Video Abstract | Reducing cardiovascular risk in hypertension with community-based intervention

We, at the Population Health Research Institute
in Canada, along with our colleagues in Colombia, Malaysia and the United Kingdom, have been
working to reduce cardiovascular risk as part of the HOPE 4 study. Hypertension is the leading cause of cardiovascular
disease worldwide. We know that lowering blood pressure reduces
stroke and ischemic heart disease. Furthermore, statins reduce cardiovascular
disease in those with hypertension. Unfortunately the detection, treatment and
control of hypertension has been low for decades. We urgently need simple and effective strategies
to help tackle this greatest contributor to the global burden of disease. Therefore, we conducted two systematic reviews
and two health system appraisals in Colombia and Malaysia to help identify context-specific
barriers to the management of hypertension. This information was then used to inform
the design of the HOPE 4 intervention. The HOPE 4 study is an open, community-based,
cluster randomised controlled trial involving individuals 50 years or older with new or
poorly controlled hypertension in urban and rural communities in Colombia and Malaysia. The HOPE 4 intervention involves community
screening and treatment of cardiovascular risk factors by non-physician health workers. They are supported by tablet-based simplified
algorithms as well as counselling programmes. We provided combination antihypertensives
and statins, and we also encouraged family and friends to be involved in their care,
to help with respect to medication adherence and healthy behaviours. Following community screening, 1371 individuals
provided informed consent and 30 communities were randomised to intervention or control. Follow-up with respect to the primary outcome
was obtained in 97% of participants at 12 months. The HOPE 4 intervention demonstrated that
there was a 75% greater reduction in Framingham Risk Score. This effect was evident across all predefined
subgroups including country, urban and rural communities, age, gender, and education level. Furthermore, there was there was a greater
than 11mm of mercury reduction in systolic blood pressure, as well as a 0.4 mmol/L larger
reduction in LDL cholesterol in the intervention group as compared to control. The proportion of patients with controlled
hypertension was significantly greater in the intervention group, at 69%, more than
double that of the control. Medication adherence and healthy behaviours
also improved. The HOPE 4 strategy is effective, pragmatic,
and has the potential to significantly reduce cardiovascular disease as compared with health
systems that are primarily physician-based. Adopting the HOPE 4 strategy can help control
hypertension and reduce cardiovascular risk factors, which will help achieve the United
Nations’ goal for a one-third reduction in cardiovascular mortality by 2030.

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