quite remarkably.   

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The lessons are clear, and to reiterate what we have said on multiple occasions before, never assume that lack of financial resources where you are located in any way translates to lack of intellectual curiosity and the motivated individual’s ability to learn.  It is the same cautionary message for titles or classic job descriptions. 

 

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As we attempt to be advocates for the appropriate hypertension roles of medical missions with a volunteer and Community Health Worker (CHW) labor force, we must also unequivocally state that proper education and training according to standards must be taken very seriously.  Otherwise, the criticism by some public health professionals about those who do not take the responsibility seriously as “medical tourists or dilletantes in the effort may be appropriate 

 If you seek the responsibility, you must be prepared.  If you are fully prepared, you should be given the responsibility. 

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From there, you can get off at whatever floor level you find appropriate.  We need to make sure that we do not in any way limit your ascent in attaining the highest level of knowledge you desire, whether that be Book Four on management, Books Five and Six on hypertension and advanced medical conditions, or even Book Seven on Advanced Leadership topics. Your final level will only be determined by your aspirations and willingness to actively participate.  We are here to help. 

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This does lead us to the concept of certification, which is discussed in more detail in Module VI, Section I., and the repeated CIC knowledge points text box summary below of why certification, with initial focus on BP measurement.  

Knowledge Points

Why Certification?

 

BP Measurement is a foundational skill that must be done with a high level of accuracy

 

#1

It has been clearly established that on average BP measurement is not generally done with optimal accuracy according to established criteria

#2

Being able to perform and teach BP measurement according to defined standards is of critical importance and the best way to document that competence is through certification

#3

The ability to perform high quality public and personal education on hypertension and overall cardiovascular risk is also a critically important function that may also lend itself to the certification approach

#4

Higher level basic hypertension management activities, as well as knowledge and management of hypertension as related to advanced clinical problems builds on the basic foundation of BP measurement expertise

I.B.1. FROM THE PHILOSOPHICAL TO THE PRACTICAL

I.B.1. FROM THE PHILOSOPHICAL TO THE PRACTICAL

I.B.1.a. IT STARTS WITH BEING ABLE TO USE THE CHARTS TO NAVIGATE

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So, let us try to navigate from the calm waters of philosophical ideas through the choppy waters of practical implementation. In actuality, being on the water in rough conditions gives a different perspective. Any voyage requires effective and informed preparation and review of a navigation chart to plan for the voyage, and knowledge of where you are during the voyage with readjustment of course as necessitated by conditions. The navigational chart is actually a good analogy. There are printed paper charts that are very detailed. Electronic charts called raster charts are simply electronic chart copies of the paper charts, also detailed with correct geo-referencing. This level of detail is important for planning a voyage and confirming safety of a planned route, but may be distracting and “too much information” when underway

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The electronic alternative is called a vector chart which is a layered digital chart. While a simple display on the surface, it allows data mining so for example if you are looking at an area of interest, you could use a cursor to drill down to further levels of specific data about that area of interest. This is used often when underway and the route has been ratified as safe, in order to have an uncluttered visual display, but with the reassurance that if you wanted further data it is easily available 

In essence, this is similar to the approach that we have taken for publication of this very comprehensive reference.  Rather than having all the detail on the surface as a printed paper or an exact electronic copy of the printing, we take a layered vector chartlike electronic approach with tabs calling attention to Dense Fact Zones with a navigational marker of   DFZ.   

Similar to colored navigational aids or charted water depths, as areas to be potentially avoided the DFZs are color coded.

Dense factual information about pathophysiology, pharmacology, biochemistry, or engineering

Indicated by:

 

Dense factual information from literature review

Indicated By:

Dense factual information about global guidelines or international organization statements

Indicated By:

Dense factual information about Colleagues In Care or partner organizations

Indicated By:

I.B.1.b.  DECIDING ON YOUR FINAL DESTINATION AND SETTING THE COURSE

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For the sake of argument, if you plan a long voyage to a distant final destination, you would use many defined waypoints along the way.  You might split the voyage into multiple legs, with their own waypoint GPS coordinates arranged into routes, and contingency plans for elective and potential safe harbors to stop along the way.  Recalling that GPS only gives you a geospatial position of latitude and longitude to define where you are, it is important to have a plan of where you are going and mark the progress that you are making.   

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The CIC/WHAG modules are similar.  They are arranged in a series of three legs: 1. The Essential Core, 2. Management, and 3. Advanced medical treatment of hypertension in complicated clinical conditions.  By virtue of the indexing table of contents system, you will always be able to identify the coordinates of exactly where you are.  Without a course route plan and defined final destination, this is not enough information.  You may not be sure of where you are going, or how much progress you have made towards your personally defined destination along pre-qualified routes!  Also, recall the reality that variation in speed directly translates into voyage duration.   

UNDERSTANDING DENSE FACT ZONES (DFZs)  

What Are DFZs

In essence, this is similar to the approach that we have taken for publication of this very comprehensive reference.  Rather than having all the detail on the surface as a printed paper or an exact electronic copy of the printing, we take a layered vector chartlike electronic approach with tabs calling attention to Dense Fact Zones with a navigational marker of   DFZ.   

Similar to colored navigational aids or charted water depths, as areas to be potentially avoided the DFZs are color coded.

DFZ Type #1

Dense factual information about pathophysiology, pharmacology, biochemistry, or engineering

Indicated by:

 

DFZ Type #2

Dense factual information from literature review

Indicated By:

DFZ Type #3

Dense factual information about global guidelines or international organization statements

Indicated By:

DFZ Type #4

Dense factual information about Colleagues In Care or partner organizations

Indicated By:

Color is also used for dense financial analysis of medication, device and other medical costs To navigate safely and efficiently, it is simply a matter of knowing your colored marker navigation aids.  You then decide your preferred course and areas that you wish to steer away from.  Further navigation aids and suggestions are discussed at the end of Module I.  

I.B.1.d.  THE EASIEST ROUTE IS NOT NECESSARILY THE BEST ROUTE 

I.B.1.d.i. KISS AND THE IMPORTANCE OF BEING BOTH STRATEGIC AND TACTICAL 

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There are many variables that would go into a safe routing plan for individual vessels.  By analogy, it is similarly possible to factor variables for individuals or a “one-design” fleet of very similar groups of participants like volunteers, nurses, doctors and program developers in order to come up with a definitive individual or defined similar group plans.   

Now assume the responsibility for developing a plan from the same starting point, along the same legs to the same final destination, but for flotilla of different vessels.  Some are motor boats of variable length, size of motors and fuel capacity.  Some are sailboats of variable design related to cruising or racing.  Indeed, because of the length of the voyage and need to split up the three defined legs, the variation in speed is so much that slower vessels would be in completely different wind and current situations, and maybe even different weather systems.  

There is no way to...

There is no way to come up with a reasonable one size fits all navigation plan as the speed and capacities of the vessels, and the experience of skippers and crews are so diverse.  Similarly, it was impossible to come up with a one size fits all plan for our multi-level potential hypertension workforce.  There were two major options, the first option was to pick a single vessel (or one-design class of participants that are the sameto focus on and ignore all others.  The alternative we chose was to try to have a constant comprehensive approach with the requisite information as a knowledge base all should be familiar with (or at least to know where to find).  The variables are the options that allow all to take full advantage of the available information to develop their own routing to similar or different destinations at their own rate of speed.  We cannot speak to all possible variable and valid destination way points along the waybut we can support all with our knowledge sharing, assistance, and even some routing suggestions.  

 

In essence...

In essence, we have researched and organized the information we needed in order to make our hypertension journey in low-resource venues.  We have now shared and summarized a “possible (if not preferred)” route that may not work for all vessels.  Now we are putting the information out there for all who can learn what they need for the journey, so that they can navigate their own course at their own speed.  

This concept of requisite information that you need to operate and navigate safely is the best practical example we could think of to try to explain our approach (in different non-technical terms from what is described within the modules)  

I.B.1.d.  THE EASIEST ROUTE IS NOT NECESSARILY THE BEST ROUTE 

I.B.1.d.i. KISS AND THE IMPORTANCE OF BEING BOTH STRATEGIC AND TACTICAL 

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One thing that marine navigation shows us is that the easiest simple route, often as the path of perceived least resistance, is not necessarily the best route.   Though possibly counter-intuitive, a simple look at a chart with intervening reefs and obstructions tells us dramatically that the easiest route is also not necessarily the shortest straight-line route.  Easy, simple, and short is not always the answer, depending upon where you are going, why you are going, and how fast you intend to get there.    

This would seem to put us in conflict with an aeronautical and systems engineering design principle attributed to Clarence Leonard Johnson called the KISS Principle, described as the warning to “Keep ISimple Stupid” , or less offensively “Keep IShort and Simple”, “Keep ISimple and Straightforward”,  or “Keep ISmart and Simple” 

This has been a constant dilemma...

This has been a constant dilemma for the primary author to balance a natural tendency to KISS when teaching one-on-one, and the need to make sure that there is access to a definitive knowledge base as reference and resource.  Our stated goals are to build a culture of service, built on the solid foundation of knowledge.  The CIC mantra has always been that knowledge is power, and most powerful when shared.  The question then becomes what is the operational definition of the knowledge base to be shared to match multiple levels of service, and then how best to share it 

Our easiest path...

Our easiest path would be to target a very simple approach to volunteers on medical missions as the “least common denominator” in the spectrum of experienced healthcare workers.  Though the easiest and simplest, this would not be consistent with our strategy to maximize leverage for building an ever-expanding system based on teaching all as the teachers to teach othersaccording to defined a standard and knowledge base.  How could people adequately teach if their personal knowledge level is based on a simplistic and superficial level of understanding that allows simple recitation of defined facts, but not the depth that allows thoughtful and accurate answers to inevitable questions by inquisitive patients or public In essence, this is the not so subtle difference between the task specific “train the trainer” and more in-depth “teach the teacher” approaches as discussed in module V. 

With this as a strategy...

With this as a strategy, then how about the tactics?  You might even ask yourself how would you approach the challenge?  As a single author who is part of small but experienced and dedicated all-volunteer group, there are pragmatic realities.  Essentially with no substantial resources you actually controlin order to have influential impact and get to scale, you need to reach out for like-minded volunteers and partner organizations who share the developed vision.  If that is an accepted limitation, what might be the best way to accomplish that goal? 

 

There are other ...

There are other pragmatic realities.  It is paradoxically easier to go from the complex to the simple than starting simple and then try to fix deficiencies by ascending the partial to complete complexity slope. The tactical question regarding what is the easier path then becomes more defined within the total picture, if you know that you will ultimately need volunteer help with multi-level expertise.  Our tactical decision was that if you presented a concept and asked for broad-based collaborative assistance to  research, develop, and write a comprehensive reference resource for hypertension in low-resource venues, it would be unwieldy with a very low probability of success and high probability to end up in the “good idea graveyard  

Paradoxically...

Paradoxicallythe option to invest substantial time and talent to actually do all the research in order for us to write the comprehensive multi-level and multi-module reference on hypertension in low-resource venues ourselves was the easier route.  By generating the “source documents” to work from, it is less onerous to ask for volunteer assistance from target FBO and NGO individuals and groups working in areas of the destitute poor to simplify what they are given as a vetted fund of knowledge for their own use.  These individuals and groups are better positioned to focus on what is appropriate to the audience, starting with the essential core curriculum”.  From the recipient perspective, hopefully this is easier than a very daunting de-novo research and generation process.  It is more a matter of simply accepting the gift, and making it work for you and your groups.

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Likewise, it is less onerous to ask for hypertension expert expertise to support novel low- resource venue hypertension program concepts such as related to pregnancy and stroke presented in the advance clinical condition series of modules, once they are written and ready for examination and review by focused problem-specific teams 

 Though both options are fraught with difficulty, it has been our judgement that the latter would have a higher chance of success.    

I.B.1.d.ii.  MINIMIZING AND DEFINING LOSS

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Arguably, all strategic and tactical decisions are based on the concept of avoiding loss.  So, what is there to lose if this endeavor is not successful?  From a personal and CIC/WHAG organizational perspective, we could lose our investment of substantial time and effort, and our very ambitious aspirational efforts judged as folly.  We can live with that. 

The alternative is to not try, with lost opportunity that translates into continued physical losses for those suffering the ravages of undiagnosed and uncontrolled hypertension in low-income communities, especially manifest by stroke.  They cannot live with that.  Neither can we.  Therefore, we must try.   

And that our friends is exactly why we did this the way that we did!   

I.C. WHY IS THE GLOBAL HYPERTENSION BATTLE SO IMPORTANT?   

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As we delve into the question of the importance of global hypertension as a problem, we are beginning an exploration that will play out with a litany of answers in virtually every single module.  At this point, we will therefore only give a brief overview in order to make the point.  We will also introduce the concept of Dense Fact Zones (DFZs), in this case the first DFZ of literature review to obtain the facts.  

DFZ. GLOBAL HYPERTENSION BRIEF LITERATURE REVIEW

Navigate to enter DFZ 

The global burden of hypertension is growing, with a previous projected increase in prevalence to 29.2% of the world’s population, or 1.56 billion by the year 2025.  We are getting closer Suffice it to say, the numbers are daunting.  A more easily remembered number quoted is one in three people worldwide, which will inevitably be modified upward for reasons to be discussed.

I.C.2. GLOBAL HYPERTENSION MORBIDITY AND MORTALITY

Navigate to enter DFZ 

The International Society of Hypertension in 2001 estimated that hypertension was responsible annually for almost 8 million deaths worldwide, contributory if not causal for 54% of stroke, 47% of ischemic heart disease, 75% of hypertensive heart and renal disease and 25% of “other cardiovascular disease”. 

A more easily remembered simple but striking statistic might hypertension responsibility for 50% of heart disease, stroke and heart failure. Not quite a decade later, in 2010 hypertension related mortality has zoomed past an estimated 9.5 million deaths towards the 10 million threshold mark.  The global trajectory has continued upward.  

The most recent 2020 American Heart Association heart disease and stroke statistics can be accessed at the following link: https://doi.org/10.1161/CIR.0000000000000757 

If you look at the time period from 1990 to 2015the global burden of disease information specifically shows that the number of people with a systolic BP > 140 mm Hg a substantial increase from 17,307 to 20,526 per 100, 000 population.  When it comes to the annual death in this group, it increased from 97.9 to 106.3 per 100,00 population.  

Throughout the modules we will refer to DALY or Disability-Adjusted Life Year as a metric for morbidity.  DALYs in this > 140 mm Hg systolic BP group over this same period of time increased from 5.2 to 7.8 million.   

As will be emphasized in more detail in Modules XVII on Stroke and XIX on Coronary Artery Disease (CAD), the bottom line was that the largest numbers of Systolic Blood Pressure (SBP)  related deaths were due to Ischemic Heart Disease (IHD) at 4.9 million deaths, followed by Hemorrhagic Stroke (HS) at 2.0 million deaths, and Ischemic Stroke (IS) at an additional 1.5 million (total 3.5 for all strokes).   

 

There is one important piece of data that will be repeated over and over again throughout all modules. Hypertension is the most important Non-Communicable Disease (NCD) with mortality exceeding all infectious diseases together. The jury is still out on the effects of Covid-19 in 2020, with preliminary findings that indeed hypertension as a co-morbid pre-existing condition worsened prognosis and risk of mortality.

Knowledge Points

DATA AND TRENDS FROM 1990-2015

#1

In 2015, almost 18 Million total cardiovascular deaths worldwide

#2

Death rate decreased in all high- and many middle-income countries, with widened gap in low-income countries, with worsening BP control rate of only 7.7%.

#3

Largest number of Systolic Blood Pressure (SBP) related deaths

  • Ischemic Heart Disease (IHD) 4.9 million
  • Hemorrhagic Stroke (HS) 2.0 million
  • Ischemic Stroke (IS) 1.5 million
  • All strokes combined. total 3.5 million

#4

Global Burden of Disease information on people with a systolic BP > 140 mm Hg from 1990-2015:

  • Numbers increased from 17,307 to 20,526 per 100, 000 population
  • Annual death increased from 97.9 to 106.3 per 100,00 population.
  • DALY or Disability-Adjusted Life Year as a metric for morbidity increased from 5.2 to 7.8 million.

DFZ. WORLD HEALTH ORGANIZATION DATA RESOURCES

Navigate to enter DFZ 

WHO data concerning mortality and hypertension disease burden is available for review by country in the Global Health Observatory (GHO) data base, requiring drilling down through the NCD section. (www.who.int/gho/countries/hti/country_profiles/en/) A quick reference with comparison to other countries and worldwide ranking according to age standardized death rates per 100,000 population standard may be found at (www.worldlifeexpectancy.com/worldhealth-rankings).

 

We suggest that for the full picture, you look beyond directly listed hypertension mortality to include evaluation of stroke mortality. Stroke is a solid surrogate metric in the developing world with a high incidence of hypertension related hemorrhagic stroke. 

Historically, in the developed world, epidemiologic review of a data set of over a million people has clearly demonstrated an oft-quoted virtually linear relationship between BP and stroke within age groups. The striking Global Burden of Disease data on hypertension and stroke, especially the differential effect on hemorrhagic stroke in LIMC can be found in Module XVII.

As you develop the full picture, you can see that the hypertension related mortality risks of kidney disease and coronary artery disease are also substantial. Another important observation to review is the age at death. You will appreciate that a higher proportion of deaths are at a younger age in low- income countries, often before usual coronary artery defined mortality risk peaks. It is recommended that this be a first step rapid analysis to get a sense of the situation in the country of your interest, as part of the situational awareness exercise. These links and other resources for public health and disease burden data can also be found in the reference and resource section, and specifically recommend: http://www.whleague.org/index.php/jstuff/the-global-burden-of-hypertension

I.C.2. GLOBAL HYPERTENSION OUTCOMES GAP (DFZ)

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It has been reported that low and middle-income countries carry 80% of the burden of hypertension- attributable disease, manifest as a disproportionate prevalence of stroke, as well as heart failure and renal dysfunction. Unfortunately, they have previously enjoyed a reported access to only 10% of global resources to effectively manage the disease and its associated complications. There has been no recent dramatic improvement in that inverse disease burden to resource ratio. This defines the pragmatic reality that at least flavors the difficult implementation of many good ideas. 

Thus, it is disappointing that recent reports of 2015 data show that we are now approaching 18 million total cardiovascular deaths worldwide. This is despite the good news that age standardized CVD death rate has decreased in all high- and many middle-income countries from 1990-2015. Strikingly, the gap has widened with concomitant worsening of indicators in low-income countries, including a falling BP control rate of only 7.7%.

The problem is potentially even more severe than the simple prevalence numbers might reflect. There is suspicion that large pockets of undiagnosed and untreated hypertension in unreported areas of the destitute rural poor may exist, with many “silent deaths”. This is another factor that strongly suggests the need for more outreach BP screening efforts in these underserved remote areas.

I.C.3. GLOBAL HYPERTENSION: AN EXPANDED PLAYING FIELD 

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As we struggle with issues of accurate diagnosis, treatment and control of hypertension, at the same time there is inflationary pressure on prevalence estimates, driven by the recent SPRINT trial’s influence on American and European guidelines. Redefining Stage I hypertension as BP > 130/80, rather than 140/90, translates directly to an associated increase in newly defined hypertension in a quantitatively unchanged BP population distribution. There is another factor of concern. Using recent CARDIA (Coronary Artery Risk Development In Young Adults) U.S data as an eye-opening reference, there is a discordant rise with newly reported hypertension prevalence in people of African ancestry over the age of 55.

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Prevalence is reported to be as high as 77.5% for black males, and 77.7% for black females. This is compared to 54.5% for white males, and 40% for white females. Using the new hypertension definition, rather concerning prevalence estimates were recently reported with projections from the US National Health and Nutrition Examination Survey (NHANES) from 2013- 2016, and the China Health and Retirement Longitudinal Study (2011-12). In the U.S., 63% of the population, or an additional 70-75 million people, would be labeled as hypertensive, with up to 11 million additional patients requiring treatment. In China, the prevalence would be 55%, but this translates into up to an additional 280 million people labeled as hypertensive, with up to an additional 76 million patients requiring therapy.

DFZ. GLOBAL HYPERTENSION BRIEF LITERATURE REVIEW

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Clearly, screening BP data in low-income countries needs to be evaluated closely, with specific attention to defined hypertension prevalence in low income populations of African ancestry to determine the size of the “new” 130-139/80-89 group representing stage one hypertension. By virtue of incorporating a heretofore untreated cohort into the global hypertension pool, this change in Stage I hypertension definition will have a confounding effect that exacerbates the reported under-performance deficit related to the bottom line of BP control in resource challenged communities.

Awaiting final global consensus on treatment goals, especially in low-to middle-income countries, there is clear movement suggesting that our BP control goals should at least generally be more vigorous as move towards 130/80. Concern related to low resource areas hypertension burden expectations has already been thoughtfully voiced by Latin America and the Caribbean PAHO partnerships. The decision to add medication to interventional counseling in ACC/AHA Stage I for high risk patients is a complex discussion. In low resource venues, this will clearly require risk stratification for substantial CV risk threshold as decide where to distribute limited medication resources, and whether treatment is an unaffordable luxury in the absence of extreme risk.

It is a difficult issue to grapple with, as recent retrospective analysis of epidemiologic data from China does suggest a higher cardiovascular risk in this Stage I subset, unless > 60 y.o. Beyond the medication cost decisions, even public community education beyond that available at the time of BP screening can be a financial challenge, and an opportunity for volunteerism. 

Our focus needs to be directed toward low-income countries, and closing the global gap. Simultaneously, as a rising tide lifts all boats, we need rising standards for all active participants in every step of the global hypertension identification to control endeavor, as many to most high- and mid-income countries may also have focal low resource venues at risk. This suggests the need for a “glocal” (global to local) response to the challenge posed by lack of resources.

I.C.3. GLOBAL HYPERTENSION: WHY DO LOW-INCOME VENUES REQUIRE A DIFFERENT MIND SET  

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We are very focused on the relationship between hypertension and stroke in low resource venues, and as a preview of coming attractions share the following knowledge point figure 11 from Module XVII. This is an appropriate segue into the next Module #II. asking the “what” questions, starting with what is it about low-resource venues that makes things so different?

Knowledge Points

THE EVIDENCE: GLOBAL BURDEN of DISEASE Studies 2010, 2013, 2017

STROKE AND LOW-INCOME

#1

Of 6.45 million stroke-related deaths, 75% in developing countries

#2

Of 112.9 million stroke-related DALYs, 81% were in developing countries

#3

Of LIMC DALY loss, 64% due to Ischemic Stroke, and 86% Hemorrhagic stroke

#4

LIMC had a disproportionate 63% of incident ischemic strokes (IS) but 80% of hemorrhagic strokes (HS).

I.D. PRACTICAL NAVIGATION HINTS AND TIPS 

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You may soon decide to embark on your knowledge quest voyage. As you begin with information available on the web site you will quickly be introduced to what is important to know about hypertension. For nurses and physicians with any level of clinical hypertension experience, you probably will blow through that level quickly. Then the question may be what is absolutely important for us to learn, and what is the quickest way to learn it? The solution for most would be to next go to the series of CIC Knowledge and WHAG Action Point text boxes

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 in order to quickly understand the things that you need to know and need to do. Indeed, you could use these streamlined bullet point summaries as somewhat of a practical handbook. For all who wish to know more and move towards the teacher, leader, and program developer levels, it is then time to move on to the voluminous and comprehensive Knowledge Base Source Documents. You now generate your own intellectual curiosity why questions as you go beyond summary knowledge and action point statements to ask “hmm, why is that”? To answer the “why is that” question, the next question becomes a what question. What is absolutely important for knowledge acquisition, versus what is relatively important? At some point, you need to make rationale decisions on what to focus on, and what to either ignore, or leave for later review.

This Section contains text on understanding Dense Fact Zones and how to utilize them

DFZ ZONE ALL CATEGORIES

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Let us use some practical examples. Suppose that you see the sections on the mechanics, physics, and engineering of aneroid and automated BP manometers (Module VI), but you are not interested in how it works and all you want to know is a utilitarian answer to how do I use this thing accurately? Suppose that you see the extensive biochemistry of glucose (sugar) and lipid (fat) metabolism (Module VII/Book Three), and recall the intense rejoicing on the last day ever of your chemistry classes! Maybe you are interested in the pharmacology of individual as well as classes of hypertension medications (Module IX, Book Four), and want to dig deeper.

 

Suppose that you are very interested in the literature review and evolution of thought concerning salt and hypertension (also Module VII/ Book Three), and passionate about maternal care and the literature review reflecting the evolution of thought concerning hypertension in pregnancy and pre-eclampsia? Maybe you are mildly intrigued by the literature review on the history of auscultation and stethoscopes (Module VI/ Book Two)? Or, maybe you just are just in the “just tell me what I need to know” mode?

 

Suppose that you do not wish to spend a lot of time tracing the development of global guidelines or statements from international health organizations? At this point, you may be in the “just tell me what to do” mode, but that may change. To know how to follow the strings of development and evolution of thought to understand what “the organizational big folks” think may become more important as you have questions. You may want to come back later.

 

Suppose that in Module III on organizational and individual inter-relationships, you wish to see discussions about concepts such as faith and medicine. It may or may not be important that CIC/WHAG demonstrates credibility that by virtue of developed inter-relationships and the history of Colleagues In Care in Haiti, they have gone beyond talking the talk, and are walking the walk. You may find the information interesting and compelling, or you may not.

 

So, how to make this work? Consider that the document has areas of absolute importance, as well as more elective DFZ zones that may be of more or less relative importance to you, depending on your background and interests, and where you are in the hypertension knowledge acquisition process.

 

It is therefore very simple. If you are interested and wish to read the section, for example salt and hypertension in pregnancy, simply proceed. If you have no interest, such as biochemistry and metabolism of lipids, use the DFZ tab essentially as an on/off switch and turn the outlined section off and the outlined section will drop into the background. If you get into reading the section and find that it is not really of interest to you, too long or too involved, you have two options. Either use your cursor to simply scan ahead, or you can go back to the DFZ tab and remove the whole section to the background.

 

What happens if you identify areas that you do not want to take the time to examine in depth now but recognize as eventually important as you increase the depth of your knowledge?  What if you find things that are entertaining like the history of auscultation and stethoscopes and may want to review when have more time and relaxed?  Likewise, what if you find that sections on alcohol, tobacco, activity and diet are things that you want to learn more about, but not on the first pass through? 

 

Recall that the compendium has an internal navigation system similar to latitude and longitude, using the table of contents format to clearly identify and mark your location. Given the size of some of the books, especially Book Three on education, you then can place a bookmark to come back to!  

REFERENCES AND RESOURCES

REFERENCES

Kearney PM, Whelton M, Reynolds K, et. al. Global burden of hypertension: analysis of worldwide data. Lancet. 2005; 365:217-223. 

Lawes CM, Vander Hoorn D, Rogers A, et. al. for the International Society of Hypertension. Global burden of blood-pressure-related disease is a global priority. Lancet. 2008;371: 1513-1518.   

MacMahon S, Alderman MH, Lindholm I, et. al. Blood-pressure-related disease is a global priority. Lancet. 2008;371: 1480-1482. 

Forouzanfar MH, Liu P, Roth GA, et. al. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm Hg, 1990-2015.  JAMA. 2017;317 (2): 165-182.   

Roger VI, Go AS, Lloyd-Jones DM, et. al., Heart disease and stroke statistics-2012 update: A report from the American Heart Association. Circulation. 2012(1);188-197. 

Benjamin EJ, Virani SS, Callaway CW, et. al., Heart disease and stroke statistics-2018 update.  A report from the American Heart Association. Circulation.2018; 137(12); e67-e492. 

Benjamin EJ, Muntner P, Alonso A, et. al. Heart disease and stroke statistics-2019 update.  A report from the American Heart Association.  Circulation. 2019; 139(10): e56-e528.  

Virani SS, Alonso A, Benjamin EJ, et. al. Heart disease and stroke statistics-2020 update: A report from the American Heart Association.  Circulation. 2020;141 (9): e139-e596.  https://doi.org/10.1161/CIR.0000000000000757 

Roth GA, Johnson C, Abajobir A, et. al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990-2015. Journal of the American College of Cardiology. 2017; 71:1-25. 

Global Burden of Disease GBD Risk Factors Collaborators.  Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386: 2287-2323.  

Feigen VL, Krishnamurthi RV, Parman P, et. al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study.  Neuroepidemiology. 2015; 45:230-236.  

Lewington S, Clarke R, Qizilbash N, et al., for the Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360: 1903–1913. 

Mills KT, Bundy JD, Kelly TN, et. al., Global disparities of hypertension prevalence and control: A systematic analysis of population-based studies from 90 countries. Circulation. 2016; 134(6):441-450.  

SPRINT Research Group, Wright JT, Williamson JD, Whelton PK, et.al., A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine. 2015; 373:2103-2116.  

Whelton PK, Carey RM, Aronow WS, et. al., 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2018;71: e127-e248.  

Munter P, Carey RM, Gidding S, et.al., Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2017;137: 109-118.  

Thomas SJ, Booth JN, Dai C, et. al., Cumulative incidence of hypertension by 55 years of age in blacks and whites: the CARDIA study. Journal of the American Heart Association. 2018;7: e007988.  

Egan B. Defining hypertension by Blood Pressure 130/80 mm Hg leads to an impressive burden of hypertension in young and middle-aged black adults: follow up in the Cardia Study. Journal of the American Heart Association. 2018;7: e00997. 

Skeete J, Connell K, Ordunez P, DiPette D.  The American College of Cardiology/ American Heart Association 2017 hypertension guideline: Implications for incorporation in Latin America, the Caribbean, and other resource-limited settings. Journal of Clinical Hypertension. 2018;20(9):1342-1349.  

Khera R, Lu Y, Lu J, et. al. Impact of 2017 ACC/AHA guidelines on prevalence of hypertension and eligibility for antihypertensive treatment in the United States and China: nationally representative cross sectional study. British Medical Journal. 2018;362: k2357.  

Qi y, Han X, Zhao D, et. al., Long-term cardiovascular risk associated with stage I hypertension defined by the 2017 ACC/AHA Hypertension Guideline.  Journal of the American College of Cardiology. 2018,72(11)1201-1210.   

Williams B, Mancia G, Spiering W, et. al., 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal. 2018;39(33): 3021-3104.   

Owolabi M, Olowoyo P, Miranda JJ, et. al. Gaps in hypertension guidelines in low-and middle-income versus high-income countries: a systematic review.  Hypertension. 2016; 68:1328-1337. 

Irazola VE, Gutierrez L, Bloomfield G, et. al. Hypertension prevalence, awareness, treatment, and control in selected LMIC communities. Results from the NHLBI/UHG Network of Centers of Excellence for chronic diseases. Global Heart. 2016; 11:47-59.  

Chow CK, Teo KK, Rangarajan S, et. al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA2013; 310:959-968.   

Roth GA, Johnson C, Abajobir A, et. al. Global, regional, and national burden of cardiovascular diseases for 10 causes. 1990-2015.  Journal of the American College of Cardiology2017; 71:1-25. 

Ezzati M, Pearson-Stuttard J, Bennet JE, Mathers C. Acting on non-communicable diseases in low- and middle-income tropical countries. Nature.2018;559:507-516.  

Kenerson JG. Hypertension in Haiti: The challenge of Best Possible Practice. Journal of Clinical Hypertension. 2014;16(2):107-114.  

RESOURCES

Institute for Health Metrics and Evaluation, 2015 University of Washington.  http://vizhub.healthdata.org/gbd-compare/. 

World Health Organization. A global brief on hypertension: Silent killer, global public health crisis.  World Health Day 2013. Geneva, Switzerland: World Health Organization; 2013.  

http://ish-world.com/downloads/pdf/global_brief_hypertension.pdf 

WHO, Geneva 2018. Global health estimates 2016: Deaths by causes, age, sex, by country and by region 2000-2016. http://www.who.int/healthinfo/global_burden_disease/estimates/en/ 

World Hypertension League.  http://www.whleague.org/index.php/j-stuff/the-global-burden-of-hypertension 

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