Hypertension in the Middle East: current state, human factors, and barriers to control

The Association Between Smoking Behavior and the Risk of Hypertension: Review of the Observational and Genetic Evidence

Background

Cigarette smoking is one of the world's largest avoidable risk factors for morbidity and mortality. Numerous studies have investigated the association between smoking and hypertension (HTN). Although observational data and cross-sectional research often exhibit a link between smoking and HTN, establishing causation remains challenging owing to potential confounding variables. Mendelian randomization (MR), a genetic epidemiological technique that employs genetic variants as instrumental variables, offers a more robust approach for evaluating causal links. This review aimed to explore both the observational and causal relationships between smoking and the risk of HTN.

Methodology

A comprehensive literature search across major electronic databases was conducted to identify relevant observational and Mendelian randomization (MR) studies on smoking and HTN risk. Various characteristics were included during study selection, such as study design, exposure assessment, and age range. Standardized processes were used for data retrieval and quality evaluation.

Results

Analysis of observational data revealed a paradoxical association between smoking and the risk of HTN, where a lower risk was observed among current smokers when compared to non-smokers. However, observational analysis also presented a dose-response effect with greater smoking intensity showed a modest linear increase in HTN risk, and older smoking initiation was associated with a slight increase in HTN risk (compared with younger). In contrast, MR-based causal estimates provide inconsistent evidence regarding the causal relationship between smoking behavior and HTN. Some MR analyses indicated a potential causal link between smoking and HTN; but this was not consistent.

Conclusion

Observational studies suggest a paradoxical association between smoking and HTN. However, MR studies do not provide sufficient evidence to establish a causal relationship. Regardless, lifestyle variables remain crucial for overall health. Healthcare professionals should regularly assess smoking status and provide counseling for quitting. Further research is needed to clarify the underlying processes, identify mediators, and evaluate the interventions.

Burden of diseases due to high systolic blood pressure in the Middle East and North Africa region from 1990 to 2019

High systolic blood pressure (HSBP) is associated with several metabolic and non-metabolic disorders. This research aimed to document the deaths and disability-adjusted life-years (DALYs) attributable to HSBP in the Middle East and North Africa (MENA) region between 1990 and 2019, by age, sex, underlying cause and socio-demographic index (SDI). We used the methodological framework and data drawn from the Global Burden of Disease study 2019 to identify the burden of diseases attributable to HSBP, from 1990 to 2019, in the MENA region. The estimates reported were presented as counts, population-attributable fractions, and age-standardised rates (per 100,000), along with 95% uncertainty intervals. In 2019, 803.6 thousand (687.1 to 923.8) deaths were attributed to HSBP in MENA, which accounted for 25.9% (22.9-28.6%) of all deaths. The number of regional DALYs caused by HSBP in 2019 was 19.0 million (16.3-21.9 million), which accounted for 11.6% (10.1-13.3%) of all DALYs, and was 23.4% (15.9-31.5%) lower than in 1990. The highest age-standardised DALY rate for 2019 was observed in Afghanistan, with the lowest in Kuwait. Additionally, the DALY rate in MENA rose with age for both sexs. Furthermore, a negative linear relationship was found between SDI and the age-standardised DALY rates. The region has a substantial HSBP-related burden. Policymakers and healthcare professionals should prioritize interventions that effectively promote the early detection of HSBP, access to quality healthcare, and lifestyle modifications to mitigate the HSBP burden in the MENA countries.

Updates in the management of hypertension

Hypertension is the leading cause of cardiovascular diseases and nephropathies. Its treatment and management require long-term follow-up which can be facilitated by the emergence of device-based therapies. Novel recommendations have been well described in the latest ESH guidelines as well as new risk factors have been identified. The authors summarized the published evidence on hypertension management. The authors also cited in this review novel treatment approaches in different settings and the intervention of medication adherence in treatment success. Such non-communicable disease requires long-term follow-up and monitoring, which is quite facilitated in the era of digitalization by cuff-less devices based on prediction tools.

Residual risk of thromboembolic events despite anticoagulation in Middle Eastern patients with atrial fibrillation. The JoFib study

OBJECTIVES

To investigate residual risk of thromboembolic events despite anticoagulation in patients with atrial fibrillation form the Middle East.

MATERIALS AND METHODS

Using data from the JoFib registry, we described the characteristics of patients treated with anticoagulants (n = 1654) and calculated the incidence rate for thromboembolic events. We constructed multivariable Cox proportional hazard models and calculated the population-attributable fraction to determine clinical factors predictive of residual thromboembolic events.

RESULTS

During the one-year follow-up, 57 thromboembolic events occurred (incidence rate 4.1 per 100 person-years). In multivariable time-to-event analysis, prior thromboembolic events (aHR 3.8, 95 %CI 2.2-6.4, p < 0.001) and diabetes (aHR 2.3, 95 %CI 1.3-4.1, p = 0.004) were independently predictive of residual thromboembolism. Percentage of thromboembolic risk attributable to prior thromboembolic events was 30.9 % (95 %CI 13.9-44.6, p = 0.001) and was 37.1 % (95 %CI 8.8-56.6, p = 0.015) for diabetes. Furthermore, the effect of diabetes on thromboembolic events depends on the type of anticoagulant, with diabetes being significantly predictive of thromboembolic events in patients anticoagulated with warfarin (aHR 4.11, 95 %CI 1.81-9.37, p = 0.001), but not non-vitamin K antagonist oral anticoagulants (aHR 1.23, 95 %CI 0.51-2.97, p = 0.643) with a p = 0.045 for interaction. Prior thromboembolism was independently predictive of thromboembolic events in both anticoagulants (aHR 2.67, 95 %CI 1.28-5.58, p = 0.009; aHR 7.33, 95 %CI 3.05-17.65, p < 0.001; respectively; p = 0.084 for interaction).

CONCLUSIONS

Middle Eastern patients with atrial fibrillation remain at significant risk of thromboembolism and its recurrence despite anticoagulation, and especially in diabetic patients. Therefore, management should focus on controlling diabetes as well as other modifiable risk factors in addition to antithrombotic therapy.

Evaluation of the prevalence of cardiometabolic disorders (diabetes, hypertension, and hyperlipidemia) diagnosed, undiagnosed, treated, and treatment goal in the elderly: Bushehr Elderly Health Program (BEH)

As the population ages, the global burden of cardiometabolic disorders will increase. This study aimed to investigate the prevalence of cardiometabolic disorders (diabetes, hypertension, and hyperlipidemia) in elderly and to evaluate the effects of various variables including age, sex, education, marital status, smoking, income, physical activity, dementia and depressed mood on untreated cardiometabolic disorders. This was a cross sectional study conducted in Bushehr Elderly Health Program. A total 2381 participants were included. Medical data were collected by trained interviewers. The mean age of the study participants was 69.34 years. Proportions of diabetes, hypertension, hyperlipidemia and hypercholesterolemia were 43.25%, 75.71%, 64.74% and 35.31% respectively. Untreated diabetes prevalence was higher for males (OR = 1.60, 95%CI = 1.20-2.15), older adults (OR = 1.02, 95%CI = 1.00-1.05), and pre-frail status (OR = 0.69, 95%CI = 0.52-0.92). Males (OR = 2.16, 95%CI = 1.64-2.84) and current smokers (OR = 1.42, 95%CI = 1.05-1.93), in contrast to married participants (OR = 0.25, 95%CI = 0.08-0.78), people with higher education levels (OR = 0.51, 95%CI = 0.29-0.89) and dementia (OR = 0.78, 95%CI = 0.61-1.00) were more likely to have untreated HTN. Untreated dyslipidemia is more common in smokers (OR = 1.78, 95%CI = 1.19-2.66) and males (OR = 1.66, 95%CI = 1.21-2.27), while untreated hypercholesteremia is more common in males (OR = 3.20, 95%CI = 1.53-6.69) and is reported lower in people with dementia (OR = 0.53, 95%CI = 0.28-1.01).

Physical activity level and sedentary time determinants among Moroccan hypertensive patients

INTRODUCTION

Hypertension is closely associated with an inactive lifestyle. Physical activity and/or exercise have been shown to delay the development of hypertension. This study aimed to assess the level of physical activity and sedentary time, and its determinants among Moroccan Hypertensive patients.

PATIENTS AND METHODS

A cross-sectional study was conducted between March and July 2019 including 680 hypertensive patients. We administered international physical activity questionnaire in face-to-face interview to assess the level of physical activity and sedentary time.

RESULTS

The results showed that only 43.4% of participants met recommended physical activity levels (≥ 600 MET min/week). Adherence to physical activity recommendations was observed more in male participants (p = 0.035), in participants aged less than 40 years (p = 0.040) and those aged between 41 and 50 years (p = 0.047). The average sedentary time was 37.19 ± 18.92 hours per week. This time was significantly longer in people aged 51 and over, in married, divorced, and widowed people, and in those with low levels of physical activity.

CONCLUSIONS

The level of physical inactivity and the sedentary time was high. In addition, participants with a high-level sedentary lifestyle had a low level of physical activity. Educational actions should be undertaken among this group of participants to prevent the risks associated with inactivity and sedentary behavior.

The Pandemic of Coronary Heart Disease in the Middle East and North Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Coronary heart disease (CHD) is the leading cause of morbidity, mortality, and disability in the Middle East and North Africa (MENA). While the prevention, diagnosis, and management of CHD have been detailed in international guidelines, we aimed in this review to quantify the pandemic of CHD in the MENA region and highlight regional patient characteristics, clinical challenges, and future directions to optimize CHD care in the region.

RECENT FINDINGS

Patients with CHD in the MENA feature younger age at presentation and worse prognosis in women. Despite the high burden of CHD risk factors, many of these factors remain underrecognized, undertreated, and uncontrolled. Additionally, CHD care is hampered by poor patient awareness, inefficient preventive strategies, and limited access to guideline-recommended therapeutics. All stakeholders involved in healthcare should work together to develop and execute strategies aimed at tackling the burden of CHD in the MENA.

Roadmap for the Management of Type 2 Diabetes and Hypertension in the Middle East: Review of the 2022 EVIDENT Summit

Type 2 diabetes mellitus (T2DM) and hypertension are leading risk factors for death and disability in the Middle East. Both conditions are highly prevalent, underdiagnosed and poorly controlled, highlighting an urgent need for a roadmap to overcome the barriers to optimal glycaemic and blood pressure management in this region. This review provides a summary of the Evidence in Diabetes and Hypertension Summit (EVIDENT) held in September 2022, which discussed current treatment guidelines, unmet clinical needs and strategies to improve treatment outcomes for patients with T2DM and hypertension in the Middle East. Current clinical guidelines recommend strict glycaemic and blood pressure targets, presenting several treatment options to achieve and maintain these targets and prevent complications. However, treatment targets are infrequently met in the Middle East, largely due to high clinical inertia among physicians and low medication adherence among patients. To address these challenges, clinical guidelines now provide individualised therapy recommendations based on drug profiles, patient preferences and management priorities. Efforts to improve the early detection of prediabetes, T2DM screening and intensive, early glucose control will minimise long-term complications. Physicians can use the T2DM Oral Agents Fact Checking programme to help navigate the wide range of treatment options and guide clinical decision-making. Sulfonylurea agents have been used successfully to manage T2DM; a newer agent, gliclazide MR (modified release formulation), has the advantages of a lower incidence of hypoglycaemia with no risk of cardiovascular events, weight neutrality and proven renal benefits. For patients with hypertension, single-pill combinations have been developed to improve efficacy and reduce treatment burden. In conjunction with pragmatic treatment algorithms and personalised therapies, greater investments in disease prevention, public awareness, training of healthcare providers, patient education, government policies and research are needed to improve the quality of care of patients with T2DM and/or hypertension in the Middle East.

Prevalence and Awareness of Hypertension among a Rural Jazan Population

BACKGROUND

Hypertension (HTN) is a major global public health problem. Knowledge of the risk factors and repercussions of HTN is crucial to preventing the disease. Rural populations have lower levels of knowledge of the disease than urban populations. However, no studies have assessed the levels of awareness of HTN and their determinants in rural regions of Saudi Arabia.

OBJECTIVES

This study aimed to assess the awareness of HTN and its determinants among a rural population of Jazan region, Saudi Arabia.

METHODOLOGY

We conducted a cross-sectional analytical study among six primary healthcare centers selected randomly from the rural areas of Jazan region. We targeted all Saudi adults visiting these centers. Information was gathered using interview questionnaires completed by 607 people. SPSS was utilized to analyze the collected data.

RESULTS

In all population groups, the prevalence of diagnosed HTN increased with age, particularly gradually increasing in those aged younger than 40 years and then rapidly and sharply increasing in those aged 40 years and over. The women (43.3%) had a higher prevalence of HTN than the men (34.6%), which is comparable with findings in other areas in Saudi Arabia and the Middle East. Approximately 65.6% of the participants without HTN and 34.4% of the participants with HTN did not know their normal blood pressure. Approximately 61.7% of the participants without HTN and 59.0% of the participants with HTN felt that pharmaceuticals are insufficient in curing HTN, while 60.7% and 64.7% believed that HTN can be cured.

CONCLUSIONS

The global prevalence of HTN is increasing annually owing to rapid changes in lifestyle and dietary habits. Furthermore, because adherence to antihypertensives is poor in rural Jazan, the Ministry of Health and researchers advocate implementing a program to increase awareness and assess patient adherence to prescribed medication for the control of HTN.

Trends in the burden and determinants of hypertensive heart disease in the Eastern Mediterranean region, 1990-2019: an analysis of the Global Burden of Disease Study 2019

Background

Hypertensive heart disease (HHD), one of the end-organ damage consequences of hypertension, is an important public health issue worldwide. Data on the HHD burden in the Eastern Mediterranean region (EMR) are scarce. We aimed to investigate the burden of HHD in the EMR, its member countries, and globally from 1990 to 2019.

Methods

We used 2019 Global Burden of Disease (GBD) data to report the HHD age-standardised prevalence, disability adjusted life years (DALYs), years of life lost (YLLs), and mortality, as well as HHD risk factors attribution percent with their 95% uncertainty interval (UI). Global data are reported alongside EMR data, and its 22 respective countries. We compared the burden of HHD by socio-demographic index (SDI), sex, age groups, and countries.

Findings

The age-standardised prevalence rate (per 100,000 population) of HHD was higher in the EMR (281.7; 95% UI: 204.5-383.4) in 2019, compared with the global prevalence (233.8; 95% UI: 170.5-312.9). The EMR age-standardised DALYs (per 100,000 population) for HHD in 2019 was 561.9 (361.0-704.1), compared with 268.2 (204.6-298.1) at the global level. There was an increase in HHD prevalence, reduction in mortality, and DALYs between 1990 and 2019 (4.01%, -7.6%, and -6.5%, respectively) in EMR. Among EMR countries, the highest versus lowest rates of age-standardised prevalence, mortality, and DALYs in 2019 [estimate (95% UI)] were in Jordan [561.62 (417.9-747.6)] versus Saudi Arabia [94.9 (69.5-129.0)]; Afghanistan [74.5 (23.7-112.3)] versus Saudi Arabia [4.3 (3.3-5.9)]; and Afghanistan [1374.1 (467.2-2020.7)] versus Qatar [87.11 (64.40-114.29)], respectively.

Interpretation

HHD remains a significant problem in the EMR, with a higher burden than global levels. Serious efforts toward high-quality management and prevention are strongly recommended. Based on this study, our recommendation for the EMR is to adopt effective preventive strategies. For example, promoting healthy dietary patterns and prompt screening for undiagnosed HTN in public places, promoting regular blood pressure measurements at home, and creating community awareness about early detection of HTN.

Funding

None.

The global burden of metabolic disease: Data from 2000 to 2019

Global estimates of prevalence, deaths, and disability-adjusted life years (DALYs) from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were examined for metabolic diseases (type 2 diabetes mellitus [T2DM], hypertension, and non-alcoholic fatty liver disease [NAFLD]). For metabolic risk factors (hyperlipidemia and obesity), estimates were limited to mortality and DALYs. From 2000 to 2019, prevalence rates increased for all metabolic diseases, with the greatest increase in high socio-demographic index (SDI) countries. Mortality rates decreased over time in hyperlipidemia, hypertension, and NAFLD, but not in T2DM and obesity. The highest mortality was found in the World Health Organization Eastern Mediterranean region, and low to low-middle SDI countries. The global prevalence of metabolic diseases has risen over the past two decades regardless of SDI. Urgent attention is needed to address the unchanging mortality rates attributed to metabolic disease and the entrenched sex-regional-socioeconomic disparities in mortality.

Knowledge, Attitudes, and Practices of Hypertensive Patients Towards Stroke Prevention Among Rural Population in Saudi Arabia: A Cross-Sectional Study

Introduction

Stroke is a significant health problem and is considered one of the leading causes of mortality and permanent disability worldwide. Hypertension is a primary risk factor for stroke. Thus, hypertensive patients' knowledge, attitudes, and practices (KAP) are essential in preventing stroke.

Objective

To examine hypertensive patients' KAP towards stroke prevention among rural population in Saudi Arabia.

Methods

The study utilized a cross-sectional design. The data were collected using a convenience sampling technique from hypertensive patients in the northwestern rural areas of Riyadh Province. A self-administered questionnaire was adapted from the Stroke Recognition Questionnaire (SRQ) and utilized to assess KAP towards stroke prevention among rural hypertensive patients. The STrengthening of the Reporting of OBservational studies in Epidemiology (STROBE) checklist was used to report the study.

Results

A total of 196 hypertensive patients participated in the study. The total mean scores categorization into three quartiles showed that most respondents had poor levels of KAP towards stroke prevention. Weak positive correlations were found between KAP of patients. There were statistically significant differences between respondents' attitudes and practices with their age, education, marital status, and occupational status.

Discussion

This study denoted poor levels of KAP towards stroke prevention among hypertensive patients living in rural areas. This study showed the importance of further considering rural population by which improving their health and quality of life. Extending health educational programs and behavior-changing strategies to rural areas is essential to increase hypertensive patients and general public awareness about their stroke prevention and other health-related concerns.

Burden of stroke in North Africa and Middle East, 1990 to 2019: a systematic analysis for the global burden of disease study 2019

BACKGROUND

While several studies investigated the epidemiology and burden of stroke in the North Africa and Middle East region, no study has comprehensively evaluated the age-standardized attributable burden to all stroke subtypes and their risk factors yet.

OBJECTIVE

The aim of the present study is to explore the regional distribution of the burden of stroke, including ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage, and the attributable burden to its risk factors in 2019 among the 21 countries of North Africa and Middle East super-region.

METHODS

The data of the Global Burden of Disease Study (GBD) 2019 on stroke incidence, prevalence, death, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs) rates, and attributed deaths, DALYs, YLLs, and YLDs to stroke risk factors were used for the present study.

RESULTS

The age-standardized deaths, DALYs, and YLLs rates were diminished statistically significant by 27.8, 32.0, and 35.1% from 1990 to 2019, respectively. Attributed deaths, DALYs, and YLLs to stroke risk factors, including high systolic blood pressure, high body-mass index, and high fasting plasma glucose shrank statistically significant by 24.9, 25.8, and 28.8%, respectively.

CONCLUSION

While the age-standardized stroke burden has reduced during these 30 years, it is still a concerning issue due to its increased burden in all-age numbers. Well-developed primary prevention, timely diagnosis and management of the stroke and its risk factors might be appreciated for further decreasing the burden of stroke and its risk factors and reaching Sustainable Development Goal 3.4 target for reducing premature mortality from non-communicable diseases.

Spotlight on hypertension in the Middle-East

The Middle-East is a diverse region with many countries of differing socio-economic status. While some countries are facing war and famine, others have a booming economy. This is reflected in the health care in these countries. Hypertension is a problem of all these countries. In this spotlight, we wish to draw attention to the barriers faced by the different countries in the region in their fight to bring blood pressure under control.

Hypertension Prevalence, Awareness, and Control Among Parents of School-Aged Children in the United Arab Emirates

BACKGROUND

Increased blood pressure (BP) is a major cardiovascular disease risk factor. The study aimed to determine the prevalence and predictors of hypertension and its awareness and control among parents of school-aged children in the United Arab Emirates (UAE).

METHODS

A total of 605 parents participated in this cross-sectional study. Information on socio-demographics, lifestyle factors, and history of chronic disease were collected through an adapted version of the World Health Organization STEPS questionnaire. Fasting blood glucose samples, BP measurements, body mass index (BMI), and waist and hip circumference were obtained using standard measurement protocols. Prevalence of hypertension was identified in the cohorts by defining hypertension using the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines (BP≥130/80 mmHg) and the World Health Organization-International Society of Hypertension Guidelines Orchid (BP≥140/90 mmHg) in association with antihypertensive medication use.

RESULTS

The mean age of participants was 42.9±7.9 years. The prevalence of hypertension was 37.2% (95% CI: 33.5-41.2) and 18.0% (95% CI: 15.2-21.3), using the 2017 and the previous WHO definitions, respectively. Little over half of the sample (51.5%) who were aware of having hypertension reported using antihypertensive medications. Of those reporting the use of antihypertensive medications in the past two days, 13 of 33 patients (39.4%) had their hypertension under control (<140/90 mmHg). The independent correlates of hypertension included age [(adjusted odds ratio (AOR): 1.09 (1.05-1.13], male sex [AOR: 2.48 (1.41-4.34], college or higher education [AOR: 0.22 (0.09-0.56)], family history of hypertension [AOR: 2.03 (1.17-3.53)], obesity [AOR: 3.15 (1.24-7.12)], and moderate or vigorous physical activity [AOR: 0.50 (0.26-0.98)].

CONCLUSION

Hypertension is prevalent among parents of school-going children. Improving lifestyle, health literacy, and introducing innovative models to raise awareness and education about hypertension are essential to achieve sustainable development goals (SDGs).