Hypertension in Pakistan: half have it, six percent are controlled

Roughly half of Pakistani adults have hypertension. Six percent of them are controlled.

That number should reorganise how you think about the condition. The interesting clinical question in Pakistan is not which agent to add fourth. It is why fifteen out of every sixteen hypertensive people are walking around uncontrolled.

The cascade

Seven in ten do not know. Fewer than one in five are treated. The losses are front-loaded — which means opportunistic measurement and correct technique will do more good than refining the regimen of the minority already on treatment.

And there is nothing to prompt you. The national guideline puts it plainly: "There are no usual signs and symptoms of Hypertension and therefore it is called the 'silent killer'." Symptoms arrive with the complications. The consultation for something else is where most undiagnosed hypertension will be found, or not found.

Pakistan has a current national guideline — use it

The 4th National Hypertension Guidelines were published in 2023 as a peer-reviewed supplement to the Journal of the Pakistan Medical Association, produced by the Pakistan Hypertension League and endorsed by the Pakistan Cardiac Society. It is the fourth update of a document first written in 1998.

One disclosure, because you should weigh it: the guideline states it was produced in collaboration with Getz Pharma, and the published supplement carries antihypertensive brand advertising. Journal peer review and Cardiac Society endorsement count against that, but it is worth knowing when reading drug-class recommendations.

Three targets, and they are staged

This is the part most likely to differ from what you are doing. The guideline does not set a single blanket number.

• Below 140/90 — "the primary target which all people other than the elderly should achieve."
• Below 130/80 — "the secondary target which most people who are not frail or elderly can achieve."
• Below 150/90 — "the target which most elderly people (>80 years of age) should achieve."

Note the structure. 130/80 is a second stage for those who tolerate it, reached after 140/90 — not the opening position. And the over-80s get a deliberately more permissive target. Chasing 130/80 in a frail 85-year-old is not what the national guideline asks for, and it buys falls and hypoperfusion rather than benefit.

The guideline also makes a point about how the tighter targets were derived: SPRINT used research-grade measurement — five minutes of seated rest in a quiet room, correct cuff application, three readings averaged from an automated device. That is not how blood pressure is usually taken in a busy clinic, which is worth remembering before treating to a number from a single hurried reading.

Confirm before you label

One high reading is not hypertension. A wrongly labelled patient is on lifelong medication they did not need.

The monitor problem

The guideline recommends a validated digital device for home monitoring. The practical obstacle here is that a large number of non-validated monitors are on the market, alongside limited physician familiarity with home-monitoring methodology and the cost of the device itself.

A home reading from an unvalidated machine is not the test the guideline is describing. If you are going to act on home readings, check the device against a validated list and check the technique — seated rest, correct cuff size, arm supported at heart level, averaged readings rather than one.

Use the Pakistani eGFR equation

Baseline workup is a lipid profile, urine detailed report, ECG and eGFR. The guideline specifies that eGFR be calculated with the CKD-EPI Pak equation, citing Jessani et al. in the American Journal of Kidney Diseases.

Equations calibrated on European and North American cohorts misestimate GFR in South Asians — and this is not academic, because kidney disease is one of the things that shifts the target.

Two practices the guideline explicitly tells you to stop

Both have their own sections in the national document, which tells you how common they are.

Sublingual nifedipine or captopril to bring down a high reading. For severe hypertension above 180/120 without symptoms, with or without chronic organ damage, the guideline states sublingual drugs are contraindicated. Sublingual nifedipine is no longer recommended because of its propensity to cause severe hypotension. More broadly, bringing the pressure down sharply is itself discouraged — it risks hypoperfusion, loss of consciousness, ischaemic stroke and myocardial infarction. A high number in an asymptomatic patient is not an emergency to be corrected in the clinic.

Anxiolytics as antihypertensive therapy. The guideline notes this practice "has been in vogue", and that Pakistani benzodiazepine use is higher than in other developing countries, largely because of over-the-counter availability, with only a small fraction of patients consulting a psychiatrist. A benzodiazepine lowers the reading in the room without treating the disease, and adds a dependence problem to an untreated cardiovascular one.

What to prescribe, and why one pill beats two

The guideline follows an A-C-D-S approach — ACE inhibitor or ARB, calcium channel blocker, diuretic, then a spironolactone-type agent. Real-world Pakistani prescribing runs calcium channel blockers at 61%, beta-blockers at 49% and ARBs at 47%.

Where a comorbidity compels a particular drug, that overrides the sequence — beta-blockers move to first line post-myocardial infarction, and heart failure calls for diuretics, beta-blockers, ARNI or ACE inhibitors/ARBs, and an aldosterone antagonist.

The more important point for a country with 6% control is the single-pill fixed-dose combination. The guideline reports better adherence with fixed-dose combinations than with monotherapy, and significantly better adherence to a calcium channel blocker plus ACE inhibitor given as one pill than as two separate ones. That is not a convenience argument — with cost a documented barrier and traditional remedies competing on price and accessibility, adherence is the bottleneck, and one daily pill is the intervention most likely to move the number.

Ask what the regimen costs the patient each month, out loud. It is a documented reason people stop.

Bottom line

Measure opportunistically, because 70% do not know. Measure properly, because the targets were built on research-grade readings. Confirm before labelling. Get to 140/90 first and treat 130/80 as a second stage — and give the over-80s 150/90. Use the CKD-EPI Pak equation. Prefer a single pill. Never reach for sublingual nifedipine or a benzodiazepine. And ask about cost, because the best regimen is the one the patient can keep buying.

Our hypertension pathway walks through this in six steps, with a target selector that makes the over-80s figure hard to miss. Also in the section: type 2 diabetes — the comorbidity that most often travels with this one — plus urinary tract infection and community-acquired pneumonia.

ReviseFCPS1 is built by doctors in Pakistan, for doctors in Pakistan. All our clinical tools and pathways are free. If you are preparing for FCPS Part 1, try it free for 7 days — 10,176 doctor-verified MCQs and 8,236 real exam recalls.