Hypertension is an asymptomatic disorder and usually comes into picture only when the patient presents with some end organ damage, hence it is referred to as a silent killer. It is the 3^rd killer disease. World Health Statistics 2012 states that, every 1 in 3 adults has a high BP.^[1] In 2000 it was estimated that 1 billion i.e. nearly a quarter of the world’s population is suffering from hypertension. Prevalence of hypertension was estimated to be 40% in adults more than 25years in 2008. It is estimated to increase to 1.56 billion by 2025.^[2]

India is the second largest country in the world on the basis of its population, so a major chunk of any disease statistics can easily be attributed to her.^[4] Hypertension is the most common chronic health disorder in India. According to the global status report 2010 by WHO; prevalence of hypertension is 32.5%. Males have a slightly higher prevalence in comparison to females. Recent studies show that for every known person with hypertension, there are two people with either undiagnosed hypertension or prehypertension.^[5] three serial epidemiological studies in the years 1994, 2001 and 2003 showed a prevalence of hypertension as 30%, 36% and 51% respectively in males while in females it was 34%, 38% and 51% respectively.

State of Kerala has high life expectancy, which is comparable to European standards. Since the prevalence of hypertension increases in elderly, Kerala has a large chunk of hypertensive patients.^[6] MOHFW reports a prevalence of 69% and 55% among urban and rural elderly population in Kerala. Another study conducted in Thiruvananthapuram district of Kerala, which showed a prevalence of 47% which is much higher than national prevalence. Another study showed an incidence of 38% in Kumarakom, a rural area in Kottayam district of Kerala.^[7]

It is worthy to note that hypertension incurs a great deal of financial burden to the families of the affected. The annual income loss due to NCDs among working adults in India was 251 billion (about US$ 50 billion) and that due to hypertension alone amounted to 43 billion according to 2004 reports.^[8]

Reducing blood pressure with life style modification and antihypertensive drugs can effectively tackle the burden of this disease on our state and the nation. Evidence from several randomized controlled trials has shown that antihypertensive drugs can effectively reduce morbidity and mortality due to hypertension.^[9]

Studying the drug utilization pattern of antihypertensive drugs and prevalence of blood pressure control with respect to the current guidelines for management of hypertension, would help to bring into light any inadequacies in management of hypertension and thus help to impede the mortality and morbidity.^[10] There are very few studies done on pattern of use of antihypertensive drugs in South India, especially in Kerala in view of the change in recommendations by the latest JNC 8 guidelines

A cross-sectional study was conducted by the department of Pharmacology in association with the department of Medicine at a Maheshwara Medical College and Hospital. A total of 460 prescriptions were included in this study.

Inclusion Criteria Patients who were above 25 years of age and had a confirmed diagnosis of hypertension were included in the study. Exclusion Criteria Indoor hypertension patients, individuals below 25 years of age, those with uncertain diagnosis, pregnant and lactating mothers, and patients who reported to the outpatient department but were subsequently admitted were excluded from the study.

This study was approved by the Institutional Ethical Committee, and informed consent was obtained from all participating patients.

Statistical Analysis the data were analyzed using statistical tools such as frequencies, means, standard deviation (SD), and percentages. Various aspects were assessed, including the average number of anti-hypertension drugs prescribed per prescription, the relationship between patient demographics and prescription patterns, indicators for which antihypertensives were prescribed, percentage usage of various anti-hypertensives, dosage forms, fixed-dose combinations (FDCs), polypharmacy, and route of administration. Additionally, the drug utilization was measured using the Anatomical Therapeutic Chemical/ Defined Daily Dose (ATC/DDD) metric system.

In this prospective study, 460 patients were enrolled, with 258 (56.1%) males and 202 (43.9%) females. The mean age of the study population was 59.69 (±9.738) years. Among them, 58% were aged ≥60 years, while 42% were <60 years.

Family history analysis revealed that 30% of patients had a history of hypertension, while 70% did not. Regarding social habits, 14 patients were smokers, 10 were alcoholics, 63 were ex-alcoholics, and 104 were ex-smokers (Table 1).

Table 1: Baseline Characteristics of Hypertensive Patients (n = 460)

Patients were classified based on blood pressure levels according to the JNC-8 guidelines. Among the 460 patients, 31.8% had stage 1 systolic hypertension, and 36.4% had stage 1 diastolic hypertension. Additionally, 23.4% had stage 2 systolic hypertension, and 14.6% had stage 2 diastolic hypertension (Table 2).

Table 2: Distribution of Patients According to Blood Pressure

Hypertension was commonly associated with comorbidities, with 416 patients (90.4%) affected. As shown in Table 3, the most prevalent condition was coronary artery disease (53%), followed by diabetes (46.6%), dyslipidemia (42%), hypothyroidism (13.4%), chronic kidney disease (5.8%), and stroke (5.2%).indicates that 367 (73.4%) patients were receiving combination therapy and only 133(26.6%) patients were receiving monotherapy

Table 3: Distribution of Patients According to Comorbidities (n = 460)

In this study, 133 patients were treated with monotherapy in that 42.1% patients were treated with amlodipine, followed by Losartan (28.57%), Telmisartan (9.77%), and Metoprolol (9.77%). Ramipril, Enalapril were used less frequently (Table 4)

Table 4: Patients on Monotherapy (n = 460)

In combination therapy most commonly used was double therapy (42.8%) followed by triple therapy (24.2%), four-drug therapy (5.6%), and five drug therapy (0.6%) (Table 5).

Table 5: Distribution of Patients According to Combination Drug Therapy (n = 460)

Among angiotensin-converting enzyme inhibitors most prescribed was Enalapril (58.49%), followed by Ramipril (38.67%) and Captopril (1.88%). The Diuretics prescribed preferably Thiazides are first-line agents for most patients with hypertension, especially in combination therapy. The result showed that Furosemide (54.05%) was the most prescribed Diuretic, followed by Hydrochlorothiazide (23.42%), Spironolactone, and Chlorthalidone 17.11%, last Torsemide (3.60%).

This prospective study analyzed the demographic, clinical, and therapeutic characteristics of 460 hypertensive patients. The findings highlight key aspects of hypertension prevalence, associated risk factors, comorbidities, and treatment patterns.^[11]

The study population had a mean age of 59.69 (±9.738) years, with 58% of patients aged ≥60 years, reinforcing the notion that hypertension predominantly affects older adults. The gender distribution showed a slight male predominance (56.1% males vs. 43.9% females), which is consistent with existing literature suggesting higher hypertension prevalence in men.^[12]

Family history analysis revealed that 30% of patients had a family history of hypertension, suggesting a genetic predisposition. Lifestyle factors were also evaluated, with 14 patients (2.8%) being active smokers, 104 (20.9%) ex-smokers, 10 (2.0%) alcoholics, and 63 (12.6%) ex-alcoholics. These findings emphasize the role of modifiable risk factors, such as smoking and alcohol consumption, in hypertension management.^[13]

Patients were categorized based on JNC-8 guidelines. The majority fell into the Stage 1 hypertension group (31.8% systolic, 36.4% diastolic), while Stage 2 hypertension was observed in 23.4% (SBP) and 14.6% (DBP). Notably, 47% of patients had normal diastolic blood pressure, indicating isolated systolic hypertension in a significant subset, which is a common condition in elderly individuals^.[14]

Hypertension was highly associated with comorbidities, with 90.4% of patients presenting at least one additional condition. The most common comorbidity was coronary artery disease (53%), followed by diabetes mellitus (46.5%) and dyslipidemia (42%). These findings align with previous studies showing a strong correlation between hypertension, cardiovascular diseases, and metabolic disorders. Additionally, hypothyroidism (13.5%), chronic kidney disease (5.9%), and stroke (5.2%) were also observed, emphasizing the need for comprehensive patient management^.[15]

The study evaluated antihypertensive medication use, with patients categorized into monotherapy and combination therapy groups.

• Monotherapy: The most commonly prescribed drug was Amlodipine (42.1%), followed by Losartan (28.6%), reflecting the preference for calcium channel blockers and angiotensin receptor blockers as first-line treatments.
• Combination Therapy: A significant proportion of patients (73.3%) required more than one antihypertensive agent. Double therapy (42.8%) was the most common regimen, followed by triple therapy (24.1%), reflecting the challenge of blood pressure control in hypertensive patients with comorbidities.^[16]

The high prevalence of comorbidities and the need for combination therapy highlight the complexity of hypertension management. The findings suggest that early screening, lifestyle modifications, and personalized treatment regimens are essential for effective blood pressure control and cardiovascular risk reduction^.[17]

Although the study provides valuable insights, it has certain limitations. The study was conducted in a specific population, which may limit its generalizability. Additionally, patient adherence to therapy and lifestyle interventions was not assessed. Future research should focus on longitudinal follow-ups, evaluating the impact of various treatment regimens on long-term cardiovascular outcomes^.[18]

Data on drug utilization linked to routine diagnoses in primary care are scarce. These data, however, are of importance in view of the fact that the prevalence of hypertension in this setting was very high (40.1% of all patients in this study). The large majority of all hypertensive patients received drug treatment, and, despite these efforts, control rates were poor. In our sample, 70.6% of all hypertensive patients were not controlled and mean BP levels were 144.5/84.5 mmHg. This was considerably higher than mean BP values sampled from^[19]   general population registries in Germany (136/ 83 mmHg in individuals aged 18–79 years)[^20]

This study emphasizes the high burden of hypertension and its associated comorbidities, demonstrating that a significant proportion of patients require combination therapy for effective management. Addressing modifiable risk factors and adopting a multidisciplinary approach to hypertension management can significantly improve patient outcomes.The overall antihypertensive medicines utilization was largely influenced by national and ESH/ESC guidelines and strongly corresponded to the positive medicine list of the national health insurance fund. Antihypertensive medicines utilization is comparable with medicine utilization trends in other countries

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