For the Dr. Pablo Gulayin, coordinator of the Department of Research in Chronic Diseases (IECS) and the Dr. Vilma Irazola, director of the Department of Research in Chronic Diseases (IECS).
High blood pressure is the leading modifiable risk factor for cardiovascular and cerebrovascular disease. The 2019 Global Burden of Disease Study estimated that it was responsible for approximately ten million deaths, contributing substantially to the burden of cardiovascular disease, particularly in low- and middle-income countries (1).
In our country, it is estimated that high blood pressure affects more than a third of the adult populationAccording to the latest National Survey of Risk Factors (2). In addition, approximately 1 in 3 people who were not known to be hypertensive had elevated blood pressure, slightly more than half of those with known hypertension were under treatment, and among these, 59,1% had elevated blood pressure during the evaluation (2).
Despite its high prevalence and the enormous impact it has on population health, Diagnosis, treatment, and control rates remain lowThis raises an uncomfortable but necessary question: Are we still failing at the basics?
A critical point is the clinical inertia and inappropriate variability in medical practiceThe persistence of behaviors guided by “usual practice,” often not aligned with clinical practice guidelines, limits adequate blood pressure control (3). Even today, we observe a high proportion of patients treated with monotherapy, when evidence and guidelines recommend initiating drug combinations early to achieve better therapeutic control (4). This is compounded by frequent delays in initiating antihypertensive treatment, as it is hoped that lifestyle changes will control blood pressure in patients for whom the protective effect of medications is documented and whose benefits require blood pressure reductions that cannot be achieved solely through lifestyle modifications (4).
Furthermore, the barriers to access and socioeconomic inequalities They undermine continuous, comprehensive, and quality health care, becoming key determinants of existing inequities in cardiovascular health (5). Hypertension is not only more frequent and disproportionately affects those living in low- and middle-income countries, where health systems are weaker, but in the most vulnerable populations of these countries it also generates a greater burden of disease, disability, and premature death, contributing to perpetuating a vicious cycle between disease and impoverishment (6).
Added to this reality is the daily reality of health systems, characterized by a High demand and limited consultation timeThis can often result in a lack of systematic measurement, incomplete measurements, or measurements that do not follow international standards, including the use of validated blood pressure monitors, which hinders the diagnosis, monitoring, and control of hypertension (7, 8). It can also lead to an incomplete assessment of cardiovascular risk, limiting the possibility of effectively guiding preventive interventions based on the estimation of long-term overall cardiovascular risk (9).
It is also important to point out that one of the main challenges is the therapeutic adherence In chronic treatments in general, adherence is an even greater public health problem in low- and middle-income countries (10, 11). It has been observed that low adherence among hypertensive patients is approximately 45%, and that the proportion rises to 83,7% among individuals with uncontrolled blood pressure (12). Adherence is one of the cornerstones of chronic disease management, yet it remains an underestimated problem. In daily practice, there is little systematic recording, scant measurement, and almost no structured intervention to improve it (13, 14).
In short, despite having more evidence, better treatments and updated guidelines, population-level results are still far from what was expected. The gap doesn't seem to be in knowledge, but in implementation.
Generating evidence is not enough
From the Chronic Diseases Research Department At the Institute for Clinical and Health Effectiveness (IECS) we work with a strong focus on implementation scienceStarting from a clear premise: generating evidence is not enough if we cannot translate that evidence into better practices and policies in the real world. Under this premise, we develop studies that seek to understand which interventions work best in local contexts, what the barriers and facilitators are for their adoption, and how they can be adapted and scaled sustainably.
Convinced that primary care is key to the diagnosis and monitoring of hypertension, we have evaluated multicomponent interventions, highlighting the role of community health workers, which demonstrated significant improvements in blood pressure control in vulnerable populations (15). Likewise, during the pandemic, we explored strategies for monitoring therapeutic adherence based on tracking medication withdrawals at pharmacies (16).
We are currently conducting a project with Harvard University involving approximately 1000 people at high cardiovascular risk, in which a digital application supports the healthcare team with personalized, risk-based recommendations aligned with current clinical practice guidelines (17). This approach allows us to help bridge the gap between what we know works and what actually happens in practice, contributing to the strengthening of more effective, equitable, and people-centered healthcare systems.
In this context, the initiative HEARTS in the AmericasThe Pan American Health Organization (PAHO) initiative proposes a paradigm shift in the approach to hypertension and cardiovascular risk, focusing on strengthening primary care, standardizing evidence-based practices, and promoting teamwork at the primary care level (18-20). Our department actively supports this agenda by generating evidence and developing implementation frameworks that promote care based on interdisciplinary teams, with clearly defined roles and coordinated participation.
On this International Hypertension Day, we know we have a clear challenge.It's not enough to know what to do; we need to do it better and on a larger scale. Prioritizing effective implementation, strengthening primary care, clearly defining which indicators to measure and how to do so, and reducing access gaps are essential steps if we want to improve the diagnosis, management, and follow-up of people with hypertension. More than developing new therapeutic approaches, the greatest impact will be achieved by effectively addressing the barriers already identified, ensuring that the benefits reach all those who need them in a timely and equitable manner.
References:
1. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study. J Am Coll Cardiol. 2020;76(25):2982-3021.
2. Fourth National Survey of Risk Factors. Final Results. National Institute of Statistics and Censuses (INDEC). Ministry of Health. Republic of Argentina. 2019 July 2024. Available from: https://www.indec.gob.ar/ftp/cuadros/publicaciones/enfr_2018_resultados_definitivos.pdf.
3. Barth JH, Misra S, Aakre KM, Langlois MR, Watine J, Twomey PJ, et al. Why are clinical practice guidelines not followed? Clin Chem Lab Med. 2016;54(7):1133-9.
4. Mancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41(12):1874-2071.
5. Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in access to cardiovascular health care: our greatest challenge. J Am Coll Cardiol. 2008;52(23):1817-25.
6. World Health Organization. Global report on hypertension: the race against a silent killer. Geneva: World Health Organization; 2023. Available from: https://iris.who.int/bitstream/handle/10665/372896/9789240081062-eng.pdf.
7. Doane J, Buu J, Penrod MJ, Bischoff M, Conroy MB, Stults B. Measuring and managing blood pressure in a primary care setting: a pragmatic implementation study. J Am Board Fam Med. 2018;31(3):375–388. doi:10.3122/jabfm.2018.03.170450.
8. Voorbrood, VM, de Schepper, EI, Bohnen, AM et al. Blood pressure measurements for diagnosing hypertension in primary care: room for improvement. BMC Prim. Care 25, 6 (2024). https://doi.org/10.1186/s12875-023-02241-z.
9. World Health Organization. WHO guideline for the pharmacological treatment of hypertension in adults. Geneva: World Health Organization; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK573627/.
10. Sabaté E. (Ed.) Adherence to long-term therapies: Evidence for action. World Health Organization, Geneva, Switzerland. (2003). Available from: https://www.paho.org/en/documents/who-adherence-long-term-therapies-evidence-action-2003.
11. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-97.
12. Abegaz TM, Shehab A, Gebreyohannes EA, Bhagavathula AS, Elnour AA. Nonadherence to antihypertensive drugs: A systematic review and meta-analysis. Medicine (Baltimore). 2017;96(4):e5641.
13. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-14.
14. Poulter NR, Borghi C, Parati G, Pathak A, Toli D, Williams B, et al. Medication adherence in hypertension. J Hypertens. 2020;38(4):579-87.
15. He J, Irazola V, Mills KT, Poggio R, Beratarrechea A, Dolan J, et al. Effect of a Community Health Worker-Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial. JAMA. 2017;318(11):1016-25.
16. Gulayin PE, Gutierrez L, Pinto D, Fontana S, Avila M, Gomez W, et al. A Multi-Component Intervention to Improve Therapeutic Adherence in Uncontrolled Hypertensive Patients Within the Primary Care Level: A Before-and-After Study. High Blood Press Cardiovasc Prev. 2024;31(3):271-8.
17. Abrahams-Gessel S, Beratarrechea A, Irazola V, Gulayin P, Gutierrez L, Mahoney M, et al. Managing high cardiovascular disease risk among adults in Argentina using a multicomponent strategy linking key aspects of care: A two-arm cluster-randomized clinical trial (PRIMECare) protocol. Contemp Clin Trials. 2023;134:107357.
18. Ordunez P, Campbell NRC, DiPette DJ, Jaffe MG, Rosende A, Martinez R, et al. HEARTS in the Americas: targeting health system change to improve population hypertension control Rev Panam Public Health. 2024;48:e17.
19. Londono E, Gupta R, Stuyft PV, Heine M, Giraldo G, Ku GM, et al. HEARTS quality: a policy framework to strengthen hypertension and cardiovascular risk management in primary healthcare-insights from HEARTS in the Americas. Lancet Reg Health Am 2026;53:101311.
20. Irazola V, Prado C, Rosende A, Flood D, Tsuyuki R, Ojeda CN, et al. Expanding team-based care for hypertension and cardiovascular risk management with HEARTS in the Americas. Rev Panam Public Health. 2025;49:e43.