Hypertension Screening and Evidence‑Based Pharmacotherapy in India: A Socioeconomic Perspective

Primary Screening Tests for Hypertension in Indian Patients

Hypertension (HTN) remains the leading modifiable risk factor for cardiovascular morbidity and mortality in India. Early detection hinges on simple, cost‑effective investigations that can be performed in primary care settings.

• Office Blood Pressure Measurement (OBPM):
  • 2–3 readings taken after 5 minutes seated, using a validated automated cuff.
  • Average of the last two readings considered.
• Ambulatory Blood Pressure Monitoring (ABPM):
  • 24‑hour recording with readings every 20 minutes during day and 30 minutes at night.
  • Detects masked or white‑coat hypertension; recommended for patients with inconsistent OBPM.
• Home Blood Pressure Monitoring (HBPM):
  • Patient‑held cuff; at least 2 readings in the morning and evening over 7 days.
  • Useful for long‑term trend analysis.
• (screened if BP ≥140/90 mmHg):
  • Serum electrolytes (Na⁺, K⁺), creatinine & eGFR.
  • Fasting plasma glucose or HbA1c (diabetes screening).
  • Lipid profile.
  • Urinalysis for microalbuminuria.
• :
  • Echocardiography for left ventricular hypertrophy (LVH).
  • Renal Doppler US if secondary causes suspected.

Evidence‑Based Medication Options Tailored to Socioeconomic Groups

The Indian Pharmacopoeia and national guidelines (e.g., NCD Guidelines 2019) recommend stepwise therapy. Cost, availability and adherence are pivotal determinants.

1. Low‑Income Patients (Public Sector, Rural)

• :
  • Thiazide diuretic (Chlorothiazide 12.5–25 mg or Chlorthalidone 12.5–25 mg).
  • Cost: <₹100 per month.
• (if BP uncontrolled):
  • ACE inhibitor (Enalapril 5–10 mg).
  • Or Calcium channel blocker (Amlodipine 2.5–5 mg).
• :
  • Chlorthalidone 12.5 mg + Hydrochlorothiazide 12.5 mg (available as 2‑pill packs).
  • Improves adherence and reduces pill burden.
• : Salt restriction (<5 g/day), DASH diet adapted to local foods, moderate physical activity (30 min brisk walk 5×/week), weight control.
• : OBPM every 4–6 weeks until target <140/90 mmHg, then every 3 months.

2. Middle‑Income Patients (Private Clinics, Urban)

• :
  • Combination of low‑dose ACEi (Enalapril 5 mg) + Thiazide (Chlorthalidone 12.5 mg).
  • Commercially available FDCs: Enalapril 5/Chlorthalidone 12.5 (₹200–₹250/month).
• :
  • Beta‑blocker (Metoprolol 25–50 mg) if concomitant ischemic heart disease.
  • ARB (Losartan 50 mg) if ACEi intolerance.
• :
  • Prefer ACEi/ARB over direct renin inhibitors (Aliskiren) due to cost and limited availability.
• :
  • Amlodipine 5 mg or Diltiazem 120 mg.
• :
  • Structured weight loss program (5–7% body‑weight reduction).
  • Salt‑free cooking workshops.
• :
  • OBPM monthly for first 3 months, then quarterly.
  • Lipid & renal panel every 6 months.

3. High‑Income Patients (Specialty Care, Affluent)

• :
  • Dual‑therapy FDC (Amlodipine 5 mg + Benazepril 10 mg) or
  • Triple therapy (Amlodipine + Benazepril + Chlorthalidone).
• :
  • Mineralocorticoid receptor antagonist (Spironolactone 25 mg) if resistant HTN.
  • Direct renin inhibitor (Aliskiren 150 mg) if intolerant to ACEi/ARB.
• :
  • MRI/MRA for suspected secondary causes (renal artery stenosis, pheochromocytoma).
  • 24‑hour ABPM in all patients with resistant HTN.
• :
  • Cardiology for LVH, CAD.
  • Nephrology if eGFR <60 ml/min/1.73 m².
• :
  • Personalized dietitian plans (Mediterranean style).
  • Fitness trainer for aerobic & resistance training.
• :
  • Digital BP cuffs with telemonitoring.
  • Biannual full metabolic panel.

Surgical & Interventional Options for Resistant Hypertension

• :
  • Indicated for patients with uncontrolled BP despite 3‑drug therapy.
  • Procedure: catheter‑based radiofrequency ablation of renal sympathetic nerves; cost varies ₹1.5–2 lakh.
• :
  • Implantable device stimulating carotid sinus; limited availability, cost >₹3 lakh.
• :
  • For significant renal artery stenosis (>70%); requires angioplasty with stent; covered partially by public insurance.

Key Takeaways for Indian Practitioners

• Start with inexpensive, evidence‑based first‑line agents (thiazide or ACEi) and use FDCs to enhance adherence.
• Tailor therapy based on socioeconomic context: prioritize affordability, availability and patient education.
• Regular monitoring (OBPM, ABPM) is essential; integrate telemedicine for remote follow‑up.
• Address secondary causes early with appropriate imaging and laboratory tests to avoid overtreatment.
• Incorporate lifestyle modification programs as a universal adjunct, leveraging community health workers and digital platforms.

• Share