Neil Poulter: upping the pressure on hypertension.

Visiting Neil Poulter at the International Centre for Circulatory Health (ICCH), which he co-directs in the west London district of White City, it might seem he’s based in one of the less exalted outposts of the centre’s parent body, Imperial College London. Not so. Poulter’s ICCH office is part of what will eventually be home to a major expansion of the college. This will incorporate new centres for molecular science, translation, and bioengineering, some of which should begin working by the end of next year. So in this respect his location is, if anything, a pointer to the future. And appropriately so with Poulter, newly installed President of the International Society of Hypertension (ISH), enthusing about what he hopes to achieve during his coming term of office. He talks passionately of the huge gains to be made simply by implementing what we already know and can do about hypertension. “When only one-third of patients being treated are being controlled, that’s nonsense. We must do better”, he urges. The point is very much in line with the manifesto of the recent Lancet Commission on Hypertension, an exercise with which Poulter and the ISH were involved. Assured by a fortune-teller when just 6 years old that he would become a doctor, Poulter made this his ambition. And he achieved it—although not, as first planned, in paediatrics. “I realised as a student (at St Mary’s Hospital Medical School in London) that sick kids made me very upset. I couldn’t face it.” Nor was he the most diligent of students, except at rugby and cricket—which was fine until the end of the course loomed close. He bought extra time for studying by taking a year out at the Wellcome Trust’s Tropical Metabolism Research Unit in Kingston, Jamaica, got a couple of research papers published, then returned “as a grown up”, he says, and qualified in 1974. 4 years later he returned to Jamaica for 3 months, this time to study urban–rural differences in blood pressure. Back at St Mary’s Poulter was subsequently offered another and similar study, but this time in Kenya at the Wellcome Trust’s research laboratories in Nairobi. “It was supposed to be for just 1 year to assess the feasibility. But then they said, OK it looks like it’ll work, will you stay for another year and get it going”, he recalls. In the end he stayed for 5 years, studying among other things the Luo people and what happened when they moved from the countryside into the cities. The findings had a major impact, says Professor Mark Caulfield, Co-Director of the William Harvey Research Institute at Queen Mary University of London. “His work on the Kenyan Luo migrants definitively demonstrated the effect on high blood pressure of moving from a rural environment, where people were living a subsistence farming existence, to an urban environment. Increased salt and alcohol intake lead to a higher blood pressure.” Caulfield adds that this work on blood pressure in relation to lifestyle is especially relevant today with the burgeoning level of hypertension in many low-income and middle-income nations. At this point Poulter realised he’d become an epidemiologist. “So when I came back to the UK I thought I’d better learn about what I’ve been doing for the past 5 years”, he says. After an MSc in epidemiology at the London School of Hygiene & Tropical Medicine he worked on cardiovascular disease and the contraceptive pill. Then came ASCOT (the Anglo-Scandinavian Cardiac Outcome Trial), a study of lipid management in hypertension comparing combinations of new versus older antihypertensives. Poulter also had a leading role in the ADVANCE trial (Action in Diabetes and Vascular Disease: Preterax and Diamicron Controlled Evaluation), which looked at blood pressure lowering in the context of improved sugar control. And there were many other trials—and more to come—in which Poulter has been influential. As Caulfield puts it, “these studies have totally changed national and international guidelines on treating hypertension and diabetes, and therefore how we prevent cardiovascular disease”. They also made Poulter, and Imperial College, star performers in the citation league tables. Appointed Professor of Preventive Cardiovascular Medicine in 1997, it was some 7 years later that Poulter, along with Professor Peter Sever, dreamed up the ICCH. It was created to form a framework within which the five or so Imperial College research groups with an interest in cardiovascular disease could work together more easily. “From bench to beside we cover a whole range of activities”, he says. Among their trials was one on a variant of the polypill concept for cardiovascular prevention. The study concluded that for people at high risk it offered substantial net benefits. Although not keen on the polypill as originally conceived, he’s an enthusiast for the more modest use of optimum drug combinations. “Neil is doggedly determined”, says Caulfield. “When he’s set himself a task he never ever gives up.” Dorairaj Prabhakaran, Executive Director of the Centre for Chronic Disease Control in New Delhi, India, adds that it’s Poulter’s personal influence which has inspired many other researchers in public health cardiology to enter the field. “An engaging teacher and a great communicator”, he adds. “He’s got an eye for detail. And he’s a good research leader.” Both men are enthusiastic about the benefits to the ISH of a Poulter Presidency. “Neil’s a very clear thinker with a global perspective”, says Caulfield. “He’s a visionary.” Prabhakaran too uses that word. “He has the vision to transform the blood pressure world and to reduce the burden of high blood pressure, particularly in low-income countries such as Africa, and parts of south Asia and China.”