A Life of Getting China’s Hypertension Under Control

The World Health Organization estimates that there are at least 270 million people living with hypertension in China — a fraction of whom are being adequately treated, if at all. Part of the problem is the size of the country and getting access to appropriate care. Improving the situation has been a lifelong goal for Ji-Guang Wang, MD, PhD, professor of cardiovascular medicine and director of the Shanghai Institute of Hypertension and of the department of hypertension at Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China.
At the European Society of Cardiology (ESC) Congress 2024, Wang spoke with Medscape about his career path and discussed some of the initiatives and research that he has been involved in recently. 
Wang is the current president of the Chinese Hypertension League and deputy president of the Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network. He is past president of the Asian-Pacific Society of Hypertension, past president of the Pulse of Asia Society, and a former executive council member of the International Society of Hypertension. In addition, he serves on the editorial board of several international and Chinese national journals in the field of hypertension and cardiovascular medicine in various capacities. 
Over the course of his career, Wang has been involved in many m ulticenter randomized clinical trials and population-based studies, published hundreds of articles on hypertension in both the international and Chinese literature, and has lectured extensively and chaired sessions at conferences at home and abroad.
I started my career in the field of cardiology, mainly focusing on hypertension, more than 30 years ago. I started my career in Beijing, in Fuwai Hospital, which is a cardiovascular institution and hospital. It’s mainly dedicated to cardiology. What I want is to be a physician-scientist. This is why I like cardiovascular medicine, because I want to do research in addition to clinical practice. That’s why I chose to be a physician instead of a surgeon, for instance. As a surgeon, you have to work mainly in the wards and do surgeries. As a physician, you can do more research, particularly to investigate the etiology and pathogenesis of various diseases. 
Regarding why cardiovascular disease, it goes back to what I predicted many, many years ago: that with the increasing economy in China, we would probably also have more patients with cardiovascular diseases, mainly coronary heart disease, but also other problems like hypertension. Rates of hypertension have indeed increased a lot in the past 30 years, from around 10% to close to 30% of all adults.
I think there are mainly two reasons. The first is because of aging; China has a large population of people over 60 years of age, and almost half of them have high blood pressure. The second is mainly the change in lifestyle; calorie intake is high and calorie expenditure is becoming lower, so we have a lot of people developing obesity. There are also problems of high salt intake and metabolic disorders, increasing the likelihood to develop hypertension.
We do several things. First of all, we of course need to write Chinese scientific guidelines for the management of hypertension. It means physicians can follow certain recommendations to manage hypertension in such a big country. 
The other thing we do is to promote research in the field, both basic research and clinical research, so we can improve our management of hypertension. It is not a single disease; it is actually a manifestation of many different diseases. So we really need to improve our knowledge. We have started several screening activities for secondary hypertension, such as that due to sleep apnea. With these programs, we can improve the management of more complicated and complex cases of hypertension.
The first Chinese hypertension guidelines were published in 1999. These have been updated four times. The current guidelines were published just a few weeks ago.Specific guidelines are needed because we have a lot of differences. We have different lifestyles. We have high salt intake, and we eat more rice than other populations. In addition, we have quite a high prevalence of cigarette smoking, and alcohol intake is also a big issue in China. We are also different sometimes in responses to disease evaluations, and we need a different diagnostic threshold in some cases. And we are of course a little bit different in size in the cardiovascular system. In the new guidelines, we define left ventricular hypertrophy using the Chinese criteria instead of the previously used European and US criteria. 
There are also a lot of treatment differences. For example, we use more calcium-channel blockers to reduce blood pressure than thiazide diuretics, because in China we have more people with hyperuricemia, and if you use standard diuretics you would induce gout and further increase the prevalence of this condition. We have also started to use more angiotensin receptor-neprilysin inhibitors. These are not approved for hypertension yet in Europe and America [although they are approved for heart failure]. That’s because in China, we probably need that drug to reduce blood pressure, especially in those patients with high salt intake and salt sensitivity. In Europe and North America, they probably have less problem in that regard.
I think we should have some more communication in that regard. Hopefully [clinicians will] not necessarily use, but refer to, the Chinese guidelines for American Asian and European Asian persons. People may still have the same Chinese lifestyle even though they live in North America or Europe.
I think we [researchers from China] should communicate more, both in the literature and at scientific meetings, such as at this European Society of Cardiology conference. I chaired one session here and participated in this year’s American College of Cardiology meeting, for example. By communicating more, we probably can improve our knowledge and understanding.
HOPE Asia is an organization that is mainly concerned with improving knowledge and, eventually, management of hypertension in Asian countries. It’s an organization of hypertension experts from more than 10 Asian countries. Together, we discuss our work and we publish consensus documents. In the past year, we published about 50 documents in almost all areas of hypertension to try to improve its management.
I mainly do clinical and epidemiologic studies. For the clinical part, I do randomized controlled trials, and also observational studies in patients with hypertension with other comorbidities such as diabetes or dyslipidemia. For the epidemiologic part, we have some cohorts with different characteristics. We have older adult cohorts, we have the general population cohort, and we also have a workplace population cohort, so we have many cohorts for epidemiologic studies. In all of these studies, we include blood pressure monitoring; we study the pathogenesis of hypertension; and we study the therapeutic management of hypertension, both lifestyle modifications and pharmacologic management. 
We just published a randomized controlled trial on the efficacy of antihypertensive treatment for target organ protection in patients with masked hypertension, which means patients who had elevated ambulatory blood pressure but normal clinic blood pressure. We had previously not really included those patients in clinical trials. It was published in eClinicalMedicine. We found that if we treat those people with elevated ambulatory blood pressure but normal clinic blood pressure, it may provide protection against organ damage, arterial stiffness, and albuminuria. It’s an intermediary outcomes study, not a hard outcomes study, but we are planning a hard outcomes study in patients with a history of stroke. So hopefully in a few years, we can do more work in this direction.
First of all, you have to measure blood pressure in almost everybody, and you need to measure accurately. Then you treat early with antihypertensive medication, but not too much, and lifestyle modification. 
Wang reports no relevant financial relationships. 
Sara Freeman is a medical journalist and writer based in London, United Kingdom. She is a regular contributor to Medscape and other specialist healthcare media outlets.