Hypertension (HTN) is recognized globally as one of the most modifiable risk factors for cardiovascular morbidity, mortality, and various health complications. It represents a significant public health burden. In 2000, an estimated 970 million people globally were affected by HTN, with 330 million in high-income countries and 640 million in low- and middle-income countries. Projections suggest that by 2025, the prevalence of HTN will increase to 1.56 billion people worldwide [1]. In India, the prevalence of HTN ranges from 4–15% in urban areas and 2–8% in rural populations [2,3]. Risk factors contributing to HTN include advancing age, obesity, unhealthy dietary habits, tobacco use, and alcohol consumption. These factors are strongly associated with the development of primary HTN [4].

Uncontrolled HTN significantly increases the risk of coronary artery disease (50%), cerebrovascular events (33%), chronic kidney disease (10–15%), and other complications. Effective management of HTN is therefore crucial [5].

This prospective study, conducted over 180 days, is the first of its kind to examine the prescription patterns for antihypertensive drugs among both inpatients and outpatients at the Department of Medicine, Silchar Medical College and Hospital (SMCH), Southern Assam. The study employed convenience sampling to select participants.

HTN continues to be a widespread condition globally, with rising prevalence in both rural and urban populations in India. Thus, a uniform approach to treatment is vital, particularly to ensure adherence to updated World Health Organization (WHO) guidelines for prescribing antihypertensive medications.

The Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure published its 7th report (JNC-7) in 2003, recommending angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), and thiazide-type diuretics as first-line treatments for most patients. It also advocated for combination therapy using two or more drugs to achieve target blood pressure (BP) levels: <130/80 mmHg for patients with chronic kidney disease (CKD), congestive heart failure (CCF), or type 2 diabetes mellitus (T2DM), and <140/90 mmHg for other hypertensive individuals. The subsequent JNC-8 guidelines (2014) revised some recommendations, excluding BBs as first-line drugs and setting a target BP of <150/90 mmHg for individuals aged 60 years or older, and <140/90 mmHg for younger individuals or those with T2DM or CKD [6,7].

The European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) guidelines (2018) also endorsed the use of five major drug classes for antihypertensive therapy. Additionally, the WHO essential medicines list (EML) includes thiazide diuretics, ARBs, CCBs, and ACEIs as essential drugs for HTN management. In 2019, fixed-dose combination antihypertensive medications were added to the EML.

The 2021 WHO guidelines provide evidence-based recommendations for initiating pharmacological management of HTN in adults, particularly those who are not pregnant. These guidelines outline when to begin treatment, follow-up intervals, BP thresholds for control, and the healthcare personnel authorized to initiate treatment. They also provide guidance on selecting single-drug, dual-drug, or fixed-dose combination therapies based on individual needs.

Recommendations for Initiating Treatment:

1. Pharmacological management is recommended when systolic BP (SBP) is ≥140 mmHg or diastolic BP (DBP) is ≥90 mmHg.
2. Antihypertensive treatment is strongly advised for individuals with cardiovascular disease and an SBP of 130–139 mmHg.
3. Antihypertensive therapy is recommended for individuals without cardiovascular disease but with elevated cardiovascular risk, CKD, or T2DM, and an SBP of 130–139 mmHg.
4. Treatment should ideally begin within 28 days of diagnosis, with earlier initiation recommended for SBP ≥160 mmHg, DBP ≥100 mmHg, or signs of end-organ damage.

Recommended First-Line Drug Groups:

1. Calcium channel blockers (CCBs)
2. Thiazide or thiazide-like diuretics
3. ACEIs or ARBs

Long-acting drugs are preferred for their efficacy and sustained control. Specific drug recommendations include CCBs or diuretics for individuals aged over 65 years and African populations, BBs for coronary artery disease, and ARBs/ACEIs for those with CCF, CKD, T2DM, or significant proteinuria [6].

Aims and Objectives

Primary Objective:

• To analyze the prescription patterns for antihypertensive medications in patients diagnosed with HTN at MKCG Medical College and Hospital.

Secondary Objective:

To evaluate the comorbidities associated with HTN.

The study was conducted at MKCG Medical College and Hospital over a six-month period, from June 2023 to November 2023. It was designed as an observational and prospective study to analyze specific patterns and outcomes related to hypertension management. A total of 280 individuals participated in the study, providing a representative sample size to ensure meaningful analysis.

To collect data, a specially designed case record form was utilized, allowing researchers to document important patient details, including demographic information such as name, age, and sex, along with the prescribed medications, their dosages, and schedules. Prior to participation, informed consent was obtained from all individuals involved in the study, ensuring ethical compliance and voluntary participation.

The collected data were systematically analyzed using Microsoft Excel, and the results were expressed in percentages to facilitate clear presentation and understanding of the findings. Participants included in the study were known cases of hypertension, of both genders, and aged between 18 and 60 years. These patients were either visiting the medicine outpatient department or admitted to the inpatient department during the study period.

Certain individuals were excluded from the study to maintain the focus and validity of the analysis. Exclusion criteria included those below 18 years or above 60 years of age, pregnant or lactating women, and patients experiencing acute conditions such as myocardial infarction, left ventricular failure, or stroke. Additionally, individuals with end-stage renal or hepatic disease were excluded from participation due to the complexity of their conditions, which could confound the results.

This meticulous approach to selecting participants and analyzing data ensured that the study could effectively evaluate the prescribed antihypertensive treatment patterns and their implications for the target population

A total of 280 participants were included in the study, comprising 174 males (62.1%) and 106 females (37.9%). The age distribution showed that the majority of participants (55.0%) belonged to the 51–60 years age group, followed by 41–50 years (27.9%), 31–40 years (15.0%), and only 2.1% were aged between 18 and 30 years. Regarding body mass index (BMI), slightly more than half of the participants (51.1%) had normal BMI, while 46.1% were classified as overweight, and 2.9% were underweight. A family history of hypertension was reported by 53.9% of the participants, whereas 46.1% did not report such a history.

In terms of comorbidities, 42.9% of participants had multiple comorbidities, 20.0% had a single comorbidity, and 37.1% reported no comorbidities. These findings highlight the demographic and clinical diversity of the study population, with a predominance of older adults, males, and individuals with multiple health conditions or a family history of hypertension.

Table 1: Demographic and Clinical Characteristics of Study Participants (N = 280)

The majority of hypertensive patients in the study were managed with monotherapy (71%), followed by dual therapy (25%) and multi-drug therapy (4%) (Figure 1).

Figure 1- FigurePatterns of drug therapy prescribed in HTN patients

Among single-drug therapies, calcium channel blockers (CCBs) were the most frequently prescribed (n=136), followed by angiotensin receptor blockers (ARBs, n=79), beta-blockers (BBs, n=32), diuretics (n=17), and angiotensin-converting enzyme inhibitors (ACEIs, n=16) (Figure 2).

Figure 2- Patterns of antihypertensive drugs prescribed in HTN patients

In patients receiving dual therapy, the combination of CCB + ARB (n=124, 44.3%) was the most commonly used, followed by ARB + diuretics (n=83, 29.6%), CCB + diuretics (n=53, 18.9%), and ARB + BB (n=20, 7.1%) (Figure 3).

Figure 3- Patterns of dual therapy antihypertensive drugs prescribed in HTN patients

In multi-drug therapy, ARB+CCB+diuretic 205 (73.2%), followed by ARB+CCB+BBs 75 (26.8%) was the most preferred treatment of choice.

Figure 4- Patterns of antihypertensive drugs prescribed in multi-drug therapy

In our study, out of individual drug choices, the most preferred was amlodipine 103 (36.8%) then telmisartan 54 (19.3%), cilnidipine 34 (12.1%), losartan 28 (10%), and the least preferred was atenolol 26 (9%). The details are provided in Figure 5

Figure 5- Patterns of individual antihypertensive drugs prescribed in patients.

Common comorbidities associated with hypertension were dyslipidaemia 107 (38.2%), Diabetes mellitus 95 (33.9%), Chronic Kidney disease 53 (18.9%), Ischemic heart disease 54 (19.3%) and Congestive heart failure 48 (17.1%)                                                                                   

Figure 6- Common comorbidities associated with hypertension.

The study findings reveal that the prevalence of hypertension (HTN) among men and women is 62.1% and 37.9%, respectively (Fig. 1). The sex distribution of hypertensive individuals has been inconsistently reported in the literature, with some studies reporting a higher prevalence among men, while others found more hypertensive women [3,7,8]. In this study, men were more frequently associated with HTN than women, aligning with the findings of Gupta et al. [9].

The majority of participants in our study were aged between 50 and 59 years, a trend consistent with earlier research, which highlights the higher risk of HTN in older adults. A significant genetic predisposition to HTN is suggested by the finding that 52% of participants reported a family history of HTN (Fig. 9) [3,8].

Regarding BMI, 51.1% of participants had a normal BMI, 46.1% were classified as overweight, and 2.9% were underweight (Fig. 10). These findings contrast with the results of Pittrow et al., who observed different BMI distributions among hypertensive individuals [10].

In terms of pharmacological treatment, monotherapy was prescribed in 71% of cases, followed by dual therapy (25%) and multidrug therapy (4%) (Fig. 2). This differs from the findings of Kulkarni et al., who emphasized the rationality of combination therapy for reducing cardiac morbidity and mortality in hypertensive patients [11]. Several studies also highlight the necessity of combination therapy in approximately 70% of hypertensive individuals to achieve optimal blood pressure control [12,13].

Among single-drug therapies, calcium channel blockers (CCBs) were most commonly prescribed, followed by angiotensin receptor blockers (ARBs), beta-blockers (BBs), diuretics, and angiotensin-converting enzyme inhibitors (ACEIs) (Fig. 3). For dual therapy, the combination of CCB and ARB was most frequently used, followed by ARB and diuretics (Fig. 4). In multidrug therapy, the ARB + CCB + diuretic combination was the most preferred (Fig. 5). These findings align with the recommendations of JNC-VII, which advocate the use of thiazide diuretics as the initial treatment option [14].

Comorbidities were commonly associated with HTN in our study, with dyslipidemia being the most frequent, followed by type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) (Fig. 7). This is consistent with the findings of Schmieder et al. [14]. Similarly, our results align with the study by Chou et al., where ACEIs (31.5%), beta-blockers, and other classes of antihypertensive drugs were commonly used [15-17].

These findings underscore the importance of personalized treatment strategies and the role of genetic and lifestyle factors in managing hypertension effectively.

This study emphasizes the critical role of evidence-based prescribing practices in the management of hypertension. Monotherapy was the most common approach, with calcium channel blockers being the preferred drug class. The prevalence of comorbidities such as dyslipidemia and diabetes highlights the need for comprehensive care strategies. Tailored treatment regimens, guided by current guidelines, can improve outcomes and reduce the burden of HTN-related complications. These findings underscore the necessity of ongoing research and education to optimize hypertension care in clinical settings

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