. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Believing impossible things: achieving universal blood pressure awareness on a global basis Ross D. Feldman 1 * and Norman R.C. Campbell 2 1 Cardiac Sciences Program, IH Asper Institute, St Boniface Hospital and the University of Manitoba, Winnipeg, Canada; and 2 Departments of Medicine, Community Health Sciences, Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Canada Online publish-ahead-of-print 17 June 2019 This editorial refers to ‘May Measurement Month 2018: a pragmatic global screening campaign to raise awareness of blood pressure by the International Society of Hypertension’ † , by T. Beaney et al., on page 2006. Alice laughed. ‘There’s no use trying,’ she said. ‘One can’t believe impossible things.’ I daresay you haven’t had much practice,’ said the Queen. ‘When I was your age, I always did it for half- an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.’ Through the Looking Glass, Lewis Carroll Beyond malnutrition/dietary risks, high blood pressure remains the single largest contributor to disease burden on a global basis 1 —a position it has held for decades. While in some countries blood pres- sure control rates have risen over this period (in Canada it increased from 10% to 70% between the 1990s and 2010s 2 ), for much of the world, especially in low- and middle-income countries, the needle has barely budged, with control rates in many middle- and lower in- come countries of <10%. The impossibility of the task of improving blood pressure control has frustrated the efforts of national public health leaders around the world. Developing global awareness campaigns to deal with impossible tasks has a long and contentious history. In 1985, the Live Aid benefit concert was held as a step towards the achievement of the impos- sible task of relieving the ongoing Ethiopian famine. Advertised as a ‘global jukebox’, its goal was fundraising, but more importantly to raise global awareness. The effectiveness of this global public aware- ness campaign is still being debated. In some respects, the report by Beaney et al. 3 in this issue of the European Heart Journal is a similar (al- though distinctly non-musical) effort, i.e. to raise local and personal awareness of blood pressure and the risk of hypertension on the basis of a global initiative. Also similarly to Live Aid, it may be difficult to determine the effectiveness of this effort. However, at least, for this iteration of the May Measurement Month (MMM) campaign, as for the Live Aid concert, we should salute the effort but be cautious about the determination of the immediate and the ultimate impact of this ambitious initiative. The classic three metrics for understanding the effectiveness of and gaps in clinical hypertension management on a population-wide basis are (i) awareness rates; (ii) treatment rates; and (iii) control rates. Of the three, lack of awareness (exceeding 50% of the hyper- tensive population on a global basis) quantitatively is the single largest determinant of poor blood pressure control and lynch pin to any ser- ious effort to control hypertension. In that context, the report by Beaney and colleagues on behalf of the May Measurement Month 2018 investigators is particularly timely and important. 3 In it, they out- line a global campaign led by the International Society of Hypertension where they were able to screen the blood pressure of >1.5 million people in 89 countries. This report describes an innovative approach for improving hyper- tension control globally. However, in evaluating this contribution and assessing its importance in providing new knowledge regarding the epidemiology of hypertension on a global basis, and most importantly on the effort to improve blood pressure control, it is critical to ap- preciate what this report is and what it is not. First, the findings described in this manuscript are notable neither for their novelty nor for the elegance of the study design. That the reported prevalence of hypertension is high (in the current study 33%) and that overall awareness rates were low (60%) with control rates of 33% is in line with the point estimates from previous national and global reports—with the relatively high control rates being affected by the under-representation in the survey of people from low-income countries (i.e. those with the lowest control rates). In regards to study design, this was a ‘cross-sectional opportunistic study of (self- selected) volunteer adults’ and thus suffers from the expected con- founders that occur with selection bias. Further, the weaknesses in: (i) determining the diagnosis of hypertension (on the basis of single The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. † doi:10.1093/eurheartj/ehz300. * Corresponding author. IH Asper Institute-CR1056, St. Boniface Hospital, 369 Tache Ave, Winnipeg, MB 2RH 2A6, Canada. Tel: þ1 204 235 3324, Fax: þ1 204 233 8783, Email: rfeldman@sbgh.mb.ca Published on behalf of the European Society of Cardiology. All rights reserved. V C The Author(s) 2019. For permissions, please email: journals.permissions@oup.com. European Heart Journal (2019) 40, 2018–2020 EDITORIAL doi:10.1093/eurheartj/ehz413 Downloaded from https://academic.oup.com/eurheartj/article/40/25/2018/5519670 by guest on 28 October 2022