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The realities of hypertension management in Ukraine

Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is currently providing primary care to internally displaced people in the east of Ukraine. He is on twitter: @drricharmitage

Hypertension is the leading modifiable risk factor for cardiovascular disease (CVD) and premature death worldwide,1 and is responsible for 8.5 million annual global deaths from stroke, ischaemic heart disease, other vascular diseases, and renal disease.2  Both the prevalence and absolute burden of hypertension is rising, especially in low- and middle-income countries,1 thereby rendering it a WHO target risk factor for the prevention of non-communicable diseases.3

34.8% of Ukraine’s adult population – some 10.8 million people – is estimated to have hypertension, only 66.4% of whom are aware of their diagnosis and only 14.4% have it adequately controlled.4  Accordingly, hypertension is the key driver of CVD in Ukraine, the country’s leading cause of premature mortality. This concerning rate of hypertension is driven by the country’s high prevalence of associated lifestyle factors, including smoking, excessive alcohol consumption, excess dietary salt, obesity and lack of physical activity.5

Patients have access to an array of medications available over-the-counter without a prescription or any other form of professional gatekeeping…

Even prior to Russia’s invasion, the Ukrainian state-funded health system was over-stretched, under reform, and considerably supplemented by out-of-pocket payments.6  Patients have access to an array of medications available over-the-counter without a prescription or any other form of professional gatekeeping, including antihypertensives of various kinds, strengths and combinations.  Such unregulated access, combined with extensive purchasing of automated blood pressure monitors and the public salience of hypertension’s dangers, has caused widespread inaccurate self-diagnosis of hypertensive disease without professional oversight or formal investigation.  Such diagnoses are often based on a single elevated blood pressure reading, without any repeated measurements, ambulatory monitoring, or knowledge of blood pressure’s normal physiology.

This self-diagnosis rarely triggers the necessary assessment of end-organ damage that such a diagnosis should subsequently trigger were it accurately made by a medical professional.  As such, testing for proteinurea, renal function and diabetes, along with fundoscopy examination and 12-lead ECG, is unlikely to occur, while assessment of overall CVD risk, including serum total cholesterol, high-density lipoprotein cholesterol, and consideration of lipid modification with the use of statins, is equally improbable.  Similarly, appropriate investigations for possible secondary causes of hypertension in those under 40 (12.7% of Ukrainians aged 18-29, and 20.4% of those aged 30-40, are estimated to have hypertension)4 are unlikely to occur, meaning significant renal, vascular and endocrine pathology may go unidentified.

General public concern over the adequate control of blood pressure is notably high within Ukraine… 

General public concern over the adequate control of blood pressure is notably high within Ukraine, possibly due to the concerning prevalence of hypertensive disease, public awareness of its associated risk factors, and successful health promotion by primary care and public health professionals.  However, without relevant knowledge and contextual understanding, this concern often results in preoccupation and general anxiety regarding one’s blood pressure.  Many individuals monitor their blood pressure multiple times each day and make behavioural decisions in response to single readings.7  Following accurate or erroneous self-diagnosis, many people purchase over-the-counter antihypertensives without no relevant prescription, pharmacological understanding, or professional guidance from the medically untrained shopkeeper.  As such, uninformed and dangerous heuristics replace considered medical advice around the acquisition and use of powerful antihypertensives, such as ‘the higher the dose, the better,’ or ‘two medications are better than one.’  This leads to the administration of combination medications, which contain two to three antihypertensives of different classifications, often in high doses without gradual titration.  Rather than being taken on a regular basis, these medications are administered in response to elevated blood pressure, which may be accurately determined by an automated machine reading, or simply assumed by the presence of a symptom such as headache.  The taking of a tablet is subsequently followed by a repeat blood pressure measurement after a period of time, and the repeat administration of the original medication if the blood pressure has not fallen to an acceptable level.  No regard is given to the potential side-effects of these medications, their adverse effects or polypharmacy interactions, or the need for close monitoring of potentially harmful impacts such as the effects on renal function of ACEi usage.  This constellation of behaviours is astonishingly common, dangerously unregulated, and entirely devoid of profession oversight.

As psychological stress and emotional anxiety are strongly associated with hypertensive disease, the war in Ukraine has exacerbated the country’s burden of this disease.  Many have sheltered from aerial bombardment in underground spaces for multiple weeks, while witnessing the loss of their homes, communities, loved ones and neighbours.  Many have fled into neighbouring regions,8 or crossed borders into countries as war refugees,9 while healthcare facilities have been widely destroyed.  Along with exacerbating existing hypertension and increasing its prevalence, this has disrupted the supply of patients’ regular medications, which both worsens the control of this chronic disease, and drives the purchase of over-the-counter medications and the harmful behaviours regarding blood pressure control.

Hypertension forms a substantial burden of disease in Ukraine, and health behaviours around this condition are dangerously unregulated.  Both these facts are exacerbated by the Russian invasion, thereby adding to the injustice created by the conflict.

Featured image by Olga Subach on Unsplash

References

  1. KT Mills, A Stefanescu, and J He. The global epidemiology of hypertension. Nature Reviews Nephrology 05 February 2020; 16: 223–237. DOI: 10.1038/s41581-019-0244-2
  2. NCD Risk Factor Collaboration. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet 11 September 2021; 398(10304): 957-980. DOI: 10.1016/S0140-6736(21)01330-1
  3. TN Nguyen and CK Chow. Global and national high blood pressure burden and control. The Lancet 11 September 2021; 398(10304): 932-933. DOI: 10.1016/S0140-6736(21)01688-3
  4. World Health Organization. Ukraine: Hypertension fact sheet. 29 June 2021. https://cdn.who.int/media/docs/default-source/country-profiles/hypertension/ukr_en.pdf?sfvrsn=430d7e56_9&download=true [accessed 03 May 2022]
  5. World Health Organization. STEPS prevalence of noncommunicable disease risk factors in Ukraine 2019. 2020. https://apps.who.int/iris/bitstream/handle/10665/336642/WHO-EURO-2020-1468-41218-56060-eng.pdf [accessed 03 May 2022]
  6. P Romaniuk and T Semigina. Ukrainian health care system and its chances for successful transition from Soviet legacies. Globalization and Health 2018; 14(116). DOI: 10.1186/s12992-018-0439-5
  7. C Antonino. In Ukraine, The Ministry Of Health Explains What To Do With A Hypertensive Crisis In Wartime. Emergency Live 11 March 2022. https://www.emergency-live.com/news/in-ukraine-the-ministry-of-health-explains-what-to-do-with-a-hypertensive-crisis-in-wartime/ [accessed 03 May 2022]
  8. IOM. Migration Data Portal: Ukraine. https://www.migrationdataportal.org/ukraine/crisis-movements [accessed 03 May 2022]
  9. UNHCR. Operational Data Portal: Ukrainian Refugee Situation. https://data2.unhcr.org/en/situations/ukraine [accessed 03 May 2022]
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