Prevalence, Awareness, Treatment and Influence of Socioeconomic Variables on Control of High Blood Pressure: Results of the ELSA-Brasil Study

Prevalence of Undiagnosed Cardiovascular Risk Factors in Adults Aged 20 - 40: A Cross-Sectional Study in 2016 in Jeddah, Saudi Arabia

Background

Cardiovascular diseases (CVDs) are the first leading cause of death worldwide. In Saudi Arabia, CVDs are the major killers with a mortality rate of 46%. CVD risk factors are not exclusive to old populations. Thus, the purpose of this study was to approximately find the prevalence of these risk factors, particularly high blood pressure (HBP), high blood glucose (HBG), obesity, and smoking.

Methods

This cross-sectional was conducted in May 2016 and took place in the Ambulatory Care Center of King Abdulaziz Medical City, Jeddah. We used a non-probability convenience sampling technique where only individuals aged 20 - 40 who were free of medical illnesses were included. We excluded pregnant women and people on medications that might interfere with our measurements. We obtained a brief history and measured blood pressure, blood glucose, height and weight. Data analysis was done in form of frequencies. Chi-square test was utilized to compare qualitative variables. P < 0.05 was used to determine statistical significance.

Results

A total of 507 participants were included (76.3% males and 23.7% females). All participants were between 20 and 40 with a mean age of 31.6 ± 6.06 SD. We found the prevalence of undiagnosed HBP to be 8.3% and males showed a significantly higher percentage (P < 0.001) when compared to females. HBG prevalence was only 0.6%. Regarding body mass index, the prevalence of overweight and obesity together was 66.3% and males showed significantly higher percentage in falling in this category (P < 0.001). Smoking prevalence was 37.9% with a significantly higher percentage among males (P < 0.001).

Conclusion

CVD risk factors are apparently quite common in young adults. Efforts must be made to increase the public awareness regarding these risk factors. CVDs are not exclusive to old people. Thus, the public should appreciate this fact in order to prevent these risk factors by establishing healthy life-styles.

Effects of acute blood pressure elevation on biochemical-metabolic parameters in individuals with hypertensive crisis

Hypertensive crisis is a common clinical situation that presents a high rate of morbidity and mortality and it is characterized by symptomatic rise of blood pressure (BP), systolic (SBP) ≥ 180 mmHg and/or diastolic (DBP) ≥ 120 mmHg. It is classified as emergency (HE) or hypertensive urgency (HU). There is no description of laboratory findings in patients who present acute BP elevation. Thus, this study had the objective to assess the biochemical-metabolic parameters of patients with HC. We studied 74 normotensive individuals (NT), 74 controlled hypertensive patients (ContrHT), 50 subjects with HU, and 78 with HE for evaluating biochemical-metabolic parameters. HE occurs in older individuals and more frequently in those with known hypertension. More patients with HE had dyslipidemia than those with HU (58% vs. 38%). The diastolic BP and heart rate were higher in the HE group (120 mmHg and 87 bpm) compared to ContrHT (71 mmHg and 71 bpm; p < 0.0001) and NT groups (75 mmHg and 68 bpm; p < 0.0001). Glycemia was higher in HE vs. NT and ContrHT (p < 0.05). HDL cholesterol was lower in HE than NT (p = 0.0088). Potassium was lower in HE vs. NT, ContrHT and HU groups (p < 0.05). Creatinine was higher in the HC group vs. NT and ContrHT (p < 0.05). The GFR was significantly lower in HE group vs. HU, ContrHT and NT (p < 0.001). In conclusion, individuals with HC show biochemical alterations when compared to ContrHT and NT. Acute BP elevations are associated with hyperglycemia, dyslipidemia, and higher potassium and creatinine levels and lower renal function. Abbreviations BMI = body mass index BP = blood pressure CH = hypertensive crisis ContrHT = controlled hypertensive DBP = diastolic blood pressure GFR = glomerular filtration rate HbA1c = glycated hemoglobin HDLc = high-density lipoprotein cholesterol HE = hypertensive emergency HPLC = high-performance liquid chromatography HR = heart rate HU = hypertensive urgency JNC 7 = VII Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure LDLc = low-density lipoprotein cholesterol MDRD = Modification of Diet in Renal Disease NT = normotensive RASB = renin-angiotensin system blockers SBP = systolic blood pressure TC = total cholesterol TG = triglycerides.

Job Strain and Casual Blood Pressure Distribution: Looking beyond the Adjusted Mean and Taking Gender, Age, and Use of Antihypertensives into Account. Results from ELSA-Brasil

Methodological issues are pointed to as the main sources of inconsistencies in studies about the association between job strain and blood pressure (BP)/hypertension. Our aim was to analyze the relationship between job strain and the whole BP distribution, as well as potential differences by gender, age, and use of antihypertensives. Additionally, we addressed issues relating to the operationalization of the exposure and outcome variables that influence the study of their inter-relations. We evaluated the baseline date of 12,038 participants enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) (2008–2010), a multicenter cohort study of 35–74-year-old civil servants. Job strain was assessed by the Demand-Control-Support Questionnaire. The distribution of casual BP by categories of job strain was compared by a combination of exploratory techniques. Participants were classified into three subgroups (normotensives, medicated hypertensives, and unmedicated hypertensives), and analyses were stratified by gender and age. The relationship between job strain and casual BP varied along the whole outcome distribution. Hypertensive participants had greater differences in casual BP by job strain category, especially medicated hypertensives. Differences in casual BP were also greater for systolic than for diastolic BP and for older participants. No differences were encountered by gender. The exclusion of participants susceptible to misclassification for the exposure and outcome variables increased the differences observed between the categories of low and high job strain. In conclusion, the relationship between job strain and casual BP varied along the whole outcome distribution and by use of antihypertensive drugs, age, and BP parameter evaluated. Misclassification for exposure and outcome variables should be considered in analyses of this topic.

Factors associated with the use of antihypertensives among seniors

OBJECTIVE

Analyze the use of antihypertensives among seniors and the association with socioeconomic and behavioral characteristics.

METHODS

In this seriate cross-sectional study, we used data from the Saúde, Bem Estar e Envelhecimento study (SABE – Health, Well-being, and Aging), conducted in 2000, 2006, and 2010 in the city of São Paulo. Association between the use of antihypertensives and the demographic, behavioral, and socioeconomic characteristics and risk factors was analyzed by using multilevel logistic regression models.

RESULTS

We observed increased proportion of use of antihypertensive, from 48.7% in 2000 to 61.3% in 2006, reaching 65.7% in 2010. Among the seniors who made use of this type of medicine, we also observed increased adoption of combined therapy in the period, from 69.9% to 82.6% from 2000 to 2006 and reaching 91.6% in 2010. Multilevel analysis indicated statistically significant increase in use of antihypertensives, even after control by socioeconomic and behavioral characteristics, both in 2006 and in 2010 (OR = 1.90; 95%CI 1.60–2.24 and OR = 1.94; 95%CI 1.62–2.33, respectively). Use of antihypertensives showed positive association with females, higher age group, black skin color, overweight, and smoking history.

CONCLUSIONS

High use of antihypertensives and its association with sociodemographic and behavioral characteristics can help guide the discussion of strategies to improve the epidemiological situation, the quality of life, and the distribution of medicines to the elderly population.

Hypertension in Latin America: Current perspectives on trends and characteristics

The region of Latin America, which includes Central America, the Caribbean and South America, is one that is rapidly developing. Signified by socio-economic growth, transition and development over the last few decades, living standards in countries like Brazil and Mexico have improved dramatically, including improvements in education and health care. An important marker of socio-economic change has been the epidemiological shift in disease burden. Cardiovascular disease is now the leading cause of death in Latin America, and the drop in prevalence of infectious diseases has been accompanied by a rise in non-communicable diseases. Hypertension is the major risk factor driving the cardiovascular disease continuum. In this article we aim to discuss the epidemiological and management trends and patterns in hypertension that may be specific or more common to Latin-American populations - what we term 'Latin American characteristics' of hypertension - via a review of the recent literature. Recognizing that there may be a specific profile of hypertension for Latin-American patients may help to improve their treatment, with the ultimate goal to reduce their cardiovascular risk. We focus somewhat on the countries of Brazil, Mexico and Venezuela, the experience of which may reflect other Latin American countries that currently have less published data regarding epidemiology and management practices.

Inequalities in healthy life expectancy by Brazilian geographic regions: findings from the National Health Survey, 2013

Background

The demographic shift and epidemiologic transition in Brazil have drawn attention to ways of measuring population health that complement studies of mortality. In this paper, we investigate regional differences in healthy life expectancy based on information from the National Health Survey (PNS), 2013.

Methods

In the survey, a three-stage cluster sampling (census tracts, households and individuals) with stratification of the primary sampling units and random selection in all stages was used to select 60,202 Brazilian adults (18 years and over). Healthy life expectancies (HLE) were estimated by Sullivan’s method according to sex, age and geographic region, using poor self-rated health for defining unhealthy status. Logistic regression models were used to investigate socioeconomic and regional inequalities in poor self-rated health, after controlling by sex and age.

Results

Wide disparities by geographic region were found with the worst indicators in the North and Northeast regions, whether considering educational attainment, material deprivation, or health care utilization. Life expectancy at birth for women and men living in the richest regions was 5 years longer than for those living in the less wealthy regions. Modeling the variation across regions for poor self-rated health, statistically significant effects (p < 0.001) were found for the North and Northeast when compared to the Southeast, even after controlling for age, sex, diagnosis of at least one non-communicable chronic disease, and schooling or socioeconomic class. Marked regional inequalities in HLE were found, with the loss of healthy life much higher among residents of the poorest regions, especially among the elderly.

Conclusions

By combining data on self-rated health status and mortality in a single indicator, Healthy Life Expectancy, this study demonstrated the excess burden of poor health experienced by populations in the less wealthy regions of Brazil. To mitigate the effects of social exclusion, the development of strategies at the regional level is essential to provide health care to all persons in need, reduce risk exposures, support prevention policies for adoption of healthy behaviors. Such strategies should prioritize population groups that will experience the greatest impact from such interventions.

Targeting stroke risk and improving outcomes in patients with atrial fibrillation in Latin America

CONTEXT AND OBJECTIVE:

To examine stroke risk factors, including atrial fibrillation, management and prevention, and stroke outcomes across Latin America.

DESIGN AND SETTING:

Narrative review conducted at Piedmont Heart Institute, United States.

METHODS:

The PubMed, Embase and Cochrane databases were searched for stroke AND "Latin America" AND epidemiology (between January 2009 and March 2015). Further studies in the SciELO, World Health Organization and Pan-American Health Organization databases were used to address specific points.

RESULTS:

Countries categorized as low or middle-income nations by the World Bank, which includes most of Latin America, account for two-thirds of all strokes. Globally, fewer than half of patients (median treatment level: 43.9%) with atrial fibrillation receive adequate anticoagulation to reduce stroke risk, which correlates with data from Latin America, where 46% of outpatients did not receive guideline-compliant anticoagulation, ranging from 41.8% in Brazil to 54.8% in Colombia.

CONCLUSIONS:

Atrial fibrillation-related stroke carries a heavy burden. Non-vitamin K antagonist oral anti-coagulants provide options for reducing the risk of atrial fibrillation-related stroke. However, cost-effectiveness comparisons with warfarin are warranted before observational health-economics study results can be applied clinically. Initiatives to remedy inequalities and improve access to care across Latin America should accompany risk factor modification and guideline-based prevention.

Race and Resting-State Heart Rate Variability in Brazilian Civil Servants and the Mediating Effects of Discrimination: An ELSA-Brasil Cohort Study

OBJECTIVES

African Americans are characterized by higher heart rate variability (HRV), a finding ostensibly associated with beneficial health outcomes. However, these findings are at odds with other evidence that blacks have worse cardiovascular outcomes. Here, we examine associations in a large cohort from the ELSA-Brasil study and determined whether these effects are mediated by discrimination.

METHODS

Three groups were compared on the basis of self-declared race: "black" (n = 2,020), "brown" (n = 3,502), and "white" (n = 6,467). Perceived discrimination was measured using a modified version of the Everyday Discrimination Scale. Resting-state HRV was extracted from 10-minute resting-state electrocardiograms. Racial differences in HRV were determined by regression analyses weighted by propensity scores, which controlled for potentially confounding variables including age, sex, education, and other health-related information. Nonlinear mediation analysis quantified the average total effect, comprising direct (race-HRV) and indirect (race-discrimination-HRV) pathways.

RESULTS

Black participants displayed higher HRV relative to brown (Cohen's d = 0.20) and white participants (Cohen's d = 0.31). Brown relative to white participants also displayed a small but significantly higher HRV (Cohen's d = 0.14). Discrimination indirectly contributed to the effects of race on HRV.

CONCLUSIONS

This large cohort from the Brazilian population shows that HRV is greatest in black, followed by brown, relative to white participants. The presence of higher HRV in these groups may reflect a sustained compensatory psychophysiological response to the adverse effects of discrimination. Additional research is needed to determine the health consequences of these differences in HRV across racial and ethnic groups.

Cardiovascular Health in Brazil: Trends and Perspectives

Brazil is a large country, with an evolving economy, but marked social inequalities. The population is formed by an admixture of native Brazilians, Europeans, and Africans; is predominantly urban; and faces rapid aging. Time trends related to health behaviors show a substantial reduction in smoking rates, but a rising prevalence of overweight and obesity, unhealthy eating habits, and insufficient physical activity. The high prevalence of hypertension and the increasing prevalence of diabetes mellitus are also causes for concern. Cardiovascular disease (CVD) has been the leading cause of mortality since the 1960s and has accounted for a substantial percentage of all hospitalizations. In 2011, CVD was responsible for 31% of all deaths, with ischemic heart disease (31%) and cerebrovascular diseases (30%) being the leading CVD causes. Despite an increase in the overall number of CVD deaths, the age-adjusted mortality rates for CVD declined 24% between 2000 and 2011. Health care delivered by Brazil's universal public health system, which focuses on primary prevention, has contributed to this achievement. However, the decline in age-adjusted mortality differs according to race, sex, and socioeconomic status with black individuals and lower-income populations sustaining the greatest impact of CVD, especially at younger ages. With one of the world's largest public health systems in terms of population coverage, Brazil has the means to implement actions to confront the high burden of CVD, focusing on health promotion and comprehensive care. Insufficient funding, low education levels, and social inequalities remain as the main barriers to be overcome.

Gender-specific determinants of blood pressure elevation in Angolan adults

BACKGROUND

Hypertension affects African-American adults more than any other ethnic group in the US. However, some of the black populations living outside Africa are well adapted to food and lifestyle. We aimed to describe the clinical characteristics underlying the gender-specific determinants of BP and the risk of hypertension in public-sector workers living in Angola.

MATERIALS AND METHODS

609 volunteers (48% men) were included in this cross-sectional and descriptive study. Demographic, socioeconomic and life style data were collected during an interview. Systolic BP (SBP) and diastolic BP (DBP) were measured, along with some anthropometric and clinical variables.

RESULTS

The prevalence of hypertension is 45.2% without difference between genders. Obesity was more prevalent in women (29.2% vs. 8.9%, p < 0.05). The age-related increment in SBP is higher in women (14.2 ± 1.1 vs 9.5 ± 1.3 mmHg/decade, p < 0.05). In men, age, BMI, cholesterol and LDLc/HDLc explained 21, 4, 2.5 and 2.9% of SBP variability, respectively. In women, age, BMI and HC explain 27, 2 and 1% of SBP variability, respectively. The risk for hypertension is 5 × high among men aged ≥45 years, and 3.5× in those having BMI ≥25. Women aged 45 years or older have 8 × risk of hypertension and 2× the risk by having BMI ≥25.

CONCLUSIONS

We found that advanced age (≥45) and overweight/obesity (BMI ≥25) are the main risk factors for hypertension in adults from Angola. However, our data suggest that age and BMI may have different influence on increasing BP in men and women.

Prevalence of high blood pressure measured in the Brazilian population, National Health Survey, 2013

CONTEXT AND OBJECTIVE

High blood pressure (hypertension) is the most frequent cause of morbidity and a major risk factor for cardiovascular complications. The aim here was to describe the prevalence of blood pressure greater than or equal to 140/90 mmHg in the adult Brazilian population and federal states, along with self-reported information about previous medical diagnoses of hypertension, use of medication and medical care for hypertension control.

DESIGN AND SETTING

Cross-sectional study analyzing information from the National Health Survey of 2013, relating to Brazil and its federal states.

METHODS

The sample size was estimated as 81,254 households and information was collected from 64,348 households. The survey consisted of interviews, physical and laboratory measurements. Systolic blood pressure was considered to be high when it was ≥ 140 mmHg and diastolic blood pressure, ≥ 90 mmHg.

RESULTS

It was found that 22.8% of the population has blood pressure measurements ≥ 140/90 mmHg. The proportion was higher among men than among women: 25.8% versus 20.0%. The frequency increased with age, reaching 47.1% in individuals over 75 years and was highest in the southeast and south. 43.2% reported previous medical diagnoses of hypertension and, of these, 81.4% reported using medication for hypertension and 69.6%, going to the doctor within the past year for pressure monitoring, thus showing regular medical follow-up.

CONCLUSION

These results are important for supporting measures for preventing and treating hypertension in Brazil, with the aim of achieving the World Health Organization's goal of reducing hypertension by 25% over the next decade.

The Impact of Dietary and Metabolic Risk Factors on Cardiovascular Diseases and Type 2 Diabetes Mortality in Brazil

BACKGROUND

Trends in food availability and metabolic risk factors in Brazil suggest a shift toward unhealthy dietary patterns and increased cardiometabolic disease risk, yet little is known about the impact of dietary and metabolic risk factors on cardiometabolic mortality in Brazil.

METHODS

Based on data from Global Burden of Disease (GBD) Study, we used comparative risk assessment to estimate the burden of 11 dietary and 4 metabolic risk factors on mortality due to cardiovascular diseases and diabetes in Brazil in 2010. Information on national diets and metabolic risks were obtained from the Brazilian Household Budget Survey, the Food and Agriculture Organization database, and large observational studies including Brazilian adults. Relative risks for each risk factor were obtained from meta-analyses of randomized trials or prospective cohort studies; and disease-specific mortality from the GBD 2010 database. We quantified uncertainty using probabilistic simulation analyses, incorporating uncertainty in dietary and metabolic data and relative risks by age and sex. Robustness of findings was evaluated by sensitivity to varying feasible optimal levels of each risk factor.

RESULTS

In 2010, high systolic blood pressure (SBP) and suboptimal diet were the largest contributors to cardiometabolic deaths in Brazil, responsible for 214,263 deaths (95% uncertainty interval [UI]: 195,073 to 233,936) and 202,949 deaths (95% UI: 194,322 to 211,747), respectively. Among individual dietary factors, low intakes of fruits and whole grains and high intakes of sodium were the largest contributors to cardiometabolic deaths. For premature cardiometabolic deaths (before age 70 years, representing 40% of cardiometabolic deaths), the leading risk factors were suboptimal diet (104,169 deaths; 95% UI: 99,964 to 108,002), high SBP (98,923 deaths; 95%UI: 92,912 to 104,609) and high body-mass index (BMI) (42,643 deaths; 95%UI: 40,161 to 45,111).

CONCLUSION

suboptimal diet, high SBP, and high BMI are major causes of cardiometabolic death in Brazil, informing priorities for policy initiatives.

Prevalence, awareness, treatment, and control of high low-density lipoprotein cholesterol in Brazil: Baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

BACKGROUND AND OBJECTIVES

Dyslipidemia is a pivotal risk factor for coronary heart disease (CHD). The purpose of this study was to identify the profile of dyslipidemia in a Brazilian population, according to high low-density lipoprotein (LDL-C) levels. We used the classification of the 2004 update of National Cholesterol Education Program Adult Treatment Panel III (ATP-III).

METHODS

Of the 15,105 men and women aged 35 to 74 years enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), we included 14,648 subjects (97%). They had data to categorize them according to the NCEP-ATP-III criteria. We compared 4 categories: "0-1" risk factors, "2 or more risk factors", "CHD or CHD risk equivalent", and "CHD at very high risk". The sociodemographic determinants used were sex, age, ethnicity, income, education, and health insurance. Poisson regression was used to estimate the prevalence ratios for cholesterol (LDL-C), frequency, awareness, treatment, and control of high LDL-C.

RESULTS

The frequencies of high LDL-C, awareness, treatment, and control were 45.5%, 58.1%, 42.3%, and 58.3%, respectively. After adjustment for sociodemographic determinants, the prevalence ratios for high LDL-C were significantly higher for men, blacks, older subjects, and subjects with lower levels of education. Low frequency of awareness, treatment, and uncontrolled values of LDL-C was observed among men, mixed race and blacks, poorer, less educated, and those who did not have private health insurance.

CONCLUSIONS

The prevalence of high LDL-C was elevated in this Brazilian population, with low rates of awareness, treatment and control, and remarkable socioeconomic disparity.

Socioeconomic Position, But Not African Genomic Ancestry, Is Associated With Blood Pressure in the Bambui-Epigen (Brazil) Cohort Study of Aging

The study objective is to examine the role of African genome origin on baseline and 11-year blood pressure trajectories in community-based ethnoracially admixed older adults in Brazil. Data come from 1272 participants (aged ≥60 years) of the Bambui cohort study of aging during 11 years of follow-up. Outcome measures were systolic blood pressure, diastolic blood pressure, and hypertension control. Potential confounding variables were demographic characteristics, socioeconomic position (schooling and household income), and health indicators (smoking, sedentary lifestyle, high-density lipoprotein cholesterol, waist circumference, diabetes mellitus, and cardiovascular diseases), including antihypertensive drug use. We used 370 539 single-nucleotide polymorphisms to estimate each individual's African, European, and Native American trihybrid ancestry proportions. Median African, European, and Native American ancestry were 9.6%, 84.0%, and 5.3%, respectively. Among those with African ancestry, 59.4% came from East and 40.6% from West Africa. Baseline systolic and diastolic blood pressure, controlled hypertension, and their respective trajectories, were not significantly (P>0.05) associated with level (in quintiles) of African genomic ancestry. Similar results were found for West and East African subcontinental origins. Lower schooling level (<4 years versus higher) showed a significant and positive association with systolic blood pressure (Adjusted β=2.92; 95% confidence interval, 0.85-4.99). Lower monthly household income per capita (<USD 180.00 versus higher) showed an inverse association with hypertension control (β=-0.35; 95% confidence interval, -0.63 to -0.08, respectively). Our results support the view that favors social and environmental factors as determinants of blood pressure and hypertension control.

Resistant hypertension: risk factors, subclinical atherosclerosis, and comorbidities among adults-the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

The frequency of resistant hypertension-defined as blood pressure (BP) ≥140/90 mm Hg with proven use of three antihypertensive medications, or as the use of four antihypertensive drug classes regardless of BP-is unknown in low-middle-income countries. Using data from the Brazilian Longitudinal Study of Adult Health, a cohort of 15,105 civil servants aged 35 to 74 years, the authors identified 4116 patients taking treatment for hypertension, 11% of who had resistant hypertension. These participants were more likely to be older, black, less educated, poorer, and obese. The adjusted prevalence ratios (95% confidence intervals) were diabetes, 1.44 (1.20-1.72); glomerular filtration rate (<60 mL/min/1.72 m(2) ), 1.95 (1.60-2.38); albumin-to-creatinine ratio (>300 mg/g), 2.43 (1.70-3.50); carotid-femoral pulse-wave velocity, 1.07 m/s (1.03-1.11 m/s); common carotid intima-media thickness, 2.57 mm (1.64-4.00 mm); left ventricular hypertrophy, 2.08 (1.21-3.57); and atrial fibrillation, 3.55 (2.02-6.25). Thus, the prevalence of resistant hypertension in Brazil is high and associated with subclinical markers of end-organ cardiovascular damage.