letter to the editor - Nature

Journal of Human Hypertension (2002) 16, 285–287  2002 Nature Publishing Group All rights reserved 0950-9240/02 $25.00 www.nature.com/jhh

LETTER TO THE EDITOR A high level of awareness but a poor control of hypertension among elderly Greeks. The Nemea primary care study Journal of Human Hypertension (2002) 16, 285–287. DOI: 10.1038/sj/jhh/1001380

Recent clinical trials in many industrialised countries have demonstrated a significant decline in cardiovascular disease morbidity and mortality by treating hypertension in older patients.1–3 Even though these trials show that treating hypertension is beneficial in reducing hypertension-associated morbidity and mortality, nearly 50% of all hypertensive patients are untreated or had a poor level of hypertension control at a threshold pressure of ⬍140/90 mm Hg. This situation is particularly unknown in Greece. There are only few data about the prevalence of hypertension in older patients and information about the levels of awareness, treatment and control of hypertension is limited.4,5 The aims of this study are to determine the prevalence of hypertension and the levels of awareness, treatment and control of hypertension in Greeks aged 65 years and older. The data for this study came from a programme on the elderly for detection of cardiovascular risk factors. Our study population comprised all those individuals who participated in this programme, residing in Nemea and in the villages of Koutsi, Leontio and Psari, located in Corinthia. The target population based on a 1991 population census in the area was 1044 subjects. A total of 637 subjects agreed to participate in the study, 22 were rejected due to incomplete data and in the end Correspondence: EA Skliros, Nestoros 32, Egaleo, 122 44 Athens, Greece. E-mail: eskliros얀otenet.gr Received 3 October 2001; revised and accepted 28 November 2001

615 participants were included in the analysis. Structured interviews were conducted with all participants. Three sitting blood pressure (BP) measurements were taken for each subject, 5 min after rest and 30 min after smoking, on the patient’s left arm, with a 2-min interval between them (Korotkoff phase V for diastolic BP). Participants with elevated BP measurement were invited to attend a second clinic visit after 7–14 days to have their BP remeasured. The average BP of the second visit was used as criterion for the diagnosis and control of hypertension. Hypertension in our survey was defined using the criteria of JNC VI6 (systolic BP ⭓140 mm Hg and/or diastolic BP ⭓90 mm Hg or current treatment with antihypertensive drugs). Treated hypertension defined as current use of antihypertensive medication as determined by review of all medication taken. Controlled hypertension definition was based on systolic BP ⬍140 mm Hg and diastolic BP ⬍90 mm Hg in subjects taking antihypertensive medication. Awareness of hypertension reflects prior knowledge of hypertension diagnosis. The data were analysed using a statistical package program (SPSS, Chicago, IL, USA). The overall response rate was 637/1044 (61.0%). However 615 (58.9%) subjects were included in the analysis. The proportion of male participants (364/518, 70.2%) was greater than that of female (251/526, 47.7%, P ⬍ 0.05). The mean age ± s.d. was 73.5 ± 6.1 years (range: 65–99 years), 364 (59.2%) were men and

251 (40.8%) were women. Mean body mass index (BMI) was 26.4 ± 3.8 kg/m2 (range: 19– 43 kg/m2). Diabetes mellitus was reported from 14.7% of the participants and hyperlipidaemia from 41.2%. Of the total population only 13.3% were current smokers, but 62.8% were current alcohol drinkers. BP distribution was approximately Gausian and the mean ± s.d. value was 140.4 ± 19.9 mm Hg and 81.2 ± 10.2 mm Hg for systolic BP and diastolic BP respectively. The overall prevalence of hypertension was 425/615 (69.1%, 95% CI: 66.5–71.6), 70.7% in men and 67% in women. Hypertension prevalence rates were increased with age, but there was no significant difference in the prevalence of hypertension among those who were ⭓ 80 years old and those who were ⬍80 years old (76.8% vs 67.8%, P = 0.076, OR = 1.070 (0.998– 1.146)). In a logistic regression analysis variables associated with hypertension were age (Wald = 7.83, P = 0.0005), BMI ⬎ 30 kg/m2 (Wald = 15.14, P = 0.0001, RR = 1.803 95% CI: 1.357–2.180) and family history of hypertension (Wald = 20.095, P = 0.0001, RR = 1.720 95% CI: 1.357–2.180). Controlling for the null hypothesis that the prevalence of hypertension in elderly rural population in Hellas is lower than 60%, our data suggests with possibility P = 0.999 that the prevalence of hypertension in Greek population is over 60%. In total, 11% (47/425) of the hypertensives were not aware of having hypertension. Of those who were aware of having hypertension (n = 378), 344 (91%) were

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Table 1 Classification of hypertensive patients n (%) Normotensives Hypertensives Controlled hypertensives Uncontrolled hypertensives Diastolic Systolic Double Untreated hypertensives Isolated diastolic BP Isolated systolic BP

190 344 169 175

(30.8) (56.0) (27.5) (28.5) 5 96 74 81 (13.2) 17 (2.7) 38 (6.2)

Male (%)

Female (%)

SBP ± s.d.

107 (56.3) 210 104 (61.5) 106 (60.5) 2 (4.0) 64 (66.7) 40 (54.1) 47 9 30

83 (43.7) 134 65 (38.5) 69 (39.5) 3 (6.0) 32 (33.3) 34 (45.9) 34 8 18

125.0 ± 11.9 146.0 ± 18.0a 131.9 ± 7.9a 159.7 ± 15.9a,* 139.0 ± 2.2 152.6 ± 7.9 170.2 ± 17.8 152.5 ± 19.0a 132.8 ± 7.2a 156.7 ± 20.1a

DBP ± s.d. 76.8 ± 8.5 82.1 ± 10.3a 77.4 ± 7.8b 86.5 ± 9.9a** 95.8 ± 4.0 79.3 ± 4.8 95.3 ± 7.1 87.1 ± 10.1a 98.5 ± 2.8a 78.8 ± 5.5c

SBP = systolic blood pressure; DBP = diastolic blood pressure. a Difference from normotensives P = 0.0001. b Difference from normotensives P = 0.452. c Difference from normotensives P = 0.08. *Difference from untreated hypertensives P = 0.002. **Difference from untreated hypertensives P = 0.0330.

treated. Table 1 shows the levels of control of hypertension for male and female hypertensives and the mean systolic and diastolic BP values for subgroups classified by treatment and control status. Among treated hypertensives (n = 344), 49.1% had systolic BP ⬍140 mm Hg and diastolic BP ⬍90 mm Hg. Of 175 uncontrolled hypertensives only five (2.8%) had systolic BP ⬍140 mm Hg and diastolic BP ⬎90 mm Hg. There was no difference in the rate of control (49.5% vs 48.5%, P = 0,290, OR = 1.016 95% CI: 0.858–1.203) among treated men compared with women. In all 42% of controlled subjects were on antihypertensive monotherapy. To appreciate our findings, the potential of selective participation should be kept in mind. Consequently, the true prevalence rate of hypertension in the Hellenic elderly population maybe somewhat lower. In our study the overall prevalence of hypertension estimated using the threshold BP of ⭓140/90 mm Hg was found to be 69.1%. However, specific information on the prevalence of hypertension in Hellas is limited. In a previous study performed in a random urban population in Athens4 several methodological problems were addressed particularly those raised by the BP measurements (only one) and by the definition of Journal of Human Hypertension

hypertension (treated hypertensives with BP ⬍140/90 mm Hg classified as normotensives). Our results can be compared only with the results of the Didima study,5 in which the prevalence of hypertension among elderly participants was found to be 50% in a relatively small subgroup (n = 189). Epidemiological surveys in the USA and in Europe have shown prevalence rates varying from 53–72.3%.7–12 Our study has potential limitations. The trend demonstrated in our study for higher prevalence among men compared with women was observed in surveys among younger study populations. However, this difference may be explained mainly in the different response rate of women and in the difference in alcohol consumption and smoking in men compared with women. A considerable proportion of hypertensives in our study are treated, reflecting an increased awareness among Greek primary health care physicians regarding risks of hypertension and benefits of control. This tendency for treatment in Greek physicians has also been mentioned in the Didima study.5 Although there was early initiation of drug therapy a considerable proportion of treated hypertensives are treated ineffectively. The proportion of controlled hypertensives in our study is higher than in the Italian8 or

Dutch7 study using the 140/90 mm Hg thresholds, or in Mexican Americans.9 The overall rates of hypertension control were remarkably similar to those of the Didima study and in the Framingham Study.10 A major finding in our study is the high level of awareness, related to the successful implementation of a local health promotion programme including the use of mass media to educate the population. In conclusion, although the high percentage of Greek elderly were aware and treated, poor control of hypertension is a major public health problem. There is a need for efforts to improve the treatment of hypertension and to prevent an epidemic of cardiovascular disease. EA Skliros1,2 I Papaioannou1 A Sotiropoulos1 G Giannakaki1 M Milingou1 C Lionis2 1 Nemea Medical Center, Nemea, Greece 2 Clinic Social and Family Medicine University of Crete, Greece References 1 Antikainen R et al. Therapy in old patients with isolated systolic hypertension: fourth progress report on the Syst- Eur trial. J Hum Hypertens 1997; 11: 263–269.

Letter to the editor

2 Scott DJ. Hypertension in the elderly. J Hum Hypertens 1998; 12: 665–666. 3 Colhour HM, Dong W, Poulter NR. Blood pressure screening, management and control in England: results from the health survey for England 1994. J Hypertens 1998; 16: 747–752. 4 Moulopoulos SD et al. Coronary heart disease risk factors in a random sample of Athenian adults: the Athens study. Am J Epidemiol 1987; 126: 882–892. 5 Stergiou GS, Thomopoulou GC, Skeva II, Mountokalakis TD. Prevalence, awareness, treatment and control of hypertension in Greece. The Didima study. Am J Hypertens 1999; 12: 959– 965. 6 Joint National Committee on Detec-

tion, Evaluation and Treatment of high blood pressure: the sixth report of the Joint National Committee on the detection, evaluation, and treatment of high blood pressure (JNC VI). Arch Intern Med 1997; 24: 2413–2446. 7 Van Rossum CT et al. Prevalence, treatment and control of hypertension by sociodemographic factors among the Dutch elderly. Hypertension 2000; 35: 814 –821. 8 Di Bari et al. Undertreatment of hypertension in a community-dwelling older adults: a drug utilization study in Dicomano, Italy. J Hypertens 1999; 17: 1633–1640. 9 Shatish S et al. Undertreatment of hypertension in older Mexican Amer-

icans. J Am Geriat Soc 1998; 46: 405– 410. 10 Loyd-Jones DM et al. Differential control of systolic and diastolic blood pressure. Hypertension 2000; 36: 594 –599. 11 Prencipe M et al. Prevalence, awareness, treatment and control of hypertension in the elderly: results from a population survey. J Hum Hypertens 2000; 14: 825–830. 12 De Backer G et al. Prevalence, awareness, treatment and control of arterial hypertension in an elderly population in Belgium. J Hum Hypertens 1998; 12: 701–706.

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