The effects of awareness, treatment and control of hypertension on cardiovascular and all-cause mortality in a community-based population

Multifactorial prevention program for cardiovascular disease in primary care: hypertension status and effect on mortality

The aim of this study was to investigate if mortality during a 13-year follow-up varied between normotensive subjects, screen-detected hypertensive subjects, and subjects with antihypertensive medication at baseline. A population-based screening and intervention program identified 2659 apparently healthy, middle-aged cardiovascular-risk persons in southwestern Finland. Screen-detected hypertension was verified by home blood pressure measurements. Lifestyle counseling was provided for all participants and preventive medications were started or intensified if needed. All-cause and cardiovascular mortality were obtained from the official statistics. Screen-detected hypertension was diagnosed in 17% of the participants, 51% were normotensive and 32% had antihypertensive medication at baseline. The screen-detected hypertensives had higher mean blood pressure and cholesterol levels than the two other groups. Altogether 289 subjects died during the follow-up, 83 (29%) from cardiovascular disease. Those with screen-detected hypertension had decreased cardiovascular mortality risk compared to the medicated hypertensives [sHR 0.40 (95% CI: 0.19 to 0.88, p = 0.023)], and comparable with that of the normotensives [sHR 0.53 (95% CI: 0.24 to 1.15)]. Newly diagnosed diabetes at baseline was a powerful predictor of cardiovascular mortality [sHR 2.71 (95% CI: 1.57 to 4.69)]. Early detection of hypertension and timely multifactorial intervention seem to be important in preventing hypertension-related mortality.

Uncontrolled hypertension increases risk of all-cause and cardiovascular disease mortality in US adults: the NHANES III Linked Mortality Study

Clinical trials had provided evidence for the benefit effect of antihypertensive treatments in preventing future cardiovascular disease (CVD) events; however, the association between hypertension, whether treated/untreated or controlled/uncontrolled and risk of mortality in US population has been poorly understood. A total of 13,947 US adults aged ≥18 years enrolled in the Third National Health and Nutrition Examination Survey (1988–1994) were used to conduct this study. Mortality outcome events included all-cause, CVD-specific, heart disease-specific and cerebrovascular disease-specific deaths, which were obtained from linked 2011 National Death Index (NDI) files. During a median follow-up of 19.1 years, there were 3,550 all-cause deaths, including 1,027 CVD deaths. Compared with normotensives, treated but uncontrolled hypertensive patients were at higher risk of all-cause (HR = 1.62, 95%CI = 1.35–1.95), CVD-specific (HR = 2.23, 95%CI = 1.66–2.99), heart disease-specific (HR = 2.19, 95%CI = 1.57–3.05) and cerebrovascular disease-specific (HR = 3.01, 95%CI = 1.91–4.73) mortality. Additionally, untreated hypertensive patients had increased risk of all-cause (HR = 1.40, 95%CI = 1.21–1.62), CVD-specific (HR = 1.77, 95%CI = 1.34–2.35), heart disease-specific (HR = 1.69, 95%CI = 1.23–2.32) and cerebrovascular disease-specific death (HR = 2.53, 95%CI = 1.52–4.23). No significant differences were identified between normotensives, and treated and controlled hypertensives (all p > 0.05). Our study findings emphasize the benefit of secondary prevention in hypertensive patients and primary prevention in general population to prevent risk of mortality later in life.

Mortality in persons with undetected and diagnosed hypertension, type 2 diabetes, and hypothyroidism, compared with persons without corresponding disease - a prospective cohort study; The HUNT Study, Norway

Background

Suggested strategies in reducing the impact of non-communicable diseases (NCD) are early diagnosing and screening. We have limited proof of benefit of population screening for NCD. Increased mortality in persons with diagnosed NCD has been shown for decades. However, mortality in undetected NCD has barely been studied. This paper explores whether all-cause mortality differed between persons with diagnosed hypothyroidism, type 2 diabetes (T2DM), and hypertension, compared with persons with undetected-, and with persons without the corresponding disease.

Methods

A prospective cohort study of the general population in Nord-Trøndelag, Norway. Persons ≥20 years at baseline 1995–97 were followed until death or June 15, 2016. Cox proportional hazards models were used to compute age and multiple adjusted hazard ratios (HR) with 95% confidence intervals (CI) for the association between disease status and all-cause mortality. The number of participants in the hypothyroidism study was 31,960, in the T2DM study 37,957, and in the hypertension study 63,371.

Results

Mortality was increased in persons with diagnosed type 2 diabetes and hypertension, compared to persons without corresponding disease; HR 1.69 (95% CI 1.55–1.84) and HR 1.23 (95% CI 1.09–1.39), respectively. Among persons with undetected T2DM, the HR was 1.21 (95% CI 1.08–1.37), whilst among undetected hypothyroidism and hypertension, mortality was not increased compared with persons without the diseases. Further, the association with mortality was stronger in persons with long duration of T2DM (HR 1.96 (95% CI 1.57–2.44)) and hypertension (HR 1.32 (95% CI 1.17–1.49)), compared with persons with short duration (HR 1.29 (1.09–1.53) and HR 1.16 (1.03-1-30) respectively).

Conclusions

Mortality was increased in persons with diagnosed T2DM and hypertension, and in undetected T2DM, compared with persons without the diseases. The strength of the association with mortality in undetected T2DM was however lower compared with persons with diagnosed T2DM, and mortality was not increased in persons with undetected hypothyroidism and hypertension, compared with persons without the diseases. Thus, future research needs to test more thoroughly if early diagnosing of these diseases, such as general population screening, is beneficial for health.

The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011

OBJECTIVES

To analyze the trends in blood pressure (BP), and the prevalence, awareness, treatment and control of hypertension and associated factors in Chinese adults from 1991 to 2011.

METHODS

On the basis of the longitudinal data of China Health and Nutrition Survey, 75 526 records of 24 410 adults were selected according to the eligibility criteria. The age-standardized levels of SBP, DBP, prevalence, awareness, treatment and control of hypertension were calculated by sex and age group within each year. Generalized estimating equation was employed to investigate the associations between demographic factors and status of hypertension, awareness, treatment and control.

RESULTS

From 1991 to 2011, the BP level elevated (SBP 120.0-124.5 mmHg, DBP 76.7-79.3 mmHg) and the prevalence of hypertension increased from 23.4 to 28.6%. The increasing levels of BP and hypertension prevalence were more apparent among men and older patients. The rates of hypertension awareness, treatment and control also increased while kept at low levels. Factors such as age, sex, smoking habit, drinking habit, household income, health insurance, BMI, residential region, marital status, educational level and nationality were significantly associated with the status of hypertension, awareness, treatment and control.

CONCLUSION

The BP level and hypertension prevalence have increased among Chinese adults in recent years. However, levels of hypertension awareness, treatment and control were quite low. To reduce the disease burden of the hypertension, improvements in health education programs, detection and treatment strategies are warranted.

Knowledge, Treatment, Control, and Risk Factors for Hypertension among Adults in Southern Iran

Hypertension is the first and the most common risk factor to diseases such as cardiovascular, stroke, and renal diseases. The aim of this study was to determine the factors relevant to hypertension knowledge, treatment, and control in southern Iran. In this cross-sectional study, conducted in Kohgiluye Boyer-Ahmad province, south of Iran, a total of 1836 hypertension patients were randomly selected to participate voluntarily in the study. Hypertension treatment and its control were defined during study. In addition, knowledge about hypertension was measured by hypertension knowledge level scale (HK-LS). Treatment rates were 75.5 and 37.7 percent for female and male, respectively. Habitat, education, income, family history with hypertension, smoking, and time of diagnosis to the disease were found to be related to the treatment of the disease. Control rates were 30.7 and 31.4 for males and females, respectively. Habitat, education, and time of diagnosis to the disease were related to control. Over 50 percent of patients had average knowledge on hypertension. Considering the low rate of control and knowledge on hypertension among patients, health care providers should reinforce their services to improve appropriate knowledge level among elders and, also, plan comprehensive programs to promote health in order to encourage patients change and reform their life style.

Hypertension: empirical evidence and implications in 2014

High blood pressure (HBP) or hypertension (HTN) is one of the leading causes of cardiovascular (CV) morbidity and mortality throughout the world. Despite this fact, there is widespread agreement that the treatment of HBP, over the last half century, has been a great achievement. However, after the release of the new Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure-8 (JNC-8) guidelines, there have been heated debates with regard to what are the most evidence-based blood pressure goals. While JNC-8 claims that the goal blood pressure for otherwise healthy patients with mild hypertension (systolic blood pressure ≥140-159 mm Hg and diastolic blood pressure ≥90-99 mm Hg) should be <140/90 mm Hg; a recent Cochrane meta-analysis is in direct conflict with these recommendations. Indeed, a 2012 Cochrane meta-analysis indicated that there is no evidence that treating otherwise healthy mild hypertension patients with antihypertensive therapy will reduce CV events or mortality. Additionally, the Cochrane meta-analysis showed that antihypertensive therapy was associated with a significant increase in withdrawal due to adverse events. Thus, the current evidence in the literature does not support the goals set by the JNC-8 guidelines. In this review we discussed the strengths and limitations of both lines of evidence and why it takes an evidence-based medication to reduce CV events/mortality (eg, how a goal blood pressure is achieved is more important than getting to the goal). As medications inherently cause side effects and come at a cost to the patient, the practice of evidence-based medicine becomes exceedingly important. Although the majority of HTN studies claim great advantages by lowering HBP, this review finds severe conflicts in the findings among the various HTN studies, as well as serious epistemological, methodological and statistical problems that cast doubt to such claims.

Factors associated with prevalence, awareness, treatment and control of hypertension among adults in Southern China: a community-based, cross-sectional survey

The aim of this study was to investigate factors associated with prevalence, awareness, treatment and control of hypertension in southern China. A cross-sectional, population-based survey was conducted in 180 villages across 15 counties in southern China from July to November 2010. Totally, 17437 persons completed all of the questionnaires, measurement examination and blood specimen collection. Adjusted rate of hypertension was 22.59% (95%CI: 22.52%-22.66%), for men 23.36% (95%CI: 23.25%-23.47%) and for women 21.77% (95%CI: 21.68%-21.86%). Multivariate logistic regression showed that old age, education attainment, alcohol use, diabetes, obesity, high TC and high TG were associated with hypertension. Among the hypertensive individuals, 54.33% were aware of their hypertension, and 46.34% were currently taking antihypertensive medication, but only 18.26% had their blood pressure controlled. Among all the hypertensive subjects, awareness was more common in those who were female, living in the urban, old age, low education attainment, diabetes, overweight, obese, Low HDL-C. Among the subjects aware of their diagnosis of hypertension, medication treatment was more common in those living in the urban, old age, nonsmoker and diabetes. Among the individuals who receiving medication treatment, controlled hypertension were less common in those living in the urban, young age, low education attainment, overweight and obese. Despite high rate of hypertension, awareness, treatment and control of hypertension still need to be strengthened.

The effects of control of systolic and diastolic hypertension on cardiovascular and all-cause mortality in a community-based population cohort

The objective of this study (follow-up of 26,113 people) was to investigate differences in the risk of cardiovascular disease (CVD) and all-cause mortality among hypertensive people according to the control of systolic blood pressure (SBP) and diastolic blood pressure (DBP). People with a history of coronary heart disease, heart failure, cancer or incomplete data at baseline (n=1113) were excluded from the study. The participants were classified into six groups according to their blood pressure status. Treated hypertensive individuals with controlled SBP and DBP did not experience an increase in all-cause mortality compared with normotensive people. The increase in all-cause mortality was 1.48-fold (95% confidence interval (CI) 1.09-2.01) among those who were treated with antihypertensive drugs and had only their DBP controlled and 1.45-fold (95% CI 1.04-2.02) among those who were treated and had only their SBP controlled. Treated patients with both SBP and DBP controlled did not have an increased risk of CVD mortality when compared with normotensive people. The risk of CVD mortality was statistically significantly higher in treated hypertensive people with SBP alone, DBP alone or both SBP and DBP uncontrolled. Our study indicates that uncontrolled SBP alone and DBP alone are risk factors of all-cause and CVD mortality.

Prevalence, awareness, treatment, and control of hypertension among adults in Beijing, China

Hypertension is an important modifiable risk factor for cardiovascular diseases. This study aimed to determine the up-to-date prevalence, awareness, treatment, and control of hypertension, and their related influencing factors in adults in Beijing, China. A cross-sectional study was conducted in 2008. A total of 5760 adults aged 18-79 years were selected from the general population. Data from a standardized questionnaire, physical examination, and blood sample were obtained. The prevalence of hypertension was 35.5% (41.8% in men, 30.9% in women) and increased with age in both sexes. The prevalence was similarly high in urban (35.6%) and in rural (34.9%) areas. Body mass index (BMI) and waist circumference were independently associated with hypertension. Participants with diabetes and/or dyslipidemia had higher prevalence of hypertension than their counterparts. Among hypertensive patients, 42.5% were aware of the diagnosis, 35.9% received treatment, and 11.8% had hypertension control. Awareness and treatment of hypertension were low in men, young people, and rural residents. Control of hypertension was lower in older people and those with lower educational attainment. High waist circumference (central obesity) resulted in low control of hypertension (odds ratio = 0.45). Our findings underscore the urgent need to develop a comprehensive health strategy for the prevention, detection, and control of hypertension to avert the cardiovascular disease epidemic in Beijing.

Factors associated with prevalence, awareness, treatment and control of hypertension in urban adults from 33 communities in China: the CHPSNE Study

Using a randomized multistage cluster sampling, we studied the factors associated with the prevalence, awareness, treatment and control of hypertension (defined as systolic and diastolic blood pressure (BP) measurements ≥140 and 90 mm Hg, respectively, or current drug treatment for hypertension) in a representative sample of the urban Chinese population. The participants were 18-74 years of age and had lived for at least 5 years in an area comprising 33 communities in three cities (Shenyang, Anshan and Jinzhou) in China. A total of 28 830 people were selected; the overall response rate was 87.4% (25 196/28 830). The overall prevalence of hypertension was 28.7% (7237/25 196). Of those with hypertension, 42.9% (3107/7237) were aware of their condition, 28.2% (2042/7237) were receiving treatment and 3.7% (264/7237) were considered controlled. More than half (57.8%) of the hypertensives did not think that high BP would endanger their lives. Multivariate analysis revealed that age, gender, education, occupation, income, body mass index, waist circumference and a family history of hypertension correlated significantly with the prevalence of hypertension. Among all the hypertensives, higher awareness (determined by odds ratios; 95% confidence intervals) was noted for persons who were white-collar workers (1.29; 1.08, 1.53, respectively), overweight (1.48; 1.30, 1.69), obese (3.37; 2.76, 4.11) or had a family history of hypertension (3.07; 2.76, 3.42). Among the individuals aware of their hypertension, treatment was more common in those with a higher level of education and less common among individuals consuming ≥2 alcoholic drinks per day (0.65; 0.52, 0.83). Controlled hypertension was much less common among older persons, and participants who were former smokers (0.49; 0.26, 0.91). The results indicate that more attention is needed to improve the awareness of the potentially fatal nature of hypertension in urban China.

Trends in mortality from all causes and cardiovascular disease among hypertensive and nonhypertensive adults in the United States

BACKGROUND

Little is known about trends in the mortality rate among people with hypertension in the United States. The objective of the present study was to examine the change in the all-cause mortality rate among people with and without hypertension in the United States and whether any such changes differed by sex or race.

METHODS AND RESULTS

Data from 10 852 participants aged 25 to 74 years of the National Health and Nutrition Examination Survey (NHANES) I Epidemiological Follow-Up Study (1971 to 1975) and of 12 420 participants of the NHANES III Linked Mortality Study (1988 to 1994) were used. The mean follow-up times were 17.5 and 14.2 years, respectively. In each cohort, the mortality rate was higher among hypertensive adults than nonhypertensive adults, among hypertensive men than hypertensive women, and among hypertensive blacks than hypertensive whites. Among all hypertensive participants, the age-adjusted mortality rate was 18.8 per 1000 person-years for NHANES I and 14.3 for NHANES III (13.3 and 9.1 per 1000 person-years for nonhypertensive participants, respectively). The reduction among hypertensive men (7.7 per 1000 person-years; 95 confidence interval, 5.2 to 10.2) exceeded that among hypertensive women (1.9 per 1000 person-years; 95 confidence interval, [-0.4 to 4.2]) (P<0.001), and the reduction among hypertensive blacks (5.4 per 1000 person-years; 95 confidence interval, [0.6 to 10.1]) exceeded that among hypertensive whites (4.4 per 1000 person-years; 95 confidence interval, [2.2 to 6.5]) (P=0.707).

CONCLUSIONS

The mortality rate decreased among hypertensive adults, but the mortality gap between adults with and without hypertension remained relatively constant. Efforts are needed to accelerate the decrease in the mortality rate among hypertensive adults.

Both hypertensive men and women are inadequately treated in Finnish general practice

A general comprehension is that men are treated poorer than women. This study was planned to assess the Finnish hypertensive care with interests in possible hypertensive and cardiovascular control differences between men and women. A cross-sectional study was carried out by nationwide questionnaire survey of 714 consecutive drug-treated hypertensive patients having visited general practice during autumn 2006. Mean (SD) blood pressure (BP) of the women was 148.3 (21.1)/86.8 (11.7) mm Hg and of men 146.5 (19.5)/89.0 (11.8). Women had significantly lower diastolic BP (P = .016). The mean LDL cholesterol of women was 2.94 (0.91) mmol/L and of men 2.95 (0.94) mmol/L (P = .94). The blood pressure target <140/85 mm Hg was reached by 25% of the women and 23% of the men (P = .70). Of the women 30.7% and of the men 31.1% reached low-density lipoprotein (LDL)-cholesterol <2.5 mmol/L. Women used more diuretics than men (P = .06). No significant difference was seen between women and men in the number of patients reaching the target pressure <140/85 mm Hg, although diastolic blood pressure of the women was significantly lower. Hypertensive women and men were equally undertreated, and regardless of the sex, antihypertensive and hyperlipidemic control of hypertensive patients should be intensified.

The science of primary health-care improvement: potential and use of community-based participatory research by practice-based research networks for translation of research into practice

There is a need for new approaches to supplement the existing methods of taking research from bench to bedside and from bedside to practice. Community-based participatory research (CBPR) is an emerging model of research that enhances ongoing clinical research by involving key stakeholders, including community members and patients. A practice-based research network (PBRN) is a group of primary care practices devoted principally not only to the primary care of patients, but also with a mission to investigate questions related to community-based practice and to improve the quality of primary care. Traditionally, PBRN research has not included patients or community members, while CBPR has excluded health providers as key stakeholders. Typical overlap topics of PBRN and CBPR research are health-care disparities, prevention, chronic disease management and mental health. The inclusion of CBPR within a PBRN has been identified as an important next step with the potential to significantly enhance the research process. This review focuses on bringing together the ideals of CBPR and PBRNs in order to tackle intractable problems such as disparities in health-care access and outcomes and translate these results into practice. Specifically, the CBPR PBRN approach can: (1) guide the research process so that studies more closely match the needs of all stakeholders (including providers, patients and community members); (2) assist in the development of the research protocol and identification of research methodologies so that the study is more amenable to participants; (3) facilitate recruitment of research participants; (4) enrich the data collection and analysis; and (5) allow rapid translation of results from the study back into clinical practice and the community. Once these mechanisms have been clearly elucidated, their widespread adoption will positively impact overall health at both a local and national level.

Lipid-lowering treatment is related to decreased risk of dementia: a population-based study (FINRISK)

BACKGROUND

Several lines of evidence have linked cholesterol to dementia.

OBJECTIVE

To investigate lipid-lowering drug use and dementia development in a Finnish population.

METHODS

FINRISK is a large population-based survey of cardiovascular risk factors carried out since 1972 every 5 years using independent, random and representative population samples from different parts of Finland. Several cohorts were part of the WHO-MONICA study. Data from cohorts 1972-2002 were linked to the Hospital Discharge Registry and Drug Reimbursement Registry (1995-2007) to ascertain dementia diagnoses and lipid-lowering treatment. Selection criteria for the study were: (1) alive and without dementia in 1995; (2) age > or = 60 years (in 1995 for earlier cohorts and in 1997 or 2002 for later cohorts; (3) treatment prescribed at least 1 year before dementia diagnosis.

RESULTS

17,597 persons were included in the study. Lipid-lowering treatment was related to decreased dementia risk. In Cox proportional hazards model, hazard ratio (95% CI) was 0.42 (0.37-0.49; controlled for age, sex, education, survey region, survey year, baseline cholesterol, body mass index and systolic blood pressure).

CONCLUSION

Preliminary results from the FINRISK study indicate that lipid-lowering drugs may have a beneficial effect in dementia prevention. Further data linkage is ongoing in order to investigate the roles of different types of lipid-lowering drugs.