Xin-Hua Zhang

Standards for the Uniform Reporting of Hypertension in Adults Using Population Survey Data: Recommendations From the World Hypertension League Expert Committee

Surveillance and monitoring of cardiovascular risk factors including raised blood pressure are critical to informing efforts to prevent and control cardiovascular disease. Yet, many countries lack the capacity for adequate national surveillance. Furthermore, hypertension indicators are often reported in different ways, which hampers the ability to compare and assess progress. In order to encourage standardized hypertension surveillance reporting, the World Hypertension League assembled an Expert Committee to develop a standard set of core indicators, definitions, and recommended analyses. The recommended core indicators are: (1) blood pressure distribution, (2) prevalence of hypertension, (3) awareness of the condition, (4) antihypertensive drug treatment, and (5) control of hypertension based on drug therapy. Each of these can be reported overall and by age group and sex, with crude and age‐standardized changes tracked over time in order to assess the impact of instituted policies and programs for hypertension prevention and control. An expanded list of indicators can also facilitate tracking of hypertension prevention and control efforts. Widespread adoption of these indicators and analyses could benefit all those conducting and analyzing hypertension surveys and will facilitate hypertension surveillance efforts.

A Call to Regulate Manufacture and Marketing of Blood Pressure Devices and Cuffs: A Position Statement From the World Hypertension League, International Society of Hypertension and Supporting Hypertension Organizations

From the Departments of Medicine, Physiology and Pharmacology and Community Health Sciences, O’Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary,Calgary, AB; Department of Family Practice, University of British Columbia, Vancouver, BC, Canada; Hypertension Center STRIDE-7, Sotiria Hospital, Third University Department of Medicine, Athens, Greece; AAMI Sphygmomanometer Committee, Pediatric Exercise Science, Memphis, TN, USA; Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Improving Health Outcomes at American Medical Association; Department of Family and Community Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Clinical Pharmacology and General Internal Medicine, University of Alberta, Edmonton, AB, Canada; MRC Research Unit on Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team, North-West University, Potchefstroom, South Africa; Molecular Pharmacology, University College Dublin, Dublin, Ireland; Corvallis, Montana, USA; and University of Glasgow, Glasgow, UK

High Blood Pressure 2016: Why Prevention and Control Are Urgent and Important. The World Hypertension League, International Society of Hypertension, World Stroke Organization, International Diabetes Foundation, International Council of Cardiovascular Prevention and Rehabilitation, International Society of Nephrology

Norm R. Campbell, MD, FRCPC; Tej Khalsa, MD, MSc; World Hypertension League Executive: Daniel T. Lackland, DrPH; Mark L. Niebylski, PhD,MBA,MS; PeterM. Nilsson,MD, PhD; Kimbree A. Redburn,MA;MarceloOrias,MD; Xin-Hua Zhang,MD, PhD; International Society of Hypertension Executive: Louise Burrell, MD, MBChB, MRCP, FRACP; Masatsugu Horiuchi, MD, PhD ; Neil R. Poulter, MBBS, MSc, FRCP, FMed Sci; Dorairaj Prabhakaran, MD, DM, MSc, FRCP, FNASc; Agustin J. Ramirez, MD, PhD; Ernesto L. Schiffrin, MD, PhD, FRSC, FRCPC ; Rhian M. Touyz, PhD, MBBCh, FRCP, FRSE; Ji-Guang Wang, MD, PhD; Michael A. Weber, MD; World Stroke Organization; International Diabetes Federation; International Council of Cardiovascular Prevention and Rehabilitation; International Society of Nephrology

The World Hypertension League challenges hypertension and cardiovascular organizations to develop strategic plans for the prevention and control of hypertension.

Increased blood pressure (BP), the leading risk for death and disability globally, is estimated to be responsible for almost one in five deaths and an estimated 7% of disability globally. In many economically developing regions, the prevalence of hypertension is both high and increasing. Globally, it is estimated that approximately one half of people with hypertension are not aware they have it and that fewer than 20% have controlled BP. The epidemic of noncommunicable diseases (NCDs) that are driven by hypertension, tobacco, unhealthy diets, physical inactivity, excess alcohol, obesity, and diabetes is viewed as a threat to the world’s development and economies apart from the widespread social and personal distress that NCDs cause. It is dismaying to realize that, with the current knowledge, these NCD risks, specifically with respect to hypertension, are largely preventable and treatable. The World Health Organization (WHO) has outlined a series of public health policies to promote healthy diets, physical activity, lower alcohol consumption, and a tobacco-free environment that would largely prevent blood pressure-related disease burden and most NCDs if fully implemented. Specifically, dietary sodium is highly relevant to the hypertension community as the primary adverse effect of excess dietary salt is mediated through increased BP and attributed to nearly one third of hypertension cases. Clinically, controlling hypertension can also prevent its adverse health consequences (although it will not impact patients with suboptimal but normal BP wherein half of BP-related risk resides). From a clinical perspective, the issue put simply is to screen BP at all encounters, diagnose patients with high BP, and treat patients to control. Underlying the simplicity of the above is the high complexity of influencing, developing, and implementing public health policy; changing community structure, values, and resources; enhancing public self-efficacy; providing comprehensive primary health care service delivery; ensuring health care providers have the information they need; and surveillance, monitoring, and evaluation to determine what is working and what is not. This speaks to the need for comprehensive systematic plans for the prevention and control of hypertension. Several high-resource countries have developed or are in the process of developing systematic plans for hypertension control. Notably, it is the United States and Canada that have long histories of developing and updating such strategies that have the highest rates of hypertension control. From these “Best Practices” and lessons learned, strides can be made in translating hypertension prevention and control to all populations. Strategic planning can be developed by either governments or nongovernmental organizations such as national hypertension societies or preferably through partnership of government and nongovernmental organizations. Strategies focusing on hypertension are perhaps the most feasible and impactful starting point to prevent and control NCDs (arguably competing with tobacco for most impactful health intervention). Several countries have cardiovascular programs that incorporate hypertension prevention and control, while the WHO advocates hypertension integration into NCD prevention and control strategies for low-resource settings. Since the most appropriate strategy is likely to depend on the specific national situation, hypertension organizations have a social responsibility to ensure that hypertension prevention and control is prominent and specifically featured in national NCD or cardiovascular strategies. In this regard, the need for focused hypertension strategies is advocated by the World Hypertension League (WHL). Specifically, that in both lowto middle-resource settings and many highresource settings, the most appropriate approach is to incorporate the hypertension strategy into a more comprehensive approach. Further, if a hypertension strategy is the primary starting focus, the ultimate plan should be eventual integration with other risks and diseases. With this framework, the WHL specifically challenges all national hypertension and cardiovascular organizations to develop focused hypertension strategies that can stand alone or are a part of a more comprehensive approach to prevent NCDs. In developing a strategy, the first step is to consider the context. Is the strategy for the organization’s internal use, to use for advocacy to outside organizations, to improve hypertension prevention and control in the population, or even broader to prevent and control NCDs? Is it limited in scope, focusing on clinical control, or is it intended to also address prevention? What are the baseline hypertension data for the population, perhaps Address for correspondence: Norm R.C. Campbell, MD, Libin Cardiovascular Institute of Alberta, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada E-mail: ncampbel@ucalgary.ca

Resources for Blood Pressure Screening Programs in Low Resource Settings: A Guide From the World Hypertension League

From the Department of Medicine, The University of Calgary, Calgary, AB, Canada; Departments of Medicine, Community Health Sciences and of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada; Public Health Foundation of India, New Delhi, India; World Hypertension League, Corvallis, MT; Department of Medicine, University of Calgary, Calgary, AB, Canada; American University of Beirut Medical Center, Beirut, Lebanon; Department of Nursing, Universit e du Qu ebec a Trois-Rivi eres, Quebec, QC, Canada; President Haiti Hypertension Center, State University of Haiti, Port Au Prince, Haiti; Colleagues in Care, Virginia Beach, VA; Douala School of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon; Universidad Nacional de C ordoba, C ordoba, Argentina; University of Sao Paulo, Ribeirao Preto, Brazil; and Beijing Hypertension League Institute, Beijing, China

2016 dietary salt fact sheet and call to action: the World Hypertension League, International Society of Hypertension, and the International Council of Cardiovascular Prevention and Rehabilitation

Norm R. C. Campbell, MD, FRCPC; Daniel T. Lackland, DrPH; Mark L. Niebylski, PhD, MBA, MS; Marcelo Orias, MD; Kimbree A. Redburn, MA; Peter M. Nilsson, MD, PhD; Xin-Hua Zhang, MD, PhD; Louise Burrell, MD, MBChB, MRCP, FRACP; Masatsugu Horiuchi, MD, PhD, FAHA; Neil R. Poulter, MBBS, MSc, FRCP, FMed Sci; Dorairaj Prabhakaran, MD, DM, MSc, FRCP, FNASc; Agustin J. Ramirez, MD, PhD; Ernesto L. Schiffrin, CM, MD, PhD, FRSC, FRCPC, FACP; Alta E. Schutte, PhD, MSc; Rhian M. Touyz, MBBCh, PhD, FRCP, FRSE; Ji-Guang Wang, MD, PhD; Michael A. Weber, MD; International Council of Cardiovascular Prevention and Rehabilitation

The World Hypertension League: where now and where to in salt reduction

High dietary salt is a leading risk for death and disability largely by causing increased blood pressure. Other associated health risks include gastric and renal cell cancers, osteoporosis, renal stones, and increased disease activity in multiple sclerosis, headache, increased body fat and Menieres disease. The World Hypertension League (WHL) has prioritized advocacy for salt reduction. WHL resources and actions include a non-governmental organization policy statement, dietary salt fact sheet, development of standardized nomenclature, call for quality research, collaboration in a weekly salt science update, development of a process to set recommended dietary salt research standards and regular literature reviews, development of adoptable power point slide sets to support WHL positions and resources, and critic of weak research studies on dietary salt. The WHL plans to continue to work with multiple governmental and non-governmental organizations to promote dietary salt reduction towards the World Health Organization (WHO) recommendations.

The World Hypertension League: A Look Back and a Vision Forward

2014 was truly an exciting year with nothing more rewarding than the newly formed alliance betweenWiley Publishing, The Journal of Clinical Hypertension (JCH), and the World Hypertension League (WHL). Together, our efforts have established a platform for developing, collecting, disseminating, and evolving the best evidence base for the prevention and control of hypertension globally. We are proud to reaffirm that JCH is now the home journal of WHL with “Free Access” to all. Please sign up by following the instructions on the WHL Web site found at http://www.whleague.org/index.php/ j-stuff/the-journal-of-clinical-hypertension. An underlying component to this effort has been Partnerships. The WHL council members are essential to our mandate and are essential to maintain a global reach at the population level. In addition, 2014 support from multiple organizations has been critical and these organizations include but are not limited to the World Health Organization, International Society of Hypertension, Pan American Health Organization, World Heart Federation, International Diabetes Federation, International Society of Nephrology, World Stroke Organization, International Council of Cardiovascular Prevention and Rehabilitation, World Action on Salt and Health, Pan African Society of Hypertension, UK Health Forum, the UK Faculty of Public Health, Canadian Stroke Network, British Hypertension Society, American Heart Association, World Stroke Organization, and multiple universities (Figure). Among the WHL publications and presentations have been a series of publications, presentations, and learning modules that are being made available through our new resource center http://www.whleague.org/index.php/ j-stuff/resource-center. With the intent to maximize our impact with the strongest evidence base, the WHL continues to develop and release resources as outlined in the Table. Our hope is to build and promote more resources in 2015 through JCH, our new Website (www.whleague. org), congresses, a WHL quarterly newsletter, and other communications. The WHL is committed to knowledge translation and sharing of success stories as the foundation of our mission. We will continue to have annual reports and news releases from members and partners as part of a team-based “Lessons Learned” effort.

World Hypertension League Position on Public Use of Blood Pressure Kiosks.

Recently, the American Society of Hypertension (ASH) developed and released the “Public Use of BP Kiosks: A Guide for Clinicians” (http://www.ash-us.org/documents/files/2015/150422-DOCUMENT-Guide-PublicUse-BP-Kiosks-(3).pdf). Blood pressure (BP) kiosks are “stations” where BP is automatically assessed by a device that is triggered by the individual who is getting their BP assessed. They are designed to operate without a healthcare professional present, are often located in pharmacies or other public or private settings to aid BP assessment, and may be accessed by large numbers of people. In the ASH guide, “out-of-office” BP assessment is indicated to play an important role in hypertension diagnosis and management. This is especially true where health resources are scarce. The World Hypertension League (WHL) supports the ASH guide for these out-of-office kiosk readings. Worldwide, about half of people with hypertension are unaware they have elevated BP, while in the United States 30% are not aware. Health literacy is also generally higher in the United States than many other areas of the world. Hence, the WHL has modified the ASH guide for a global audience. To support the ASH guide, Alpert and colleagues reviewed critical issues relating to accuracy and reliability of many BP kiosks. Based on the review, the ASH guide highlights the need for kiosk devices to pass American National Standards Institute/Association for the Advancement of Medical Instrumentation/International Standards. Internationally, other accuracy standards are often used and are acceptable, including the British Hypertension Society standard and the European Society of Hypertension International Protocol. Devices that have not been assessed or have not passed these accuracy standards should not be used. Unfortunately, many devices that are not publically documented to have passed accuracy standards or that are documented to have failed accuracy standards are still marketed. Appropriate cuff size is another important factor relating to the accuracy of the reading highlighted by the ASHguide.Most BP kiosks have only one cuff size and this can cause a falsely low reading if the cuff is too large or a falsely high reading if the cuff is too small. The ASH guide indicates a kiosk device marketed by PharmaSmart (Rochester, NY) that has passed accuracy standards and has an innovative technology that adapts the cuff size to that of the arm. In the absence of a correct cuff size or such technology, BP kiosk readings cannot be regarded as accurate and should not be supported. The WHL also recommends that BP kiosks be located in an environment conducive to accurate readings and that there are appropriate resources to help inform people how to take a reading and understand the meaning of the reading. For accurate readings, the kiosks should be in a quiet, comfortable place. The device should be designed to have the person sitting with the arm supported at heart level with the feet on the floor. Adequate, easy-to-read instructions should inform the person of how to best perform the process for an accurate reading, including the impact of stress, pain, and smoking on a BP reading. In addition, information should be available to help interpret the BP reading. The individual being assessed should be provided their BP reading to take home or to their healthcare provider. Ideally, the BP kiosks should be in a location where the person can get advice from a pharmacist or other healthcare professional (eg, in-store pharmacy). The WHL supports the ASH guide on BP kiosks and provides additional advice relevant for use in many areas of the world.

A needs assessment of national hypertension organizations for hypertension prevention and control programs.

From the Department of Medicine, University of Calgary, Calgary, AB, Canada; Departments of Medicine, Community Health Sciences and of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada; Department of Neurosciences, Medical University of South Carolina, Charleston, SC; Beijing Hypertension League Institute, Fu Wai Hospital, Beijing, China; World Hypertension League, Clancy, MT; and Department of Medicine, Beijing Hypertension League Institute, Beijing, China