European Journal of Cardiovascular Medicine

Hypertension represents an enormous global public health-care challenge. The World Health Organization (WHO) has projected that 1.5 billion people globally are likely to suffer from hypertension by 2025 [1]. The overall prevalence of hypertension in India is estimated at 29% [2]. Cardiovascular diseases are responsible for 1.5 million deaths in India annually. Hypertension is linked to 57% of all stroke deaths and 24% of all coronary event deaths [3]. Hypertension is ranked as the third most important risk factor for attributable disease burden in South Asia [4]. Hypertension is arguably the single most important risk factor for cardiovascular, cerebrovascular, and renal disease that can be modified by timely detection as well as decisive therapeutic intervention. The guidelines for the treatment of hypertension are put forward by the Joint National Committee (JNC) on detection, evaluation, and treatment of blood pressure. The Indian guidelines, endorsed by the Cardiology Society of India, the Hypertension Society of India, and the Indian College of Physicians, closely follow the JNC Guidelines (JNC7 and JNC8) [5,6]. These guidelines recommended angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), beta blockers (BB), calcium channel blockers (CCB), or thiazide-type diuretic classes as initial therapy but recommended thiazide-type diuretics as initial therapy for most patients without compelling indication for another class, and the use of ≥2 antihypertensive agents from different drug classes to achieve the goal of BP control (BP of <130/80 mm Hg for patients with diabetes mellitus or chronic kidney disease; and a BP of <140/90 mm Hg for all other hypertensive people) [7].

The study aims to analyze the utilization pattern of antihypertensive drugs across different levels of healthcare, including primary, secondary, and tertiary care centers. Understanding how these medications are prescribed and utilized in various healthcare settings can provide valuable insights into treatment practices, accessibility, and adherence to guidelines. By examining prescription trends, healthcare providers can identify potential gaps in treatment and optimize strategies to improve patient outcomes. Another important aspect of the study is the categorization of antihypertensive drugs based on their therapeutic class. This includes distinguishing between monotherapy, where a single drug is used for treatment, and fixed-dose combinations (FDCs), which involve multiple drugs combined into a single formulation. Categorizing these medications helps in assessing their effectiveness, prescribing patterns, and the rationale behind their selection in different clinical scenarios. Additionally, the study aims to analyze the adverse effects associated with antihypertensive drugs.

This study was conducted to analyze the utilization pattern of antihypertensive drugs across primary, secondary, and tertiary healthcare centers, categorize monotherapy and fixed-dose combinations (FDCs) based on their therapeutic class, and assess the adverse effects associated with these medications. A comprehensive approach was employed to ensure accurate data collection, analysis, and interpretation.

The study was conducted in accordance with ethical guidelines, ensuring patient confidentiality and informed consent. Approval was obtained from the institutional ethics committee, and healthcare providers were briefed on the study objectives to facilitate cooperation. Patients were informed about the purpose of the study, and their participation was voluntary, with the assurance that their medical data would be anonymized and used solely for research purposes.

Study Design and Setting

A cross-sectional, observational study was carried out across multiple healthcare centers, including primary, secondary, and tertiary care facilities. The selection of healthcare centers was based on accessibility, patient volume, and availability of antihypertensive medications. The study included both urban and rural healthcare settings to provide a broader perspective on prescribing patterns and drug utilization.

Data Collection

Data were collected from patient records, prescription audits, and direct interviews with healthcare providers and patients. Prescriptions were analyzed to determine the frequency and pattern of antihypertensive drug use, including the choice of monotherapy versus FDCs. Information regarding the therapeutic class of prescribed drugs was recorded, categorizing them into different pharmacological groups such as diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and others. To assess adverse effects, patient interviews and medical records were reviewed for documented side effects associated with antihypertensive therapy. Patients experiencing adverse effects were further evaluated to determine the severity, onset, and management strategies employed by healthcare providers.

Inclusion and Exclusion Criteria

Patients diagnosed with hypertension and receiving antihypertensive treatment at the selected healthcare centers were included in the study. Those with incomplete medical records, patients on temporary antihypertensive therapy, and individuals with secondary hypertension due to underlying conditions were excluded to maintain the study's focus on primary hypertension management.

Data Analysis

The collected data were systematically analyzed using statistical methods to identify trends in drug utilization, prescribing preferences, and the incidence of adverse effects. Descriptive statistics were used to summarize the frequency of monotherapy versus FDC prescriptions, while comparative analysis was conducted to assess differences in prescribing patterns across healthcare levels. Adverse effects were categorized based on their nature and severity, and correlations between specific drug classes and reported side effects were examined.

Table 1: Distribution of Antihypertensive Drug Classes Prescribed Across Healthcare Levels

Table 1 shows the prescription patterns of antihypertensive drug classes across primary, secondary, and tertiary care. Calcium Channel Blockers (CCBs) were the most prescribed class overall (34.34%), followed by Angiotensin Receptor Blockers (ARBs) (31.33%). ARBs were more common in tertiary care (35.04%), while CCBs were most prescribed in secondary care (40.08%). ACE Inhibitors (ACEIs) and Beta-Blockers (BBs) were less frequently prescribed, with ACEIs being more common in primary care (15.11%). Diuretics and Fixed-Dose Combinations (FDCs) had the lowest prescription rates, suggesting a preference for monotherapy or other drug classes.

Table 2: Prescription Patterns – Monotherapy vs. Combination Therapy

Table 2 compares the use of monotherapy versus combination therapy across different healthcare levels. Monotherapy was more common in primary care (70.1%), decreasing in secondary (59.92%) and tertiary care (54.99%). Conversely, combination therapy increased with healthcare level, peaking in tertiary care (45.01%). This suggests that more complex hypertension cases in higher care levels require multiple drugs, while primary care often manages milder cases with single agents.

Table 3: DDD/PDD Ratios of Common Anti-hypertensives

Table 3 evaluates the Defined Daily Dose (DDD) versus the Prescribed Daily Dose (PDD) for key antihypertensives. Amlodipine (CCB) had a PDD/DDD ratio of 1.24, indicating slight overuse, while Losartan (ARB) and Ramipril (ACEI) showed near-optimal dosing (0.9 and 0.96, respectively). Metoprolol (BB) and Hydrochlorothiazide (Diuretic) were underused (0.75 and 0.5, respectively), suggesting suboptimal dosing that may affect treatment efficacy.

Figure 1: Most Common ADRs Associated with Antihypertensives

Dry Cough was reported by 6% of patients mildly and 2% moderately, while Ankle Edema affected 10% mildly and 2% moderately. Fatigue/Dizziness was experienced by 4% mildly and 1% moderately, and Headache was reported by 3% mildly. Hypokalemia was observed in 3% moderately and 1% severely [Figure 1].

Table 4: Compliance with JNC-8 Guidelines

Table 4 assesses adherence to JNC-8 hypertension guidelines. First-line drug use (CCB/ARB/ACEI/Thiazide) was highest in tertiary care (85.04%) and lowest in primary care (74.92%). Appropriate combination therapy also increased with care level (60.13% in primary vs. 75.07% in tertiary). Blood pressure (BP) target achievement (<140/90 mmHg) followed a similar trend, with tertiary care performing best (69.94%). Overall, guideline compliance improved with higher healthcare levels, indicating better management in specialized settings.

The study provides a comprehensive analysis of antihypertensive prescription patterns across primary, secondary, and tertiary healthcare levels, offering valuable insights into current practices and areas for improvement in hypertension management. The findings reveal that Calcium Channel Blockers (CCBs) were the most prescribed class overall (34.34%), followed closely by Angiotensin Receptor Blockers (ARBs) (31.33%). Notably, ARBs were more frequently prescribed in tertiary care (35.04%), while CCBs dominated in secondary care (40.08%). In contrast, ACE Inhibitors (ACEIs) and Beta-Blockers (BBs) were less commonly used, with ACEIs being more prevalent in primary care (15.11%). Diuretics and Fixed-Dose Combinations (FDCs) had the lowest prescription rates, suggesting a preference for monotherapy or other drug classes. This underuse of diuretics is particularly noteworthy, as they are cost-effective and recommended in guidelines, highlighting a potential gap in evidence-based practice [8].

A key observation was the shift from monotherapy to combination therapy as patients moved from primary to higher levels of care. Monotherapy was most common in primary care (70.1%), decreasing in secondary (59.92%) and tertiary care (54.99%), while combination therapy rose to 45.01% in tertiary settings. This trend aligns with the clinical expectation that more complex hypertension cases, often managed in specialized care, require multiple agents for effective blood pressure control [9]. However, the study also identified suboptimal dosing patterns, particularly for Metoprolol (BB) and Hydrochlorothiazide (Diuretic), which were underused (PDD/DDD ratios of 0.75 and 0.5, respectively). Such dosing discrepancies may compromise treatment efficacy, underscoring the need for better adherence to guideline-recommended doses.

Adverse drug reactions (ADRs) further influenced prescribing trends, with ankle edema (10% mild, 2% moderate) and dry cough (6% mild, 2% moderate) being the most reported. These findings may explain the declining use of ACEIs in favor of ARBs, which have a more favorable side effect profile. Compliance with JNC-8 guidelines was higher in tertiary care, where first-line drug use (85.04%) and blood pressure target achievement (69.94%) were most successful. In contrast, primary care lagged in both metrics (74.92% and 54.98%, respectively), suggesting a need for enhanced training and support in these settings to improve adherence to best practices.

When compared to previous studies, the results show both consistencies and variations. For instance, Varakantham et al. (2018) observed a shift from beta-blockers to ACEIs and CCBs, while our study found greater ARB use, possibly reflecting updated guideline preferences [10]. Singh et al. (2020) also reported CCBs as the most prescribed monotherapy (25.1%), similar to our findings, and noted a comparable proportion of combination therapy (40.9%) [11]. Meanwhile, Alkaabi et al. (2019) and Datta et al. (2017) highlighted the dominance of CCBs and underuse of diuretics, reinforcing the need for better guideline adherence [12, 13]. Poudel et al. (2017) found higher FDC use in tertiary care, though our study reported lower overall FDC prescriptions, indicating regional differences in prescribing habits [14].

The study highlights the importance of standardizing antihypertensive prescribing practices in line with clinical guidelines, particularly in primary care. Addressing dosing inaccuracies, promoting the rational use of diuretics, and enhancing provider education are critical steps toward optimizing hypertension management. Future research should explore barriers to guideline adherence and evaluate interventions, such as clinician training programs or decision-support tools, to bridge these gaps and improve patient outcomes.

One limitation of our study is the reliance on prescription audits and patient interviews, which may introduce recall bias and incomplete data collection. Additionally, the study is cross-sectional, limiting our ability to assess long-term trends in antihypertensive drug utilization and treatment outcomes. The exclusion of patients with secondary hypertension may restrict the generalizability of findings to broader hypertensive populations.

Our study provides valuable insights into the prescribing patterns and utilization of antihypertensive drugs across primary, secondary, and tertiary healthcare centers in eastern India. The findings highlight a preference for calcium channel blockers and angiotensin receptor blockers, with a gradual shift from monotherapy to combination therapy in higher levels of care. While adherence to JNC-8 guidelines was higher in tertiary care, primary care settings showed gaps in guideline compliance and blood pressure target achievement. The study also identified suboptimal dosing patterns and adverse drug reactions that may influence prescribing decisions. Addressing these gaps through improved clinician education, standardized prescribing practices, and enhanced patient monitoring can optimize hypertension management and improve patient outcomes.

Acknowledgement: Special thanks to Dr. Saajid Hameed and Dr. Md. Jawed Akhtar, IGIMS, Patna (Bihar), for guiding and helping us to prepare a good research paper.

Funding sources: None

Conflict of Interest: None declared

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