CLASSES TO BE USED AS FIRST-LINE AGENTS For adults with hypertension requiring pharmacological treatment, WHO recommends the use of drugs from any of the following three classes of pharmacological antihypertensive medications as an initial treatment: 1. thiazide and thiazide-like agents 2. angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) 3. long-acting dihydropyridine calcium channel blockers (CCBs). Strong recommendation, high-certainty evidence 5. RECOMMENDATION ON COMBINATION THERAPY For adults with hypertension requiring pharmacological treatment, WHO suggests combination therapy, preferably with a single-pill combination (to improve adherence and persistence), as an initial treatment. Antihypertensive medications used in combination therapy should be chosen from the following three drug classes: diuretics (thiazide or thiazide-like), angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers (CCBs). Conditional recommendation, moderate-certainty evidence 6. RECOMMENDATIONS ON TARGET BLOOD PRESSURE WHO recommends a target blood pressure treatment goal of 1.4 months prior to initiation of treatment had a hazard ratio of 1.12 (1.05–1.20) for a major adverse cardiovascular event (MACE) compared to those who started treatment at 2.7 months before re-evaluation had a hazard ratio of 1.18 (1.11–1.25) for MACE compared to those reassessed at USD 50 000/QALY out of 28 studies. Most of the remaining cost data presented were related to self-monitoring and not to the question of physician-led vs nonphysician-led care. However, if it is assumed that nonphysician salaries are lower, then potentially costs will be lower, but that assumes that only limited effort by physicians is involved in any oversight of nonphysicians. Kulchaitanaroai et al. found similar results with a physician–pharmacist collaborative system (81). The two available analyses, by Jacob et al. and Kulchaitanaroai et al., focused on team-based interventions as opposed to specifically physician vs other provider, and it is not clear if incremental costeffectiveness ratios fit countries in all economic categories, nor whether the countries’ willingness- topay thresholds were analysed. All values appear to be below USD 50 000/QALY. For the US, the results were highly cost-effective, with most estimates well under USD 50 000/QALY but it remains unclear exactly how these may be translated to countries in lower economic categories. Even at USD 10 000/ QALY, however, this would be acceptable for most MICs, though perhaps not for all LICs. However, if the costs were the same or lower in programmes led by nurses or pharmacists compared to those led by physicians then cost-saving was likely. The GDG proposed four conditions that must be met for nonphysician-prescribing of antihypertensives. These focused on the prescribers having proper training, prescribing authority in their locale, working within specific management protocols and having physician oversight. Community HCWs were suggested as personnel who could assist with tasks such as education, delivery of medications, BP measurement and monitoring through an established collaborative care model. Telemonitoring supervised by HCWs, and community- or home-based self-care, were considered as tools to enhance BP control as part of an integrated management system. 20 4 Special settings 4.1 Hypertension in disaster, humanitarian and emergency settings Hypertension (HTN) is seen in a range of humanitarian crises and disaster settings (natural or humanmade). This includes, but is not limited to, the wars in Syria and Iraq, the impact of the Great East Japan Earthquake and Hurricane Katrina, and the living conditions of Palestinian refugees. The burden of HTN on those populations can be considerable (82). There are very little data on HTN control, access to care and treatment, and patient understanding of HTN from Africa and Asia (except Japan), despite protracted refugee situations on these continents. Violent and protracted conflicts are disastrous to civilian populations and their health care systems, and result in interruptions to treatment and care (83, 84). Armed conflicts are associated with increased short-term and long-term cardiac morbidity and mortality and increases in blood pressure (BP) (85). Following exposure to conflict, research in military populations shows that post-traumatic stress disorder and severe injury are independent risk factors for the development of HTN (86). The rates of treatment ranged from 53.4% to 98.1% of patients with HTN in this population (87, 88). There are currently no data regarding target BP or the best antihypertensive agent to treat disasterrelated HTN. Opinion-based recommendation is that the target BP control level should be less than 140 mmHg for SBP and less than 90 mmHg for DBP. According to Kario et al, long-acting CCBs are preferred because they are metabolically neutral, and best at reducing BP variability, which is an independent predictor of clinical outcomes, especially stroke. In addition, the BP-lowering effect of long-acting CCBs is dose-dependent, and the degree of BP reduction that can be anticipated from these agents is known (89).