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 Table of Contents  
Year : 2023  |  Volume : 11  |  Issue : 1  |  Page : 19-27

Hypertension clinical care in the era of coronavirus disease 2019: Practical insights from India

1 Shilpa Medical Research Centre, Mumbai, Maharashtra, India
2 Fortis Hospital, Bengaluru, Karnataka, India
3 Subam Heart and Diabetes Care, Chennai, Tamil Nadu, India
4 Marwari Hospitals, Guwahati, Assam, India
5 Allahabad Heart Center, Allahabad, Uttar Pradesh, India
6 Scientific Services, USV Private Limited, Mumbai, Maharashtra, India

Date of Submission04-Jan-2023
Date of Acceptance21-Feb-2023
Date of Web Publication12-Apr-2023

Correspondence Address:
Santosh Revankar
Scientific Services, USV Private Limited, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_1_23

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Objective: The objective of this study was to seek the opinion of Indian health-care professionals (HCPs) about hypertension (HTN) care during coronavirus disease 2019 (COVID-19) era.
Methods: HCPs' opinions (n = 2832) were recorded based on survey and round table meetings. Standard questionnaire consisting of nine questions pertaining to HTN care in COVID-19 was prepared, discussed, and evaluated by experts who treat patients with HTN during COVID-19 era.
Results: Smoking/tobacco use, obesity, and comorbidities (diabetes/dyslipidemia) were ranked as the top three modifiable risk factors. A total of 37% and 33% of HCPs reported an increase in blood pressure (BP) during the lockdown period in 10%–20% and 20%–40% of hypertensive patients, respectively, who were on monotherapy. Around 35% of HCPs reported that 20%–30% of their patients with HTN showed uncontrolled BP (>150/100 mmHg). Dual-drug therapy in patients with uncontrolled BP was preferred by 56% of HCPs. Nearly 71% preferred dual combination for HTN management. In dual combination, 27% preferred angiotensin receptor blockers (ARBs) + diuretic, 26% preferred ARB + calcium channel blockers, and 18% preferred ARB + beta-blockers. The majority of HCPs (44%) consider that <30% of their patients with HTN check BP at home. A total of 47% of HCPs reported acute coronary syndrome as the most common HTN-related complication. The majority of HCPs (57%) considered that avoiding contamination during BP measurement is the challenging parameter. Around 32% considered self-BP monitoring (SBPM) as the best method to improve medication adherence.
Conclusion: SBPM, combination therapies, and digital connect with patients are critical aspects of HTN management during COVID-19 pandemic.

Keywords: Acute coronary syndrome, digital connect, dual-drug therapy, obesity, smoking

How to cite this article:
Tiwaskar M, Koregol PC, Krishnan HH, Agarwal D, Hasan O, Abhyankar M, Revankar S, Kumar N. Hypertension clinical care in the era of coronavirus disease 2019: Practical insights from India. Heart India 2023;11:19-27

How to cite this URL:
Tiwaskar M, Koregol PC, Krishnan HH, Agarwal D, Hasan O, Abhyankar M, Revankar S, Kumar N. Hypertension clinical care in the era of coronavirus disease 2019: Practical insights from India. Heart India [serial online] 2023 [cited 2023 May 31];11:19-27. Available from: https://www.heartindia.net/text.asp?2023/11/1/19/374098

  Introduction Top

According to the global burden, hypertension (HTN) is the most significant cause of mortality worldwide. An estimated 57% of stroke- and 24% of coronary artery-related deaths due to HTN have been reported. The national-level survey in India reported 30.7% of HTN prevalence; of them, young adults (20–44 years) showed a high prevalence of HTN (22.4%). Among the same age group, the pre-HTN prevalence was reported to be 45.5%, which is an alarming situation for Indian population since such a trend increases the risk of premature mortality due to cardiovascular disease.[1]

The coronavirus disease 2019 (COVID-19) pandemic associated with severe acute respiratory syndrome coronavirus 2 has taken a heavy toll of people all over the world. The first case was reported in Wuhan (China) in December 2019, and since then, the incidence has been rising and researchers are grappling to find an effective therapy. HTN itself is a key risk factor to serious health issues including heart and renal problems and clinical studies are in progress to determine whether HTN is an independent risk factor for COVID-19 as well as management strategies for HTN during COVID-19. It has been reported that patients with HTN not taking medications have an additional risk of mortality from COVID-19. A meta-analysis assessing the prevalence of underlying disease in deceased people with COVID-19 determined that the highest prevalence was associated with HTN which was estimated as 46% (37%–55%).[2]

Hypertensive patients with COVID-19 infection were observed to have severe pneumonia, extreme inflammatory reactions, and organ and tissue damage than those without HTN. Hence, these patients need to be routinely monitored for managing their blood pressure (BP) using appropriate antihypertensive agents.[3] A meta-analysis of 18 studies including 5160 patients, of which 1315 patients had HTN, showed that HTN was moderately associated with severity and mortality for COVID-19 (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 2.37–3.75 and OR: 2.88 [2.22–3.74]).[4]

During COVID-19, multiple societies such as the European Society of Cardiology (ESC), the American College of Cardiology (ACC), the American Heart Association (AHA), and the International Society of Hypertension (ISH) published guidance/statements on the management of cardiovascular disease including HTN during COVID-19 condition. In self-isolated hypertensive patients, ESC recommends to continue BP monitoring at home, no need to routine clinical review, if required use video or phone consultation. Also suggest to continue the same therapy with no change in medications. Regarding the use of renin–angiotensin–aldosterone system (RAAS) antagonists, the Heart Failure Society of America, ACC, and AHA recommend the continuation of RAAS antagonists for those patients who are currently prescribed such agents for indications for which these agents are known to be beneficial.[5] ESC also recommends no need to adjust medication or stop angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blocker (ARB) medication for HTN management and the same was also strongly endorsed by ISH.[6],[7]

Owing to COVID-19, the Government of India announced a lockdown effective from March 22, 2020, and since then, it has been challenging for health-care professionals (HCPs) to manage patients with HTN. HTN care was hampered during COVID-19 pandemic due to the collapse of overall health-care infrastructure. Several factors affecting HTN management included hospitalization of COVID-19 patients, fear of contact COVID-19, preexisting comorbidities, telephonic consultation, nonavailability of clinicians, transportation issues, and several hospitals converted to COVID-19 hospitals. There are less data from India reporting challenges faced by the HCPs in managing patients with HTN during COVID-19. Hence, this study was planned to seek the opinion of Indian HCPs about HTN care during COVID-19.

  Methods Top

HCPs' opinions (n = 2832) were recorded based on survey and round table meetings (RTMs). Standard questionnaire pertaining to HTN care in COVID-19 was prepared, discussed, and evaluated by experts who treat patients with HTN during COVID-19 era. Majority of the HCPs were consulting physicians (n = 2037), followed by diabetologists/endocrinologists (n = 350), cardiologists (n = 270), and family physicians (n = 175). To avoid result bias, HCPs were enrolled across all four zones of the country. The majority of participants were from the south region (n = 1111), followed by the west (n = 839), north (n = 529), and east (n = 353) regions of India. The average experience of participants was 15 years (range: 1–50 years).

The study included total nine questions. The identified HCPs were sent an introductory E-mail containing a link of survey and requested voluntary participation. The survey was only available in English and took 6 weeks (from June 2020 to July 2020) to complete it. The survey results were discussed during the 52 pan India RTMs meeting between July 2020 and September 2020 and opinion taken from HCPs.

  Results Top

Study outcomes

A total of 2832 HCPs participated in the survey and RTMs, of which majority were consulting physicians, followed by diabetologists/endocrinologists, cardiologists, and family physicians. The majority of participants were from the south zone, followed by the west, north, and east zones of India. The following points related to HTN care were discussed and data were collected.

Modifiable risk factors for hypertension

Smoking or tobacco use, obesity, and comorbidities (diabetes or dyslipidemia) were ranked as the top three modifiable risk factors during COVID-19 era. Additionally, alcohol intake, emotional stress, dietary salt, and lack of physical activity were other modifiable risk factors for HTN during COVID-19 era. Similar risk factors were observed in pre-COVID-19 era except for emotional stress and dietary salt which were ranked above alcohol intake [Figure 1].
Figure 1: Risk factors for hypertensive patients during pre-COVID-19 and during COVID-19 era. COVID-19: Coronavirus disease 2019

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Home blood pressure monitoring

Home BP monitoring depends on the patient's location (rural or urban) and educational and financial status. In the initial phase of lockdown, home BP monitoring was challenging, but over the period, most of the patients initiated this use of home BP monitoring. The majority of HCPs (44%) consider that <30% of their patients with HTN check BP at home and 36% reported 30%–50% check BP at home during COVID-19 era.

Patients on monotherapy with increase in blood pressure

A total of 37% and 33% of HCPs reported an increase in BP during the lockdown period in 10%–20% and 20%–40% of hypertensive patients, respectively, who were on monotherapy. Around 16% and 14% of HCPs reported that <10% and >40% of patients, respectively, showed an increase in BP during the lockdown period.

Uncontrolled blood pressure (>150/100 mmHg) during lockdown

The study showed that around 35% of HCPs reported that, 20%–30% of their patients with HTN showed uncontrolled BP (>150/100 mmHg) when they consulted in the office during lockdown. The remaining 28%, 20%, and 17% of HCPs reported uncontrolled BP in 30%–40%, <20%, and >40% of their patients, respectively.

Preferable therapy for uncontrolled blood pressure (>150/100 mmHg)

56% of HCPs preferred dual-drug therapy in patients with uncontrolled BP; however, 34% and 10% of HCPs preferred triple-drug therapy and high-dose monotherapy, respectively.

Important combination therapy for hypertension management

Nearly 71% preferred dual-combination therapy for HTN management during COVID-19. In dual combination, 27% preferred ARB + diuretic, 26% preferred ARB + calcium channel blockers (CCB), and 18% preferred ARB + beta-blockers (BB). Furthermore, 28% of HCPs preferred ARB + diuretic + CCB in triple-combination therapy [Figure 2].
Figure 2: Important aspects of HTN care during COVID-19 and physician's opinion. COVID-19: Coronavirus disease 2019, HTN: Hypertension

Click here to view

Hypertension-related complications

A total of 47% of HCPs reported acute coronary syndrome (ACS) as the most common HTN-related complication in the current COVID-19 era. Other anticipated complications cerebral hemorrhage and cerebral ischemia (14% each) were renal function (17%), blindness (3%), and others (5%) [Figure 2].

Challenging parameters in hypertension care

The majority of HCPs (57%) consider that in the current COVID-19 era, avoiding contamination during BP measurement is the challenging parameter in HTN care. Other challenging parameters include advising drug treatment on teleconsultation (48%), drug modification (41%), compliance (32%), transport-related issues (30%), and others (3%) [Figure 2].

Best method to improve medication adherence

Around 32% of HCPs considered self-BP monitoring (SBPM) as the best method to improve medication adherence; however, 24% considered that economical medicines can improve adherence. A total of 16% and 15% considered that digital connect with patients and providing information on the risks of HTN and the benefits of treatment, respectively, are the best methods to improve medication adherence. However, 13% considered that the use of single-pill combination therapy is the best method. Across all the specialties, the majority considered SBPM, economical medication, patient awareness and single-pill combination were important parameters to improve medication adherence during COVID-19 and in future[8] [Figure 2].

  Discussion Top

Comorbidities including diabetes and HTN pose a greater risk of acquiring COVID-19 infection in patients. The Government of India has taken several public health measures to decrease the risk of COVID-19 infection as well as important initiatives such as education of self-care practices and teleconsultation (eSanjeevani) to manage HTN during the current COVID-19 era. The India Hypertension Control Initiative, another multi-partner initiative by the Indian government, provided access to standardized care for HTN through the availability of effective free medicines at the doorsteps. Such initiatives ensured compliance to self-care by the patients amid lockdown.

Smoking/tobacco use and obesity were ranked higher while emotional stress was ranked lower as the modifiable risk factors during COVID-19 era. Indian and global studies report a significant association between HTN and modifiable risk factors including smoking, physical inactivity, obesity, and alcohol in pre-COVID-19 era.[9],[10] Additionally, work from home could have resulted in lack of physical activity with unhealthy eating leading to significant weight gain; hence, obesity may have increased during COVID-19 era. A retrospective study by Simonnet et al. showed a high incidence of obesity in patients admitted in intensive care for COVID-19 infection.[11] Obesity is a critical disorder leading to other comorbidities such as HTN, diabetes, dyslipidemia, and atherosclerosis as well as deteriorates the clinical course of COVID-19.[12] A meta-analysis of 75 studies from English and Chinese literature showed that obesity increased the risk of COVID-19 and further increased >46.0% hospitalization, 113% intensive care unit (ICU) admission, and 48% increase in deaths.[13] A systematic review showed that diabetes, HTN, and cholesterol levels possess an apparent relation to COVID-19 severity.[14] Diabetes is a risk factor for speedy progression and poor prognosis of COVID-19, and studies have revealed a remarkable number of patients with diabetes. Bello-Chavolla et al. established a mechanistic score associated with obesity and diabetes to COVID-19 consequences. Further, it was reported that early-onset diabetes resulted in higher risk of hospitalization while obesity substantially increased the risk for ICU admission and intubation.[15]

Majority of the participants opined that emotional stress has been reduced during the COVID-19 era that may be due to lowered work pressure owing to work from home facility, flexibility to work, less or no travel, home food, and more family time. However, in a couple of meetings, it was discussed that emotional stress has increased probably due to the risk of job loss, financial burden, irregular patterns of sleep, and risk of infection. Initially, emotional stress was high, but perhaps later, people have accepted the fact that henceforth this is now the new normal. There was a mixed opinion that cardiovascular events and stroke have increased in the past couple of months, which can be correlated with stress; however, few mentioned that these events have decreased during the COVID-19 era which is consistent with the study outcomes.

Alcohol consumption has increased during the COVID-19 era possibly due to less or no work; however, in areas where alcohol is banned or not available due to lockdown, it may be reported as a low-risk area both before and during the COVID-19 era. People with secure job or financial stability may continue having good physical activity; in contrast to those who lost their jobs or faced a heavy salary cut may be stressed and tend to disregard physical activity.

The COVID-19 norms dramatically reduced the clinic visits and follow-up of patients owing to the burden on HCPs and difficult-to-access health-care facilities enhanced the need for home BP monitoring.[16] In the initial phase of lockdown, home BP monitoring was challenging, but over the period, most of the patients initiated the use of home BP monitoring. It generally depends on the patient's location (rural or urban) and educational and financial status. During the COVID-19 era, a majority of healthcare providers (44%) reported that <30% of their patients with hypertension check their BP at home. Another 36% reported that 30%-50% of their patients check their BP at home. It was also interesting to note that not only cardiologists or consulting physicians but also diabetologists and family physicians are motivated to guide patients to monitor BP at home. It is important to create awareness and educate them on BP monitoring using a digital apparatus that can be done during online consultation with a demo.

In general, 10%–20% of patients have uncontrolled BP with monotherapy irrespective of lockdown. However, additionally, 10%–20% may have been added due to stress and financial burden. Similarly, for patients on dual or triple drugs, sometimes even if one drug is finished, they continued with the available drug(s) which may result in an increase in BP. Another aspect is the availability of medicines during lockdown due to which people skipped their medicine resulting in an increased BP. A total of 37% and 33% of HCPs reported an increase in BP during the lockdown period in 10%–20% and 20%–40% of patients with HTN, respectively, who were on monotherapy. Around 16% and 14% HCPs reported that <10% and >40% of patients, respectively, showed an increase in BP during the lockdown period. The results should be generalized carefully considering a set of populations who continue medicines without consultation.

The study showed that around 35% of HCPs report that 20%–30% of their patients with HTN showed uncontrolled BP (>150/100 mmHg) when they consulted in the office during lockdown. The remaining 28%, 20%, and 17% of HCPs reported uncontrolled BP in 30%–40%, <20%, and >40% of their patients, respectively. The most common reason for surge is noncompliance with HTN treatment, inaccessibility of medicines during lockdown, delayed follow-up visits, and incorrect BP monitoring at home. Other reasons which may have contributed to such an increase are increased stress, lack of exercise, and excessive salt intake. These similar results were reported by Bharatia et al. in Indian patients in pre-COVID-19 era.[17]

The study indicates that dual-drug therapy is most preferred in uncontrolled BP during this COVID-19 period. Monotherapy should be started in newly diagnosed patients. If BP remains uncontrolled with monotherapy, clinicians recommend shifting to dual-drug therapy. After 2-4 weeks, if BP is still uncontrolled, one can consider triple-drug therapy. The ISH's Global Hypertension Practice Guidelines 2020 recommend initiating pharmacotherapy with dual combination instead of high-dose monotherapy. Combination therapy shows better results rather than increasing the monotherapy dose, which may increase the risk of adverse events.[18] Combination therapy as a single pill is beneficial if started early as it avoids polypharmacy, increases compliance, and reduces cost.[19] Clinicians have opined that chronotherapy may benefit individuals who take all their medications in the morning, either as a single pill or as separate drugs. Cardiovascular morbidity and mortality are more than those who are taking at least one drug at bedtime.

Achieving BP target with intensive BP-lowering drugs is important for HTN management and hence needs an effective pharmacological strategy which in turn will mitigate the associated cardiovascular and cerebrovascular complications.[20] Dual-drug therapy comprising ARB + diuretics and ARB + CCBs are most preferred for uncontrolled BP during this COVID-19 period. Around 28% of HCPs preferred the triple combination, particularly of ARB + diuretic + CCB. HCPs opined that therapeutic regimen depends on conditions such as duration of HTN, comorbid condition, and patient response. In younger patients, ARB + diuretics and, in older patients (>65 years), ARB + CCB can be used. Another perspective was using ARB + diuretics in younger patients (<60 years) and CCB + BB in older patients (>65 years). In conditions such as edema or in patients with a higher risk of heart failure, ARB + diuretic is beneficial, since it quickly decreases BP reducing the risk of mortality and morbidity.[18] A study reported that dihydropyridine CCBs including nifedipine and amlodipine are beneficial in patients with HTN and COVID-19.[21] Another aspect is poor salt control which may need the use of diuretics. The addition of diuretic will enhance the effect of ARB or ACEi. Chlorthalidone can be preferred with ARB. However, it should be avoided in the elderly as it may cause electrolyte imbalance. In patients with coronary artery disease, BB should be the drug of choice; however, ARB and diuretics are a better combination. One antihypertensive must be given at night because there are long-acting medications such as amlodipine or telmisartan having a 24 h effect. In patients with HTN and diabetes whether they have chronic kidney disease (CKD) or not, RAASi has a better antihypertensive effect.[22] Clinical studies do not show any association of any antihypertensive agents and COVID-19 infection, while the use of ACEi or ARBs lowered the risk of all-cause mortality when compared to nonusers.[23],[24] This finding is also supported with a meta-analysis by Barochiner and Martínez including 18 studies with 17,311 patients.[25] In patients with HTN and diabetes, the combination with ARB or ACEi can be used with amlodipine.[26] While ACE inhibitors have some advantages over ARBs, ARBs may be more suitable for patients with nephropathy or progressive CKD. Additionally, patients may experience issues with compliance and cough when taking ACE inhibitors. In the study, HCPs opined that new drugs should not be introduced by digital consultation in patients with uncontrolled BP. However, dose adjustments can be done for existing drugs. Once the patient is comfortable with home BP monitoring, noble decisions can be taken.

A total of 47% of participants reported ACS as the most common HTN-related complication in the current COVID-19 era that was agreed upon by all HCPs. Other anticipated complications cerebral hemorrhage and cerebral ischemia (14% each) were renal function (17%), blindness (3%), and others (5%).

Majority of ACS cases were seen within 7 days of COVID-19 infection and sudden cardiac deaths have occurred. Many patients who recovered from COVID-19 also showed a delayed presentation of acute myocardial infarction or ACS with a sudden sweating and chest pain followed by collapse, possibly due to the inflammatory process and underlying myocarditis; hence, patients should be discharged only after all the inflammatory markers are within normal limits.[27],[28] All the spectrum of cardiovascular diseases precipitated due to uncontrolled BP.

Moreover, inaccessibility of diagnostic centers, catheterization labs, ICU, and critical care unit to COVID-19 infection patients with HTN and cardiovascular diseases, result in poor health care and with increased mortality. Lack of physical activity or exercise due to lockdown, improper dietary habits, and stress were other possible reasons for ACS. A systematic review and meta-analysis of 28 studies including 4189 patients showed a significant trend for elevated levels of cardiac biomarkers in patients' severe COVID-19. The meta-regression analysis demonstrated that HTN was the only factor significantly associated with raised levels of cardiac injury biomarkers (P = 0.03).[29] COVID-19 may cause fibrosis of cardiomyocytes leading to different arrhythmias, heart attack, myocarditis, and cardiac impairment.[30]

Majority of HCPs agreed that avoiding contamination during BP measurement is the most critical challenge during COVID-19. Asking patients to come to the clinic from the periphery during the pandemic has a high-risk involvement, due to traveling and clinic waiting for consultation. Hence, teleconsultation and home BP monitoring are the best-recommended steps to manage HTN. The patients with HTN should continue their medication and if BP increases or decreases than usual, teleconsultation with the HCPs without modifying the treatment themself.

Anticipating the increased need of teleconsultation, the Medical Council of India released practice guidelines in March 2020 to encourage the use of telemedicine in routine practice by the clinicians.[31],[32] Teleconsultation can be done through several modes (video, audio, and text based) and includes benefits such as convenience, timely access, and economics. Although teleconsultation cannot replace in-person consultation, it has substantially benefitted in pandemic in managing chronic diseases, providing psychosocial support, thus curtailing the burden on hospitals and clinics. It was discussed that although, in the study, 48% opined that advising treatment on teleconsultation is challenging, it is important to adapt this new normal, at least for the few more months. Recently, a cuff protector to be worn on the arm was introduced to reduce the risk of contamination while checking the BP. The HCPs suggested to use a long tube and plastic sheets during BP measurement and also to educate the patients about digital BP apparatus. One of the HCPs mentioned that he places tissue papers along with cuff to avoid contamination and sanitizes it before and after use.

Nevertheless, dose modification is sometimes difficult due to lack of clear history from patients and few things such as pedal edema may not be noted during teleconsultation and may be difficult for new patients. Dose modification through home BP monitoring along with patient education and counseling is imperative for optimal HTN management.

Non-compliance is the major factor responsible for unsuccessful medical treatment. Major contributing factors for noncompliance with antihypertensive drugs include misunderstandings and complexity of therapeutic regimen, side effects, concerns about medications, and patient–physician relationship.[33] However, compliance has increased in patients with chronic diseases considering the risk of fatal outcomes and increased awareness in patients and family members.A cross-sectional community-based survey from India found a compliance rate of 82.2% for hypertension medication. The survey also identified high cost and the unpredictable nature of the disease as common reasons for noncompliance.[34]

Skeete et al. have enumerated barriers and challenges in COVID-19 pandemic in managing HTN and rated limited access to health care as the chief barrier. Other barriers to hypertension management include therapeutic/clinical inertia, misinformation about the use of ACE inhibitors and ARBs, limited access to teleconsultation for technophobic patients, medication rationing, failure to fill prescriptions, and gaps in treatment.[35]

The majority of HCPs considered SBPM as the best method to improve medication adherence followed by availability of economical medicines, digital connect with patients, and information on the risks of HTN and the benefits of treatment. Self-BP monitoring is an important tool to improve medication compliance and BP control. It is reproducible, economical, and simple to learn and convenient to use. This approach engages patients in self-care and positively influences their perceptions in HTN management.[8] A large-scale prospective observational study of 7751 patients demonstrated that SBPM is associated with reduced BP (142/88–129/80 mmHg [P < 0.001]), better BP control rate (32% to 59% [P < 0.001]), greater drug adherence (0.86 days–0.53 days [P < 0.001]), and improved awareness of BP by the patients (90%–98%).[36]

Higher medication costs for patients have directly been associated with reduced rates of long-term therapeutic compliance and frequent discontinuation of medication.[37] Clinicians should prescribe generic drugs as they are cost-effective and thus enable better long-term compliance to therapies.

In teleconsultation, patients have 10–15 min of appointment that can be utilized better in contrast to the routine clinical practice wherein the time is very much restricted. For the follow-up patients, the use of teleconsultation was recommended, particularly in patients with chronic condition, and in urban areas, teleconsultation could be used during and even post-COVID-19. Patients should be asked to get a validated device. Currently, digital apparatus is economical with limited maintenance cost.

Patient counseling plays a key role in improving medication adherence. Educating patients about their treatment and creating awareness about the target BP will help improve the current pandemic period. Previously, majority of the patients consulted HCPs only in emergency health issues, but during COVID-19 period, an increased awareness was observed in patients about BP control and HCPs are being consulted regularly.

Single-pill combination improves compliance owing to simple regimen and less expensive. Drug compliance can be enhanced with reduction in the pill burden using dual-drug combination therapy. A systematic rapid evidence assessment of 29 randomized controlled and observational studies by Tsioufis et al. demonstrated that compliance and persistence were generally greater with single-pill combination versus free-dose combination.[38] Similar findings of single-pill combination were reported in a retrospective assessment of data of 106,621 patients from 180 practice sites having uncontrolled BP.[19] A meta-analysis by Conn et al. emphasized that the improvement of medication adherence requires a multifaceted strategy such as providing adherence feedback to patients, SMBP, special packaging of medicines, and motivational interviewing.[39]

Key summary points

  • Smoking or tobacco use, obesity, and comorbidities (such as diabetes or dyslipidemia) were ranked as the top three modifiable risk factors in pre- and during COVID-19 era. Alcohol consumption and emotional stress were other important factors
  • Due to COVID-19 pandemic, the percentage of patients with home BP monitoring is increased
  • There is an increase in the uncontrolled BP level during COVID-19
  • Dual-drug therapy was the most preferred therapy for patients with uncontrolled BP, and the preferred combinations were ARB + diuretic and ARB + CCB
  • ACS was the most common HTN-related complication
  • Avoiding contamination during BP measurement is the most challenging parameter in HTN care during the current COVID-19 era
  • SBPM is the best method to improve medication adherence followed by the use of economical medicines.

  Conclusion Top

SBPM, combination therapies, and digital connect with patients are critical aspects of HTN management during COVID-19 pandemic.


We acknowledge Ms. Farida Hussain, Mr. Aji Verghese, and Mr. Sagar Patil from USV Pvt Ltd for their assistance in carrying out the project. The medical writing support was provided by Snehal Khanolkar from Sqarona Medical Communications LLP (Pune).

Financial support and sponsorship

The study was funded by USV Pvt Ltd.

Conflicts of interest

Mahesh Abhyankar, Santosh Revankar Neeraj Kumar are employees of USV Pvt Ltd. All other authors have no conflicts of interest to declare.

Authors' contributions

All authors have contributed to the manuscript and meet ICMJE authorship criterias.

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