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Hipertensión
ISSN: 1889-1837
Hypertension in Latin America:
Current perspectives
on trends and characteristics
L.M. Ruilope, A.C.P. Chagas, A.A. Brandão, R. Gómez-Berroterán,
J.J.A. Alcalá, J.V. Paris, J.J.O. Cerda
Órgano oficial de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión
Arterial, de la Sociedad Argentina de Hipertensión Arterial y de la Latin American Society of Hypertension
www.elsevier.es/hipertension
Indexada en:
Medline en 2015
y riesgo vascular
Latin American Society of Hypertension
Reprinted from Hipertens Riesgo Vasc. 2017;34:50-56
Hipertens Riesgo Vasc. 2017;34(1):50---56
www.elsevier.es/hipertension
SPECIAL ARTICLE
Hypertension in Latin America: Current perspectives
on trends and characteristics
L.M. Ruilopea,b,∗, A.C.P. Chagas c, A.A. Brandãod, R. Gómez-Berroteráne, J.J.A. Alcaláf,
J.V. Parisg, J.J.O. Cerdah
a‘‘Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular’’, Universidad Autónoma de Madrid, Spain
bHypertension Unit, Institute of Research i+12: Hypertension and Cardiovascular Risk Group, Hospital Universitario 12
de Octubre & Department of Preventive Medicine and Public Health Universidad Autónoma de Madrid, Madrid, Spain
cChief Cardiology Division, ABC Medical School, Av. Principe de Gales, 821, 09060-870 Santo André, SP, Brazil
dDepartment of Cardiology --- Hypertension Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
eSocial Security, Hospital Dr. Domingo Luciani, Rio de Janeiro av. Municipio Sucre, Caracas 1073, Venezuela
f‘‘Hospital Dr. Domingo Luciani’’ --- Institute Venezuelan of the Safe Social (IVSS), Caracas, Venezuela
gInstituto Nacional de Cardiologia ‘‘Ignacio Chávez’’, Mexico City, Mexico
hResearch and Education General Director, Grupo Angeles Servicios de Salud, Mexico City, Mexico
Received 2 November 2016; accepted 28 November 2016
Available online 20 December 2016
KEYWORDS
Hypertension;
Latin America;
Brazil;
Mexico;
Venezuela;
Cardiovascular
disease;
Blood pressure
control;
Lifestyle;
Obesity
Abstract The region of Latin America, which includes Central America, the Caribbean and
South America, is one that is rapidly developing. Signified by socio-economic growth, transi-
tion and development over the last few decades, living standards in countries like Brazil and
Mexico have improved dramatically, including improvements in education and health care. An
important marker of socio-economic change has been the epidemiological shift in disease bur-
den. Cardiovascular disease is now the leading cause of death in Latin America, and the drop
in prevalence of infectious diseases has been accompanied by a rise in non-communicable dis-
eases. Hypertension is the major risk factor driving the cardiovascular disease continuum. In this
article we aim to discuss the epidemiological and management trends and patterns in hyper-
tension that may be specific or more common to Latin-American populations --- what we term
‘Latin American characteristics’ of hypertension --- via a review of the recent literature. Rec-
ognizing that there may be a specific profile of hypertension for Latin-American patients may
help to improve their treatment, with the ultimate goal to reduce their cardiovascular risk.
We focus somewhat on the countries of Brazil, Mexico and Venezuela, the experience of which
may reflect other Latin American countries that currently have less published data regarding
epidemiology and management practices.
© 2016 SEH-LELHA. Published by Elsevier Espa˜
na, S.L.U. All rights reserved.
∗Corresponding author.
E-mail address: ruilope@ad-hocbox.com (L.M. Ruilope).
http://dx.doi.org/10.1016/j.hipert.2016.11.005
1889-1837/© 2016 SEH-LELHA. Published by Elsevier Espa˜
na, S.L.U. All rights reserved.
Hypertension in Latin America 51
PALABRAS CLAVE
Hipertensión;
América Latina;
Brasil;
México;
Venezuela;
Enfermedad
cardiovascular;
Control de la tensión
arterial;
Estilo de vida;
Obesidad
Hipertensión en América Latina: perspectivas actuales de las tendencias
y características
Resumen La región de América Latina, que incluye Centroamérica, el Caribe y Sudamérica,
está atravesando una rápida evolución. Esto se refleja en el crecimiento socioeconómico, la
transición y el desarrollo durante las últimas décadas; las condiciones de vida en países como
Brasil o México han mejorado drásticamente, lo que incluye reformas educativas y sanitarias. Un
marcador importante de cambio socioeconómico ha sido el giro epidemiológico en la carga que
suponen las enfermedades. Los trastornos cardiovasculares son la principal causa de mortalidad
en América Latina, y la reducción en la prevalencia de enfermedades infecciosas se ha visto
acompa˜
nada de un aumento de las enfermedades no contagiosas. La hipertensión es el factor
de riesgo que lidera la continuidad de las enfermedades cardiovasculares. En este artículo
pretendemos analizar las tendencias y los patrones en materia de epidemiología y gestión de la
hipertensión que podrían ser específicos o más comunes en la población latinoamericana ---lo que
hemos llamado «características latinoamericanas»de la hipertensión--- por medio de una revisión
de la literatura reciente. Reconocer que podría existir un perfil específico de hipertensión
para los pacientes latinoamericanos podría mejorar su tratamiento, con el objetivo final de
reducir su riesgo cardiovascular. Nos centramos levemente en los países de Brasil, México y
Venezuela, cuyas experiencias podrían verse reflejadas en otros países de América Latina que
en la actualidad disponen de menos datos publicados en lo que respecta a las prácticas de
epidemiología y gestión.
© 2016 SEH-LELHA. Publicado por Elsevier Espa˜
na, S.L.U. Todos los derechos reservados.
Hypertension in Latin America: prevalence,
awareness and control rate
Hypertension is the most important risk factor contributing
to the burden of cardiovascular disease, the leading cause
of death in all Latin American countries.1,2 Up to 40% of the
adult Latin American population is estimated to be affected
by hypertension --- similar to that in developed countries ---
although there are considerable variations between ethnic
and racial groups, men and women, and different countries
within the region. For example, the Brazilian Longitudi-
nal Study of Adult Health (ELSA-Brasil) showed that the
adjusted prevalence of hypertension was highest amongst
Blacks (49.2%) compared with Whites (30.3%) and Browns
(38.2%).3Variations in hypertension prevalence within the
same country also exist, which may be partly explained
by regional differences in diet.4 --- 6 Like elsewhere, hyper-
tension increases with age in Latin America: data from
Mexico City showed a sharp increase in the prevalence of
treated hypertension from middle age (26% among 35---44
year olds) to elderly (59% among 75---84 year olds), with
this increase being significantly greater in women than in
men.7
Moreover, as in other parts of the world, the low rates
of awareness, treatment and control of hypertension in
Latin America reveal the difficulty and inadequacy in man-
aging this chronic disease on a population level.8---10 In a
recent cross-sectional survey of around 7500 adults from
four cities across Argentina, Chile and Uruguay, around
42.5% had hypertension and 32.5% had pre-hypertension.11
Of this population, around 63.0% were aware of their dis-
ease, 48.7% were taking prescribed medications to lower
their blood pressure (BP), but only 21.1% of all hypertensive
patients, and 43.3% of treated hypertensive patients, had
their BP controlled to target.11 Similarly, the ELSA-Brasil
study found a high proportion of uncontrolled hypertension
among its cohort of more than 15,000 subjects recruited
from universities and research institutions.12 In total, 34% of
ELSA-Brasil participants knew they had hypertension and 29%
were taking BP medication; however, among those receiving
treatment, 31% did not have controlled BP. Perhaps not sur-
prisingly, controlled BP was more frequent in those with a
higher education level (postgraduate).3
There are many reasons for inadequate BP control,
including poor treatment adherence, physician’s inertia,
patient’s baseline cardiovascular risk, and poor adherence
to guidelines by the treating physician. Regarding the last
point, physicians’ criteria for diagnosing and determining
high BP may be highly subjective, based on a ‘personal
appreciation’, without much heed to criteria specified in
regional and international management guidelines. In a
recently published study by Ragot et al.,13 the rates of con-
trolled hypertension were evaluated in 2185 hypertensive
adults across five countries, including Venezuela. Part of the
study compared BP control rates, as determined by physi-
cians’ perception, with BP control rates determined using
the 2007 European Society of Hypertension/European Soci-
ety of Cardiology (ESH/ESC) guideline criteria. There was
a marked divergence between physicians’ assessment and
that based on the guidelines, with doctors grossly over-
estimating the BP control rate: according to physicians,
72% of patients had controlled hypertension when, actu-
ally, according to ESH/ESC criteria, only 40% had controlled
BP.13 The study found that other important factors lead-
ing to inadequate BP control were the presence of high or
very high cardiovascular risk; high salt intake; treatment
52 L.M. Ruilope et al.
non-adherence; lack of understanding of the treatment’s
importance; comorbidity; and depression.13
Clinical relevance of BP variability in Latin
American populations
Furthermore, in today’s context, the optimal control of a
person’s BP should necessarily involve some attention to
BP variability, particularly in at-risk individuals such as the
elderly. This rationale is based on accumulating evidence
which indicates that some BP variability parameters have
significant prognostic value for cardiovascular and cere-
brovascular outcomes.14,15 Although these data have been
derived from post hoc analyses and observational studies,
and evidence is sorely needed from prospective, random-
ized, controlled trials, they nevertheless suggest that more
can be learned from looking beyond 24-h mean BP values
alone.
Short-term (within 24 h) BP variability includes excessive
morning BP surge and non-dipping or excessive dipping of
night-time BP, while long-term BP variability includes visit-
to-visit BP variability. In the seminal study by Kario et al.,16
an excessive surge in morning BP was significantly associ-
ated with an increased risk of stroke in elderly Japanese
patients with hypertension. Subsequently, this correlation
between exaggerated morning BP surge and stroke and mor-
tality has been consistently demonstrated,17 including in a
recent retrospective study of Brazilian patients.18 In this
study, analysis of ambulatory BP monitoring (ABPM) data
from Brazilian hypertensive patients attending a single cen-
ter in São Paulo showed that those with an exaggerated
morning BP surge (morning systolic BP surge ≥41 mmHg) had
a significant --- almost threefold --- increase in the risk of
death compared with patients who had a normal morning BP
surge (<41 mmHg).18 Patients who had exaggerated morning
systolic BP surge were more likely to be older, had a higher
daytime systolic BP as well as higher systolic and diastolic
BP dipping, and a lower night-time diastolic BP.
In the first reported study of its kind in Latin America,
researchers in Argentina retrospectively evaluated the dif-
ference in morning and evening BP (MEdiff), as measured
by home BP monitoring (HBPM), in hypertensive outpatients
living in Buenos Aires, and correlated MEdiff with indepen-
dent determinants.19 Older age, smoking, total cholesterol
and use of calcium channel blockers were found to be inde-
pendent determinants of the home-based MEdiff. Moreover,
looking at the MEdiff BP profile, home diastolic BP was found
to be significantly higher in the morning than in the evening
for all patients apart from smokers. After excluding smok-
ers from the cohort for further analysis, both home systolic
BP and diastolic BP were significantly higher in the morning
than in the evening. This result was interesting in that it
aligned with data obtained from Northeast Asian hyperten-
sive populations, but not with European study findings.
Though limited in scope, these regional data highlight
that BP variability may be an important factor to consider in
the management of hypertension in Latin American patients
as a means to improve cardiovascular and stroke outcomes.
Undoubtedly, more extensive but selective use of HBPM
and ABPM --- i.e., facilitating the mapping of an individual’s
BP --- would help to enhance the rate and accuracy of BP
diagnosis and control, but the major drawback currently
lies in the limited availability of these devices. Neverthe-
less, the uptake of ABPM in Brazilian clinical practice has
steadily increased since the Brazilian Societies of Cardiol-
ogy, Hypertension and Nephrology first published guidelines
on its use in 1993, and specific training on ABPM was provided
via professional courses across the country.20
Consequences of hypertension in Latin
America: cardiovascular disease and stroke
In Venezuela, data from the 2012 Annual Mortality Report
published by the Ministry of Health showed that cardiac
diseases accounted for 30,000 deaths per year; can-
cer accounted for 22,000 deaths per year, and stroke,
11,000 deaths per year. Thus, in Venezuela, 41,000 deaths
per year, or an average of 112 deaths per day, can
be attributed to cardiovascular disease and stroke. The
recently updated Panorama of Mortality from Cardiovascu-
lar Disease in Brazil, a descriptive epidemiological study that
analyzed data from the 437 health regions of Brazil, reported
on the trends in age-adjusted rates of total cardiovascular
mortality in adults from 2003 to 2012. Cardiovascular dis-
ease remained the leading cause of death: in 2012, it was
responsible for 31% of all deaths in Brazil, with ischemic
heart disease (IHD) and cerebrovascular diseases being the
leading causes, accounting for 31% and 30% of these deaths,
respectively. A similar picture can be found across Latin
America, particularly in those countries with burgeoning
economies. Furthermore, unlike in developed nations such
as the USA, where cardiovascular mortality has declined
through consistent efforts to reduce hypertension and other
risk factors, cardiovascular mortality in Latin America is
rising.21
A comparison of data from two longitudinal cohort stud-
ies --- the Bambui Cohort Study of Ageing (Brazil) and the
English Longitudinal Study of Ageing (ELSA) --- exemplify the
fact that mortality risk associated with hypertension in Latin
America significantly exceeds that in developed nations.22 In
this analysis, the 6-year mortality risk attributable to smok-
ing, hypertension and diabetes was compared between more
than 3000 English and Brazilian patients with hypertension.
One of the key findings was that the mortality rates and
hazard ratios for mortality by hypertension in the Brazilian
cohort were significantly higher than in the English cohort,
and this difference was most pronounced in patients older
than 75 years. Since the Bambui study purposefully recruited
individuals with low income and level of schooling --- a demo-
graphic very different to that in ELSA --- the comparison
of these two cohorts served also to highlight the impact
of social or economic differences on hypertension and its
outcomes.
In terms of stroke, it is encouraging that stroke mortality
in Brazil has improved in recent years. In 2011, data from
the Brazilian Ministry of Health showed for the first time
that the number of deaths due to coronary heart disease
(CHD) exceeded that from stroke. Nevertheless, stroke is a
neglected disease in Brazil and it cannot be overstated that
the risk of premature death due to stroke in Brazil remains
one of the highest in the world.23 According to data from the
2013 Global Burden Disease report,24 the years of life lost
Hypertension in Latin America 53
(YLL) due to premature death from CHD in Brazil was similar
to that of other countries; however, the YLL from cere-
brovascular disease in Brazil was significantly higher than
the mean of most other countries (Fig. 1).24 Ultimately, the
suboptimal control of risk factors for stroke, beginning with
hypertension, represents a huge missed opportunity for pri-
mary prevention which, in Brazil, is tremendously felt in
terms of morbidity, mortality and financial loss.25
Hypertension and obesity are common
comorbid risk factors for cardiovascular
disease in Latin American populations
A recent review of literature from Latin American countries
(Argentina, Bolivia, Brazil, Chile, Costa Rica, Colombia,
Cuba, Ecuador, El Salvador, Honduras, Guatemala, Mexico,
Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Venezuela,
Uruguay and Dominican Republic; N=7,192,262; 45 eligi-
ble studies) found that the most frequent cardiovascular
risk factors in the region were, in order of most preva-
lent: arterial hypertension, overweight/obesity, diabetes
and smoking.26 Interestingly, the overall majority of car-
diovascular risk factors were significantly more prevalent
in women than in men; for the specific risk factors of
overweight/obesity, physical inactivity, smoking and alco-
hol consumption, however, there was no difference between
the sexes, underscoring the fact that detrimental lifestyle
factors are indiscriminately affecting the Latin American
population.
Part of the INTERHEART Latin American study evaluated
the risk factors contributing to a first acute myocardial
infarction (MI) in matched controls from Argentina, Brazil,
Colombia, Chile, Guatemala and Mexico.27 This showed that
abdominal obesity, abnormal lipids and smoking were asso-
ciated with the highest population-attributable risks (PARs)
of 48.5%, 40.8% and 38.4%, respectively (Table 1).27 Mean-
while, the more recent INTERSTROKE study determined
that ten potentially modifiable risk factors (hypertension,
physical inactivity, apolipoprotein (Apo)B/ApoA1 ratio, diet,
waist-to-hip ratio, psychosocial factors, smoking, cardiac
causes, alcohol consumption and type 2 diabetes) collec-
tively accounted for 90% of the PARs of stroke, regardless
of geographical region, ethnic group, sex and age, with
hypertension being the most dominant.28 There were, how-
ever, important regional variations in terms of the relative
impact of most individual risk factors for stroke, which
may partly explain the worldwide variations in frequency
and case-mix of stroke. The most important message from
INTERSTROKE was that stroke is a largely preventable dis-
ease: through the elimination of hypertension alone, stroke
cases would be almost halved (reduced by 48%); with phys-
ical activity alone, by 36%; and with a healthier diet alone,
by 19%.28
5000
4000
Higher than
the average
a
b
Lower than
the average
Average
Coronary heart disease
Higher than
the average
Years of life lost Years of life lost
Lower than
the average
Average
Stroke
3000
2000
1000
0
Russia
India
Indonesia
Saudi Arabia
Tur k ey
Brazil
Average
United States
Argentina
China
Mexico
South Africa
Germany
Canada
United Kingdom
Australia
Italy
France
South Korea
Japan
5000
4000
3000
2000
1000
0
Indonesia
Russia
China
India
South Africa
Brazil
Saudi Arabia
Average
Tur k ey
Argentina
South Korea
Mexico
Japan
United Kingdom
Germany
Italy
United States
Australia
France
Canada
Figure 1 Age-adjusted years of life lost (in thousands) for (a) CHD and (b) stroke among 19 selected countries in 2013.
Adapted from Ref. 24.
54 L.M. Ruilope et al.
Table 1 Comparison of Latin American (LA) INTERHEART population with INTERHEART-Rest of World (IH-ROW) population
excluding LA: risk factors associated with IHD.
Risk factor Controls (%) PAR (95% CI)
LA IH-ROW LA IH-ROW
ApoB/ApoA1 42.0 32 40.8 (30.3---52.2) 44.2 (41.3---47.1)
Smoking 48.1 48.1 38.4 (32.8---44.4) 35.3 (33.3---37.4)
Type 2 diabetes 9.5 7.2 12.9 (10.3---16.1) 12.2 (11.3---13.1)
Hypertension 29.1 20.8 32.9 (28.7---37.5) 22.0 (20.7---23.4)
Waist/hip ratio 48.6 31.2 48.5 (35.8---56.2) 30.2 (27.4---33.2)
Depression 28.9 15.8 4.7 (1.4---13.9) 8.4 (7.3---9.7)
Permanent stress 6.8 3.9 28.1 (18.5---40.3) 7.8 (4.6---13.1)
Regular exercise 22.0 18.9 28.0 (17.7---41.3) 24.8 (20.6---29.6)
Alcohol 19.4 11.9 −3.2 (−18 to 11.7) 16.3 (12.7---20.6)
Daily consumption of fruits and vegetables 84.3 83.7 6.9 (3.35---10.5) 4.1 (2.9---5.3)
All combined 88.1 (82.3---93.8) 85.1 (82.9---87.2)
ApoB/ApoA1, apolipoprotein (Apo)B/ApoA1 ratio; CI, confidence interval; IHD, ischemic heart disease; PAR, population-attributable risk.
Adapted from Ref. 27.
A closer look at obesity and physical inactivity
In Brazil, physical inactivity was found to account for
15% of all hospitalizations among patients with chronic
non-communicable diseases, including IHD and diabetes,
incurring annual costs exceeding US$730 million.29 Further-
more, not only has the prevalence of obesity increased
among Brazilian adults in recent years, but data indicate
that this is also happening in children.30 In a cross-sectional
study of two population samples in Rio de Janeiro, in which
the prevalence of obesity was compared between similar
cohorts in 1986/1987 and in 2016, comprising more than
5000 schoolchildren aged 10---15 years, the prevalence of
overweight/obesity levels was found to have almost dou-
bled, from 17% in 1986 to 32% in 2016, and the prevalence
of obesity trebled, from 6% to 18%.30 Central obesity was
present in 46% of the 2016 cohort, and 60% of these children
did not take part in any physical activity. Worryingly, the rise
in obesity rates was accompanied by an increased preva-
lence of isolated diastolic hypertension and systo-diastolic
hypertension compared with 30 years before. Although the
overall prevalence of hypertension declined in this period
(from 11% to 8%), the researchers speculated whether this
was an artifact of the different methods of BP measurement
used, i.e., reflecting the difference between the ausculta-
tory method used in 1986 and 1987, and the oscillometric
method used in 2016.
In Mexico, the National Health and Nutrition Survey com-
pared data from 2012 with that from 2006, which showed
a significant increase in the prevalence of physical inactiv-
ity among adults based on the World Health Organization
definition (less than 150 min per week of moderate physical
activity, or 75 min of vigorous activity, or their respective
combination).31 The increase in prevalence, from 13.4% in
2006 to 19.4% in 2012, represented an absolute increase
of 6%, or relative increase of 44%. Individuals older than
60 years and those in the highest socioeconomic tertile
were significantly more likely to be physically inactive, as
were those who were obese. It has been previously esti-
mated that physical inactivity may directly account for 6%
of all CHD cases and 8% of all type 2 diabetes cases in
Mexico.32
Possible ‘characteristics’ of hypertension
in Latin America
Thus, compared with other populations, Latin Americans
appear to have a predominance of the clustering of hyper-
tension with diabetes and lipid abnormalities --- often
referred to as the metabolic syndrome.33 The prevalence of
the metabolic syndrome in Latin America currently ranges
from 25% to 45% and it is increasing.33 Another observation
peculiar to Latin America is the high prevalence of arte-
rial hypertension in children, adolescents and adults with
nutritional stunting.33,34 Changes in the sympatho-adrenal
and renin---angiotensin systems have also been reported in
children small for their gestational age.35 This evidence
has led researchers to speculate whether environmental or
epigenetic factors underlie or contribute to the apparent
increased propensity and susceptibility of Latin Americans to
the metabolic syndrome, hypertension and diabetes.36 The
hypothesis is that poor nutritional status in early life, and
even in the fetal period, may have differential effects on
cardiovascular and metabolic diseases manifesting in later
life. The increased rates of hypertension, metabolic syn-
drome and type 2 diabetes observed in Latin America today
may be due to the discrepancy between the nutritional envi-
ronment during fetal and early life (‘fetal programming’),
and the adult environment, in which substantial lifestyle
changes have occurred due to socio-economic transition.33
Though controversial, these limited, preliminary available
data suggest that genes and environmental factors may
contribute to a profile or ‘characteristic’ of hypertension
that is particular to Latin American individuals, which warr-
ants further study. Moreover, improved early nutrition and
good eating habits sustained over the lifetime might par-
ticularly help to lower the risk of hypertension in Latin
Americans.
Hypertension in Latin America 55
Primary prevention of hypertension
and cardiovascular disease
Given that social and economic inequality in Latin America
greatly restricts an individual’s access to quality or indi-
vidualized health care, primary prevention has never been
more important as a key strategy for reducing the burden
of hypertension and cardiovascular disease. In this setting,
the media play an important role, as do frontline health-
care professionals, who are often the only source of reliable
medical advice on lifestyle and diet,37 and the first point
of healthcare contact, for many patients. Population-wide
public health campaigns have met with some success --- the
public policy against smoking in Brazil is one example38 ---
but they have been largely limited in terms of time and
resources invested. It is generally acknowledged among the
Latin American medical community that, for these public
health campaigns to make a greater, more tangible differ-
ence in changing lifestyle and behavior across populations,
and to reap benefits in terms of improving disease outcomes
in the long term, the investment in time and money needs
to be far greater and sustained for considerably longer.
Conclusion
If every person with hypertension knew their diagnosis and
received proper treatment with at least one antihyperten-
sive drug, it is very likely that cardiovascular disease would
no longer be the leading cause of death in Latin America or,
indeed, the rest of the world. Better and more timely control
of hypertension in Latin America --- taking into account the
BP profile and ‘characteristics’ of the Latin American hyper-
tensive patient --- may go a long way to reducing the impact
of this major cardiovascular risk factor. More knowledge of
local epidemiological patterns of hypertension, derived via
a national registry for example, as has been established in
countries like Brazil,39 will provide more insight, and help to
tailor and optimize management. In terms of public health
initiatives and policy, we strongly advocate the need for
institutional disease awareness campaigns, similar to those
conducted for certain types of cancer, in order to motivate
the population to measure their BP and consult the physi-
cian as soon as their values go outside of the normal range.
We firmly believe that this is the way forward to reducing
cardiovascular mortality in Latin America and worldwide.
Ethical disclosures
Protection of human and animal subjects. The authors
declare that the procedures followed were in accordance
with the regulations of the relevant clinical research ethics
committee and with those of the Code of Ethics of the World
Medical Association (Declaration of Helsinki).
Confidentiality of data. The authors declare that they have
followed the protocols of their work center on the publica-
tion of patient data.
Right to privacy and informed consent. The authors have
obtained the written informed consent of the patients or
subjects mentioned in the article. The corresponding author
is in possession of this document.
Conflicts of interest
The authors have served as speaker/advisors for Daiichi-
Sankyo.
Acknowledgements
This paper was supported by an unrestricted grant from
Daiichi-Sankyo Japan. We also want to express our gratitude
to Miss Cathy Chow for their invaluable help in writing the
paper.
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