Prevalence, awareness, treatment, and control of hypertension in Lebanon

Unconventional Cardiovascular Risk Factors and Systematic Coronary Risk Estimation (SCORE) in the Lebanese Rural Population: The Forgotten Factors

Purpose

To evaluate the correlation between unconventional risk factors and the Systematic Coronary Risk Estimation (SCORE), and estimate the prevalence of conventional and unconventional cardiovascular (CV) risk factors in the rural Lebanese population in order to assess their CV risk.

Methods

This is a retrospective descriptive study conducted between November 2017 and June 2019 among the Lebanese rural population. The risk factors were analyzed from the files of the patients who presented for the CV disease screening days organized by a non governmental organization. The CV risk estimation tool is the SCORE. The classification of socio-economic level ranges from zero (low level) to 3 (high level).

Results

A total of 433 patients were included. The prevalence of hypertension, diabetes, dyslipidemia, smoking, and metabolic syndrome was 45.1%, 31.2%, 39.2%, 50% and 42.9% respectively. Only 13.6% of hypertensive patients and 6.7% of diabetics were controlled. A total of 0 or 1 point for the classification of socio-economic status was found in 62.6% of cases. A family history of CV diseases was present in 87.3% of participants. The SCORE was correlated with diabetes and metabolic syndrome (p = 0.000), without being correlated to socio-economic status (HR = -0.104; p = 0.059) or to family history (p = 0.834).

Conclusion

The socio-economic status and the family history of CV disease must be evaluated in addition to the classical risk calculation of the SCORE to better pinpoint the actual risk of the targeted population. The risk factors are prevalent but poorly controlled, hence the need for a national effort to ensure better care for the rural Lebanese population.

Assessment of medication adherence among Lebanese adult patients with non-communicable diseases during COVID-19 lockdown: a cross-sectional study

Background

Medical treatment is considered a cornerstone in non-communicable diseases (NCDs) management, lack of adherence remains the main challenge that may compromise optimal therapeutic outcome achievement.

Purpose

This study aimed to evaluate treatment adherence levels and associated factors among Lebanese adult patients with non-communicable diseases.

Materials and methods

A cross-sectional survey conducted during the COVID-19 lockdown imposed by the Lebanese Government (between September 2020 and January 2021) enrolled 263 adult patients through an anonymous online questionnaire to assess adherence to medications using the Lebanese Medication Adherence Scale (LMAS-14).

Results

Of the total sample, 50.2% showed low adherence with a total mean adherence score of 4.41 ± 3.94. The results showed that depression (β = 1.351) and peptic ulcer (β = 1.279) were significantly associated with higher LMAS scores (lower adherence). However, age between 50 and 70 (β = -1.591, p = 0.011), practicing physical exercise (β = -1.397, p = 0.006), having kidney disease (β = -1.701, p = 0.032), and an intermediate (β = -1.336, p = 0.006) to high income (β = -3.207, p < 0.001) were significantly associated with lower LMAS scores (higher adherence).

Conclusion

Our study shed light on the factors affecting medication adherence in patients with non-communicable diseases. It showed that depression and peptic ulcer were associated with lower adherence, contrary to older age, exercising, having chronic kidney disease, and a higher socioeconomic status.

Homocysteine levels, H-Hypertension, and the MTHFR C677T genotypes: A complex interaction

Background and objectives

High homocysteine levels are associated with increased risk of hypertension and stroke. Homocysteine is metabolized by the methylenetetrahydrofolate reductase (MTHFR). We aimed to investigate the levels of homocysteine and their association with hypertension, stroke, and antihypertensive medication usage in patients with different MTHFR C677T genotypes.

Methods and results

Genotype frequency of MTHFR polymorphism was performed, and plasma homocysteine levels were measured in 2,640 adult Lebanese patients. Hypertension, history of stroke, and list of medications were documented, among other clinical and demographic parameters. The TT mutant genotype and the T mutant allele of MTHFR were more prevalent in hyperhomocysteinemia (HHcy) and H-hypertensive (H-HTN, defined as hypertension with hyperhomocysteinemia) patients when compared to non-HHcy subjects and non H-HTN patients respectively. Homocysteine levels were significantly higher in hypertensive patients specifically among those on diuretics. A higher level of homocysteine was found in hypertensive patients with the MTHFR T allele compared to patients carrying the C allele. Among the T allele carriers, the average plasma homocysteine level was 13.3 ± 0.193 μmol/L for hypertensive subjects compared to 11.9 ± 0.173 μmol/L (non-hypertensives). Furthermore, homocysteine levels significantly correlated with stroke risk in patients with the T alleles.

Conclusions

We found an association of homocysteine with hypertension, hypertensive medication, and stroke risk among patients with the MTHFR T allele and the TT genotype. The association of diuretics therapy with higher homocysteine levels calls for routine measurements and therapeutic control of homocysteine in patients on diuretic, to improve health-related outcomes.

Impact of Preexisting Alcohol Use Disorder, Bipolar Disorder, and Schizophrenia on Ischemic Stroke Risk and Severity: A Lebanese Case-Control Study

BACKGROUND

Stroke remains a major leading cause of morbidity and death globally. For ischemic stroke, the most frequent type of stroke, there are numerous risk models and risk assessments offered. Further research into potential risk factors or triggers is being sought to improve stroke risk models. Schizophrenia, bipolar disorder, and alcohol use disorder are all common causes of serious mental illnesses in the general population. Due to the tangled relationship between stroke and many chronic illnesses, lifestyle factors, and diet that may be present in a patient with a mental disease, the relationship between mental diseases and stroke requires further validation. Consequently, the purpose of this study is to assess the potential influence of bipolar disorder, schizophrenia, and alcohol use disorder on stroke patients as compared to non-stroke participants, after controlling for demographic, physical, and medical conditions. We aimed, as a secondary objective, to evaluate the impact of these pre-existing disorders on stroke severity levels.

METHODS

This research is a case-control survey study involving 113 Lebanese patients with a clinical diagnosis of ischemic stroke and 451 gender-matched volunteers without clinical signs of stroke as controls recruited from several hospitals in Lebanon (April 2020-April 2021). Based on the participant's consent, data was collected by filling out an anonymous paper-based questionnaire.

RESULTS

All of the odds ratios (ORs) generated by our regression model were greater than 1, indicating that the factors studied were associated with an increased risk of ischemic stroke. As such having schizophrenia (adjusted OR [aOR]: 6.162, 95% confidence interval [CI]: 1.136-33.423), bipolar disorder (aOR: 4.653, 95% CI: 1.214-17.834), alcohol use disorder (aOR: 3.918, 95% CI: 1.584-9.689), atrial fibrillation (aOR: 2.415, 95% CI: 1.235-4.721), diabetes (aOR: 1.865, 95% CI: 1.117-3.115), heart diseases (aOR: 9.890, 95% CI: 5.099-19.184), and asthma-COPD (aOR: 1.971, 95% CI: 1.190-3.263) were all involved with a high risk of developing an ischemic stroke. Moreover, obesity (aOR: 1.732, 95% CI: 1.049-2.861) and vigorous physical activity (aOR: 4.614, 95% CI: 2.669-7.978) were also linked to an increased risk of stroke. Moreover, our multinomial regression model revealed that the odds of moderate to severe/severe stroke were significantly higher in people with pre-stroke alcohol use disorder (aOR: 1.719, 95% CI: 1.385-2.133), bipolar disorder (aOR: 1.656, 95% CI: 1.281-2.141), and schizophrenia (aOR: 6.884, 95% CI: 3.294-11.492) compared to people who had never had a stroke.

CONCLUSION

The findings in our study suggest that individuals with schizophrenia, bipolar disorder, and alcohol use disorder may be at a higher risk for ischemic stroke and exhibit more severe symptoms. We believe that the first step toward creating beneficial preventative and treatment interventions is determining individuals with schizophrenia, bipolar disorder, or alcohol use disorder, assessing their risk of ischemic stroke, developing more integrated treatments, and closely monitoring the long-term outcome in the event of an ischemic stroke.

Observational study of factors associated with morbidity and mortality from COVID-19 in Lebanon, 2020-2021

BACKGROUND

The COVID-19 pandemic claimed millions of lives worldwide without clear signs of abating despite several mitigation efforts and vaccination campaigns. There have been tremendous interests in understanding the etiology of the disease particularly in what makes it severe and fatal in certain patients. Studies have shown that COVID-19 patients with kidney injury on admission were more likely to develop severe disease, and acute kidney disease was associated with high mortality in COVID-19 hospitalized patients.

METHODS

This study investigated 819 COVID-19 patients admitted between January 2020-April 2021 to the COVID-19 ward at a tertiary care center in Lebanon and evaluated their vital signs and biomarkers while probing for two main outcomes: intubation and fatality. Logistic and Cox regressions were performed to investigate the association between clinical and metabolic variables and disease outcomes, mainly intubation and mortality. Times were defined in terms of admission and discharge/fatality for COVID-19, with no other exclusions.

RESULTS

Regression analysis revealed that the following are independent risk factors for both intubation and fatality respectively: diabetes (p = 0.021 and p = 0.04), being overweight (p = 0.021 and p = 0.072), chronic kidney disease (p = 0.045 and p = 0.001), and gender (p = 0.016 and p = 0.114). Further, shortness of breath (p<0.001), age (p<0.001) and being overweight (p = 0.014) associated with intubation, while fatality with shortness of breath (p<0.001) in our group of patients. Elevated level of serum creatinine was the highest factor associated with fatality (p = 0.002), while both white blood count (p<0.001) and serum glutamic-oxaloacetic transaminase levels (p<0.001) emerged as independent risk factors for intubation.

CONCLUSIONS

Collectively our data show that high creatinine levels were significantly associated with fatality in our COVID-19 study patients, underscoring the importance of kidney function as a main modulator of SARS-CoV-2 morbidity and favor a careful and proactive management of patients with elevated creatinine levels on admission.

Knowledge, Attitude, and Practice Toward Hypertension Among Hypertensive Patients Residing in Lebanon

Background and Objectives

Hypertension (HTN) is a major health concern that leads to cardiovascular disease and premature death. Assessing HTN knowledge, attitude, and practice (KAP) is crucial for controlling HTN. This study aimed to determine HTN KAP among hypertensive patients residing in Lebanon.

Methods

This cross-sectional study involved 342 hypertensive patients. A questionnaire form was used to collect data related to patients’ characteristics. SPSS was used to determine KAP scores, descriptive statistics, and correlations.

Results

Data from HTN patients was analyzed of whom 98.2% were Lebanese and 51.2% were males. The median age was 59.15 ± 13.55 years old. A proportion of 40.4% had HTN duration for at least 10 years and 67.3% had HTN family history. Patients had fair HTN knowledge and practice, but good attitude toward HTN. Only 45.3% regularly checked their blood pressure. Positive correlations were observed between HTN attitude and each of knowledge and practice. HTN knowledge and attitude were associated with many studied factors, whereas no relationship was found regarding practice.

Conclusion

Hypertensive patients had fair levels of knowledge and practice, and a good level of attitude concerning their disease. We provided a model for predictors of HTN KAP scores that will allow the development of efficient campaigns related to HTN.

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

Hypertension is the leading source of morbidity and death. In the 21st century, there still is a major gap between high and low to middle-income countries in awareness, management, and control; countries in the Middle East represent an example of such disparities. In this review of the literature, light is shed on the prevalence and modifiable risk factors of hypertension specific to the region, as well as regional disparities in diagnosis and management. The crude prevalence rate is estimated to be around 29.5% with wide variability between countries. Various modifiable factors affect the prevalence of hypertension in this region such as excessively high rates of smoking, obesity, a sedentary lifestyle, some gender gap, and a suboptimal healthcare system; socio-economic factors and disparities in education, literacy, and urbanization play a significant role. Patient adherence to treatment is a determining factor of blood pressure control and nonadherence adversely affect outcomes. In addition, physician adherence to international guidelines is poor. Recognizing these barriers to hypertension management, this review serves as a call for increased national and regional efforts to implement favorable healthcare policies and improve clinical outcomes.

The Sweet and Salty Dietary Face of Hypertension and Cardiovascular Disease in Lebanon

According to the World Health Organization (WHO), an estimated 1.28 billion adults aged 30–79 years worldwide have hypertension; and every year, hypertension takes 7.6 million lives. High intakes of salt and sugar (mainly fructose from added sugars) have been linked to the etiology of hypertension, and this may be particularly true for countries undergoing the nutrition transition, such as Lebanon. Salt-induced hypertension and fructose-induced hypertension are manifested in different mechanisms, including Inflammation, aldosterone-mineralocorticoid receptor pathway, aldosterone independent mineralocorticoid receptor pathway, renin-angiotensin system (RAS), sympathetic nervous system (SNS) activity, and genetic mechanisms. This review describes the evolution of hypertension and cardiovascular diseases (CVDs) in Lebanon and aims to elucidate potential mechanisms where salt and fructose work together to induce hypertension. These mechanisms increase salt absorption, decrease salt excretion, induce endogenous fructose production, activate fructose-insulin-salt interaction, and trigger oxidative stress, thus leading to hypertension. The review also provides an up-to-date appraisal of current intake levels of salt and fructose in Lebanon and their main food contributors. It identifies ongoing salt and sugar intake reduction strategies in Lebanon while acknowledging the country’s limited scope of regulation and legislation. Finally, the review concludes with proposed public health strategies and suggestions for future research, which can reduce the intake levels of salt and fructose levels and contribute to curbing the CVD epidemic in the country.

Hypertension and pre-hypertension in Middle East and North Africa (MENA): A meta-analysis of prevalence, awareness, treatment, and control

Hypertension (HTN) is one of the most important public health challenges, especially in developing countries. Despite individual studies, information on the exact prevalence of prehypertension (pre-HTN) and HTN in the Middle East and North Africa (MENA) is lacking. This meta-analysis was conducted to evaluate prevalence of pre-HTN and HTN, awareness, treatment, and control in the MENA region. PubMed, Web of Science, and Scopus databases were searched from inception to April 30, 2021. Keywords included hypertension, pre-hypertension, awareness, treatment, and control. The quality of the included studies was evaluated using the Hoy scale. A random-effects model was evaluated based on overall HTN. The heterogeneity of the preliminary studies was evaluated using the I² test. A total of 147 studies involving 1,312,244 participants were included in the meta-analysis. Based on the results of the random-effects method (95% CI), the Prevalence of pre-HTN and HTN were 30.6% (95% CI: 25.2, 36.0%; I² = 99.9%), and 26.2% (95% CI: 24.6, 27.9%; I² = 99.8%), respectively. The prevalence of HTN awareness was 51.3% (95% CI: 47.7, 54.8; I² = 99.0%). The prevalence of HTN treatment was 47.0% (95% CI: 34.8, 59.2; I² = 99.9%). The prevalence of HTN control among treated patients was 43.1% (95% CI: 38.3, 47.9; I² = 99.3%). Considering the high prevalence of HTN, very low awareness, and poor HTN control in the region, more attention should be paid to preventive programs for HTN reduction.

Mild Cognitive Impairment and modifiable risk factors among Lebanese older adults in primary care

OBJECTIVE

Mild Cognitive Impairment (MCI) is an intermediate state between normal cognition and dementia. Identification of MCI and associated risk factors is important for early intervention. This study investigated the prevalence of MCI among Lebanese older adults and associated risk factors in primary care.

METHODS

For this cross-sectional study, 337 adults aged 60 years and older met inclusion criteria and were recruited at a primary care clinic associated with a tertiary medical center in Beirut, Lebanon. The validated Arabic version of the Montreal Cognitive Assessment, the 5-item Geriatric Depression Scale, and the Lawton Instrumental Activities of Daily Living Scale were administered. Data about sociodemographic, behavioral, and clinical characteristics was obtained.

RESULTS

There was no difference in the mean age between those with normal cognition and those with MCI (mean age 70.38 ± 7.4 and 72.12 ± 7.6 years, respectively). The prevalence of MCI was 14.8% (50 out of 337), 42% were males and 58% were women. Participants having more than 12 years of education (OR = 0.297; CI = 0.112-0.788; P = 0.015) were less likely to have MCI. Participants with history of smoking (OR = 2.599; CI = 1.266-5.339; P = 0.012) or at risk of depression (OR = 2.847; CI = 1.392-5.819; P = 0.004) were more likely to have MCI.

CONCLUSION

Identification of patients with history of smoking and at risk of depression may serve as an opportunity to offer intensive counseling and targeted treatment to delay the onset or progression of MCI to Alzheimer's disease.

Long-term Trends in Hypertension Prevalence, Awareness, Treatment, and Control Rate in the Middle East and North Africa: a Systematic Review and Meta-analysis of 178 Population-Based Studies

PURPOSE OF REVIEW

This study investigated and pooled the long-term trends in prevalence, awareness, treatment, and control of hypertension (HTN) in the Middle East and North Africa (MENA) region. In this systematic review and meta-analysis, we searched MEDLINE/PubMed, Web of Science, Google Scholar, EMBASE, and Scopus between database inception and November 2020. All cross-sectional studies that investigated the prevalence of pre-HTN, HTN, awareness, treatment, and control in the MENA counties were included. The selection study, data extraction, and quality assessment were conducted by two investigators independently. Heterogeneity between studies was assessed using Cochran's Q test and I-squared, and due to sever heterogeneity between studies, the random effect model was used to pool the estimates. Sensitivity analysis was performed to estimate the long-term trends in prevalence, awareness, treatment, and control rates of HTN according to definition of HTN as systolic blood pressure of 140 mm Hg or more, or diastolic blood pressure of 90 mm Hg or more, or being on pharmacological treatment for HTN.

RECENT FINDINGS

Overall, 178 studies met the inclusion criteria. Studies comprised 2,262,797 participants with a mean age of 45.72 ± 8.84 years. According to random effect model, the pooled prevalence of pre-HTN and HTN was 33% (95% CI 28, 39) and 26% (25, 27), respectively. Over the past three decades, prevalence of hypertension increased significantly in the region. The pooled awareness, treatment, and control rates were 50% (48, 53), 41% (38, 44), and 19% (17, 21), receptively. The pooled awareness, treatment, and control rates of HTN were lower significantly in men than women. According to definition of HTN as blood pressures above 140/90 mm Hg, over the past three decades, although the awareness and treatment rates did not change significantly, the control rates improved significantly in the region. The findings showed that HTN is a significant public health problem in the MENA region. Although there are low levels of pooled awareness, treatment, and control rates, the control rates improved over the past three decades in the region.

May Measurement Month 2019: an analysis of blood pressure screening results from Lebanon

Hypertension is an important public health concern of high prevalence among adults. It is associated with an increased mortality rate. The prevalence of hypertension in Lebanon has increased during the last decades, affecting around one-third of the Lebanese population. Since diagnosis and treatment of hypertension is associated with a better prognosis, annual screening and raising awareness about this ‘silent killer’ disease is of extreme value. We conducted a cross-sectional survey in various Lebanese cities in 2019. We recruited adults (≥18 years old) from different sites, through an opportunistic sampling method. For each participant, three blood pressure (BP) readings were recorded and the average of the last two was analysed. In addition, data on lifestyle factors and comorbidities were collected. Participants were considered hypertensive if they had at least one of the following: systolic or diastolic BP ≥140 and/or ≥90 mmHg, respectively, or taking antihypertensive medication. Blood pressure was measured in 7019 participants. The mean age was 46.0 (SD 16.6) years. In total, 2572 participants (36.6%) had hypertension among whom only 64.1% were aware of their disease and 62.3% were on treatment. Blood pressure was controlled in 62.6% of participants taking antihypertensive medications. This study is the largest on hypertension prevalence in Lebanon. The results demonstrated that around one-third of the hypertensive population were not aware of their disease, and that a high percentage was not being treated. These results suggest the need for rapid interventions aimed at raising awareness regarding hypertension in the Lebanese population.

The Health Status of Lebanese Community Pharmacists: Prevalence of Poor Lifestyle Behaviors and Chronic Conditions

Background

Community pharmacists are drug therapy experts providing pharmaceutical care for various patients. Their stressful daily tasks can affect their lifestyle and wellbeing.

Objectives

To assess the health status of the Lebanese community pharmacists, to determine the prevalence of chronic conditions and unhealthy lifestyle behaviors, and their association with pharmacists' professional responsibilities.

Methods

A cross-sectional study was conducted on 300 randomly selected pharmacists between May and August 2017. A four-page questionnaire was carried out targeting their health characteristics, lifestyle factors, and job details.

Results

Thirty-seven percent of the studied sample were males, with a mean age of 30.9 ± 9.1 years and mean Body Mass Index (BMI) of 23.4 ± 3.71 kg/m². Twenty-six percent were smokers and smoking was significantly related to gender, BMI, workplace region, work shifts, educational level, number of patients/day, and transportation time to work (p < 0.05 for all). Twenty-one percent were alcohol consumers, 89.3% were caffeine consumers, and 41.7% were physically active. Moreover, 72% were fast food consumers, 89.7% consumed sweets, and 87.7% consumed salted food. Concerning chronic diseases, 6.3% were hypertensive and hypertension was significantly related to age, marital status, education level, working hours per day, working days per week, owning a pharmacy, work shift, and the number of patients per day (p < 0.05 for all).

Conclusion

Lebanese pharmacists might have a lower prevalence of chronic diseases compared to the general population. However, the prevalence of bad lifestyle behaviors such as low physical activity, smoking, consumption of salt, sweet, fast food, and caffeine is considered high among the study sample and this would raise a concern about pharmacists' awareness and role as healthcare providers.

Prevalence and Correlates of Hypertension Unawareness among Lebanese Adults: The Need to Target Those “Left Behind”

Introduction. Hypertension unawareness is context-specific, and our understanding of factors associated with it has implications on primary healthcare practices locally and contributes to achieving cardiovascular disease (CVD) targets, globally. In this study, we examine the prevalence and correlates of hypertension unawareness among adult Lebanese population. Methods. The study sample included a nationally representative sample of 2214 adults ≥25 years of age from the Noncommunicable Disease (NCD) Risk Factor WHO-STEPS cross-sectional survey conducted in Lebanon. In the first step, hypertension was assessed based on reported morbidity using face-to-face interviews, and in the second step, based on blood pressure (BP) measurement. We defined hypertension prevalence as systolic/diastolic blood pressure ≥140/90 mmHg and/or ongoing treatment for hypertension. Hypertension unawareness was described as lack of prior knowledge of hypertensive status. Those responding negatively to the face-to-face interview question “whether they had ever been told by a health worker that they have hypertension” were labelled as “apparently healthy.” Results. Overall prevalence of hypertension was 30.7%. A total of 369 subjects were unaware of their condition, representing 51.8% of all hypertensives and 15.9% of the apparently healthy. Multivariable analysis controlling for a number of confounders showed that, among apparently healthy participants, insurance coverage and contact with healthcare services were not associated with higher likelihood for hypertension awareness. Among all hypertensives, hypertension unawareness was significantly higher in the young, those with BMI <25 kg/m2 (adjusted OR (aOR): 2.52; 95% CI: 1.35–4.69), no CVD (aOR: 3.30; 95% CI: 1.74–6.29), and participants with no reported family history of hypertension (aOR: 4.87; 95% CI: 2.89–8.22), compared to their counterparts. Conclusion. In Lebanon, unawareness of hypertension occurred in those clinically least perceived to be at risk. These findings are key for optimizing current screening practices and informing NCD prevention efforts in the country and contribute to achieving global targets of the SDGs of “leaving no one behind.”

An exploratory randomised controlled trial evaluating text prompts in Lebanon to encourage health-seeking behaviour for hypertension

AIMS OF THE STUDY

The current study evaluates the effectiveness of an opportunistic mobile screening on the percentage of people who are aware of whether they may be hypertensive (in an observational study) and the effectiveness of reminder prompts on the percentage of people who seek further medical attention (in a randomised controlled trial).

METHODS USED TO CONDUCT THE STUDY

The screening of 1227 participants (529 female) was conducted during the registration period of the 2018 Beirut International Marathon in Lebanon. Next, 266 participants whose screening indicated hypertension (64 Female) were randomly allocated to a treatment group or a control group in a 1:1 fashion. The treatment group received a reminder prompt to seek further medical attention for their potential hypertension and the control group did not. The overt nature of the text message meant that participants in the treatment group could not be blinded to their group allocation. The primary outcome is participants' self-reports of whether they sought further medical attention.

RESULTS OF THE STUDY

For the opportunistic screening, a 25% prevalence rate and a 24% awareness rate of hypertension was indicated. A McNemar analysis suggested that the screening increased participant awareness (X² (N = 1227) = 72.16, P < .001). For the randomised controlled trial, 219 participants provided follow-up data via a phone call (82% retention). A Chi-squared analysis suggested that the reminder prompt successfully encouraged more participants to seek further medical attention, 45.5% treatment group vs 28.0% control group (X² (1, N = 219) = 7.19, P = .007, φ = 0.18).

CONCLUSIONS DRAWN AND CLINICAL IMPLICATIONS

Extra support in the form of a brief reminder message can increase the percentage of people who seek further medical attention after attending an opportunistic screening at a marathon event. The discussion reviews how the results align with previous research, strengths and limitations of the current study, and implications for future research and practice.

Hypertension prevalence and control among community-dwelling lebanese older adults

There is a high prevalence of hypertension among Lebanese adults, but no evidence is available on its prevalence and control exclusively among older adults (65 + years). This study provides the first evidence on a representative sample of 502 community elderly and presents the basis for future research and policy implications. Results show an overall prevalence of 52% with a significantly higher female-to-male ratio. Factors independently associated with hypertension were older age, body mass index, and dementia. More than a third of those with a positive history of hypertension had uncontrolled blood levels. Uncontrolled hypertension was higher among women. Increasing awareness about medication adherence and controlling multi-morbidities constitute promising measures to lowering the burden of hypertension among Lebanese older adults, especially women.

Assessing Barriers to and Level of Adherence to Hypertension Therapy among Palestinians Living in the Gaza Strip: A Chance for Policy Innovation

Introduction

Hypertension is a major health concern, especially in low-income countries. Nonadherence and poor or no persistence in adhering to hypertension treatment regimens result in uncontrolled high blood pressure, increasing rates of mortality and morbidity, and preventable healthcare costs. The aim of this study was to assess the level of adherence and barriers to treatment regimens among hypertensive patients living in the Gaza Strip, Palestine.

Methods

A convenience sample of 648 participants completed the Hill-Bone Compliance to High Blood Pressure Therapy Scale. The great majority of participants (n = 521, 80.4%) was highly adherent to their treatment regimen, 123 participants (18.98%) were classified as moderately nonadherent, and 4 (0.62%) participants were classified as highly nonadherent to their hypertension treatment regimen. Participants of this study showed the highest adherence rate to the domain of medication adherence (mean of 1.42 out of 4) followed by appointment keeping (mean 1.8), while they were least adherent to diet (mean of 2.18). The greatest three barriers to adherence to the recommended treatment regimen reported by participants were inability to exercise, inability to resist fast and fried food, and inability to keep themselves away from salty foods.

Conclusion

Overall adherence to medication in Gaza was surprisingly good in patients with a diagnosis of hypertension for at least one year. However, adherence to lifestyle advice or dietary regimes remains poor. A combination of interventions using low-cost mobile technology, combined with face-to-face interventions by healthcare professionals, can be applied to improve adherence to hypertension treatment regimens in order to reduce the consequences of uncontrolled blood pressure.

Evaluation of risk factors and drug adherence in the occurrence of stroke in patients with atrial fibrillation

Background:

Atrial fibrillation (AF) patients are at high risk of developing a stroke and anticoagulant medications are generally prescribed to prevent stroke in AF population.

Objective:

This study aims to evaluate stroke risk factors among hospitalized patients with AF and to assess the level of adherence to medications in AF patients and their relation with stroke.

Methods:

This is a case-control study conducted between June 1^st, 2018 and December 31^th, 2018 among AF patients admitted to seven tertiary Lebanese hospitals. Data were collected using a standardized questionnaire. Adherence to medications was assessed using the Lebanese Medication Adherence Scale-14. Odds ratios (OR) expressed the strength of association between the independent variables and the dependent variable and were estimated using unconditional logistic regression adjusted for confounding factors. P<0.05 determined statistical significance.

Results:

In total, 174 cases of AF patients were included with 87 cases and 87 controls. The risk of stroke among AF significantly increased with the presence of a history of hypertension, aOR 16.04 (95%CI, 2.27-113.37; p=0.005), history of coronary heart disease/myocardial infarction, and history of obesity. Anticoagulant medication significantly decreased the risk of stroke among AF patients, aOR 0.27 (95%CI, 0.07-0.98; P=0.047). High adherence to medications was significantly associated with a reduced risk of stroke, aOR 0.04 (95%CI, 0.01-0.23; p<0.001).

Conclusions:

Having a history of hypertension is one of the strongest risk factors for stroke among AF patients in Lebanon. While anticoagulant medication use was associated with a reduced risk for stroke, high adherence to medications is critical for stroke prevention. Public health interventions are needed to tackle low-adherence to medication and prevent stroke among AF patients.

The cascade of care in managing hypertension in the Arab world: a systematic assessment of the evidence on awareness, treatment and control

BACKGROUND

Hypertension is a leading risk factor for mortality and morbidity globally and in the Arab world. We summarize the evidence on awareness, treatment, and control of hypertension, to assess the extent of gaps in the hypertension continuum of care. We also assess the influence of gender and other social determinants at each level of the cascade of care.

METHODS

We searched MEDLINE and SSCI databases for studies published between 2000 and 2017, reporting the rates of awareness, treatment or control of hypertension and/or their determinants in the Arab region. We included sources on both general populations and on clinical populations. The review process was based on the PRISMA guidelines. We present rates on the three stages of the care cascade corresponding to (1) awareness (2) treatment and (3) control of blood pressure, and estimated the losses that occur when moving from one stage to another. We also take stock of the evidence on social determinants and assess the statistical significance of gender differences in awareness, treatment and control.

RESULTS

Data from 73 articles were included. Substantial proportions of hypertensives were lost at each step of the hypertension care continuum, with more missed opportunities for care resulting from lack of awareness of hypertension and from uncontrolled blood pressure. More than 40% and 19% of all hypertensive individuals were found to be unaware and to have uncontrolled blood pressure, respectively, but among individuals diagnosed with hypertension, less than 21% were untreated. Awareness rates were higher among women than men but this advantage was not consistently translated into better blood pressure control rates among women.

CONCLUSIONS

This analysis of the cascade of care indicates that barriers to proper diagnosis and adequate control are greater than barriers to delivery of treatment, and discusses potential factors that may contribute to the gaps in delivery.

The influence of socio-environmental determinants on hypertension. A spatial analysis in Athens metropolitan area, Greece

INTRODUCTION

While epidemiological and pathophysiological aspects of hypertension are still being investigated, there is an increased global interest between hypertension and social health determinants and environmental factors that this study aims to examine.

METHODS

The sample size used in this work included 2,445 individuals, from Athens metropolitan area, who were randomly enrolled in ATTICA study, during 2001 to 2002. Principal component analysis (PCA), Poisson regression modeling and geographical analysis, based on Geographic Information Systems (GIS) technology, were applied.

RESULTS

Geographical analysis and thematic mapping revealed that the West municipalities of Athens had the lowest socio-environmental status. Three components were derived from PCA: high, low and mixed socio-environmental status. Poisson regression analysis showed that high socio-environmental status, educational and economic level were negatively correlated with hypertension in some sectors of Athens (p < 0.05, for all).

CONCLUSIONS

Through the use of geospatial surveillance the underlying epidemiology of hypertension, and those at greater risk, can be more precisely determined. This study underlines the need to account for environmental factors when developing public health policies and programs for effective hypertension prevention or reduction.

Factors Associated with Antihypertensive Medication Non-Adherence: A Cross-Sectional Study Among Lebanese Hypertensive Adults

BACKGROUND

Poor adherence to antihypertensives is associated with negative outcome of the disease as well as loss of health-care resources. Addressing the epidemic of poor adherence requires identifying factors associated with this behaviour. The aim of this study is to describe adherence to antihypertensive medication among Lebanese hypertensive patients and to evaluate the association between socio-economic, patient- and conditions-related factors and non-adherence.

METHODS

A cross-sectional study was carried out on adherence to antihypertensive medications covering all governorates of Lebanon. This study was conducted between February 2018 and January 2019 on a random sample of 1497 hypertensive patients. A face-to-face questionnaire was used to assess adherence to antihypertensive medication and its determinants according to the five World Health Organization (WHO) main categories. Logistic regression analysis was performed to test the adjusted association between the multiple exposure factors, and drug adherence data were collected by trained interviewers.

RESULTS

Adherence to antihypertensive medications was reported by 1253 (83.7%) of the patients. After multivariate analysis, patients who tried to control their stress level (OR = 0.77, 95% CI [0.38-0.95]), those who had normal BP readings (OR =0.49, 95% CI [0.18-0.97]), and those who believed in the effectiveness of their treatment (OR = 0.31, 95% CI [0.14-0.76]) had a significantly lower chance to exhibit non-adherence to their treatment. However, older patients (OR= 1.87, 95% CI [1.23-2.21]), divorced/separated patients (OR= 2.14, 95% CI [1.31-5.48]), married (OR=1.96, 95% CI [1.27-3.90]), widowed (OR=2.11, 95% CI [1.62-6.50]), obese patients (OR = 1.76, 95% CI [1.21-1.94]), and patients who smoked hookah and cigarettes (OR = 2.62, 95% CI [1.17-6.76]) were more likely to exhibit non-adherence.

CONCLUSION

Our study highlights the influence of factors such as old age, marital status, BMI and high level of emotional stress on non-adherence to medication in hypertensive patients. These determinants should be incorporated into adherence improving strategies.

Significance of Clostridium difficile in community-acquired diarrhea in a tertiary care center in Lebanon

Clostridium difficile infection (CDI) is becoming a cause of community-acquired diarrhea. The aim is to describe (CDI) as a cause of acute diarrhea in patients presenting from the community to the Emergency Department (ED) of a tertiary care center in Lebanon. A retrospective study conducted in the ED at the American University of Beirut Medical Center (AUBMC). Adult patients presenting with the chief complaint of diarrhea and having positive CDI by stool laboratory testing (toxins A and B), during a three-year period were included. 125 patients with CDI were included. Average age was 61.43 (±20.42) with roughly equal sex prevalence. 30% (n = 36) of patients had neither antibiotic exposure nor recent hospitalization prior to current CDI. Mortality was 9.6% (n = 12), CDI was attributed as the cause in 16.7% (n = 2) and a contributing factor in 41.6% (n = 5). Recurrence within 3 months occurred in 9.6% (n = 11) in mainly those taking Proton Pump Inhibitors (PPIs) and having multiple co-morbidities. There is a high rate of community acquired CDI in Lebanon. Review of patients’ medications (PPIs and antibiotics) is crucial. More studies are needed to assess mortality associated with CDI and the outcome of coinfection with other enteric pathogens.

Insight into blood pressure targets for universal coverage of hypertension services in Iran: the 2017 ACC/AHA versus JNC 8 hypertension guidelines

BACKGROUND

We compared the prevalence, awareness, treatment, and control of hypertension in Iran based on two hypertension guidelines; the 2017 ACC/AHA -with an aggressive blood pressure target of 130/80 mmHg- and the commonly used JNC8 guideline cut-off of 140/90 mmHg. We shed light on the implications of the 2017 ACC/AHA for population subgroups and high-risk individuals who were eligible for non-pharmacologic and pharmacologic therapies.

METHODS

Data was obtained from the Iran national STEPS 2016 study. Participants included 27,738 adults aged ≥25 years as a representative sample of Iranians. Regression models of survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension.

RESULTS

The prevalence of hypertension based on JNC8 was 29.9% (95% CI: 29.2-30.6), which soared to 53.7% (52.9-54.4) based on the 2017 ACC/AHA. The percentage of awareness, treatment, and control were 59.2% (58.0-60.3), 80.2% (78.9-81.4), and 39.1% (37.4-40.7) based on JNC8, which dropped to 37.1% (36.2-38.0), 71.3% (69.9-72.7), and 19.6% (18.3-21.0), respectively, by applying the 2017 ACC/AHA. Based on the new guideline, adults aged 25-34 years had the largest increase in prevalence (from 7.3 to 30.7%). They also had the lowest awareness and treatment rate, contrary to the highest control rate (36.5%) between age groups. Compared with JNC8, based on the 2017 ACC/AHA, 24, 15, 17, and 11% more individuals with dyslipidaemia, high triglycerides, diabetes, and cardiovascular disease events, respectively, fell into the hypertensive category. Yet, based on the 2017 ACC/AHA, 68.2% of individuals falling into the hypertensive category were eligible for receiving pharmacologic therapy (versus 95.7% in JNC8). LDL cholesterol< 130 mg/dL, sufficient physical activity (Metabolic Equivalents≥600/week), and Body Mass Index were found to change blood pressure by - 3.56(- 4.38, - 2.74), - 2.04(- 2.58, - 1.50), and 0.48(0.42, 0.53) mmHg, respectively.

CONCLUSIONS

Switching from JNC8 to 2017 ACC/AHA sharply increased the prevalence and drastically decreased the awareness, treatment, and control in Iran. Based on the 2017 ACC/AHA, more young adults and those with chronic comorbidities fell into the hypertensive category; these individuals might benefit from earlier interventions such as lifestyle modifications. The low control rate among individuals receiving treatment warrants a critical review of hypertension services.

Knowledge of Stroke Warning Signs, Risk Factors, and Response to Stroke among Lebanese Older Adults in Beirut

BACKGROUND AND OBJECTIVES

Stroke is a global burden. In Lebanon, recent studies have shown that stroke prevalence may be higher than other developing countries. While older people are particularly vulnerable to stroke, research suggests that they have poor stroke awareness. Since awareness is crucial for early hospital admission, thereby outcome, the main objectives of this study were to assess knowledge of stroke ie, symptoms, risk factors, and intended behavior in case of stroke suspicion.

METHODS

A community-based survey targeting adults aged 50 and above was conducted at 20 random pharmacies in Beirut from May to October 2018 through face to face interviews utilizing a structured questionnaire composed of open and closed ended questions. Descriptive and multivariable analyses were performed.

MAIN RESULTS

In total, 390 participants completed the questionnaire. Sixty-eight percent were able to spontaneously recall at least 1 stroke symptom, most frequently headache (29.2%), hemiparesis (25.4%), and dizziness (19.5%). Furthermore, 85.4% spontaneously recalled at least 1 risk factor, most frequently hypertension (48.2%), smoking (20.5%), and stress (43.1%). In case of stroke suspicion 57.69% would call an ambulance. Knowing a stroke patient and educational level were predictors for recall of more symptoms and risk factors for stroke. Adequate response to stroke was positively associated with identification of more stroke symptoms but inversely associated with having diabetes.

CONCLUSIONS AND RECOMMENDATIONS

There are major gaps in stroke knowledge among Beirut's older population. Culturally tailored awareness campaigns should be implemented at multiple levels using different media methods to target vulnerable populations at higher risk for stroke and their families. These campaigns should focus on improving stroke symptoms awareness and actions to take when suspecting stroke.

mHealth use for non-communicable diseases care in primary health: patients' perspective from rural settings and refugee camps

Background

Non-communicable diseases (NCDs) account for 85% of deaths in Lebanon and contribute to remarkable morbidity and mortality among refugees and underserved populations. This study assesses the perspectives of individuals with hypertension and/or diabetes in rural areas and Palestinian refugee camps towards a population based mHealth intervention called 'eSahha'.

Methods

The study employs a mixed-methods design to evaluate the effectiveness of SMSs on self-reported perceptions of lifestyle modifications. Quantitative data was collected through phone surveys, and qualitative data through focus group discussions. Descriptive statistics and bivariate analysis were performed.

Results

About 93.9% (n = 1000) of respondents perceived the SMSs as useful and easy to read and understand. About 76.9% reported compliance with SMSs through daily behavioral modifications. Women (P = 0.007), people aged ≥76 years (P < 0.001), unemployed individuals (P < 0.001), individuals who only read and write (P < 0.001) or those who are illiterate (P < 0.001) were significantly more likely to receive and not read the SMSs. Behavior change across settings was statistically significant (P < 0.001).

Conclusion

While SMS-based interventions targeting individuals with hypertension and/or diabetes were generally satisfactory among those living in rural areas and Palestinian refugee camps in Lebanon, a more tailored approach for older, illiterate and unemployed individuals is needed.

Keywords

e-health, refugees.

Antihypertensive Indigenous Lebanese Plants: Ethnopharmacology and a Clinical Trial

Hypertension is highly prevalent among the Lebanese adult population and is indeed the major cause of mortality in Lebanon. Traditional use of antihypertensive medicinal plants has long been practiced. The aim of this study is to document this traditional knowledge and clinically test the antihypertensive capacity of three of the most commonly used wild plant species Mentha longifolia, Viola odorata and Urtica dioica. Ethno-pharmacological data was collected by personal interviews with herbalists and traditional healers using a semi structured survey questionnaire and assessing relative frequency of citation (RFC). The clinical study was conducted by a randomized, blind, placebo-controlled trial in 29 subjects with mild hypertension distributed in four groups, three plant extract treatments and one placebo. Systolic (SBP) and diastolic blood pressures (DBP) as well as mean arterial blood pressures (MAP) were monitored at weeks 4, 8, 12 and 16 during the treatment with 300 mL/day of plant extract. Results showed that M. longifolia, U. dioica and V. odorata exhibited the highest values of RCF (0.95) followed by Allium ampeloprasum (0.94), Apium graveolens (0.92) and Crataegus azarolus (0.90). The clinical trial revealed dose- and duration-dependent significant reductions in SBP, DBP and MAP of subjects treated with M. longifolia, U. dioica or V. odorata. Our findings indicate that extracts of these plants present an effective, safe and promising potential as a phyto-therapuetical approach for the treatment of mild hypertension. More research on the phytochemistry, pharmacological effects and the underlying mechanisms is necessary.

Prevalence, awareness, treatment, and control of hypertension in a small northern town in Nicaragua: The Elieth-HIFARI study

BACKGROUND AND AIMS

Hypertension is considered the most important risk factor for cardiovascular disease and is associated with high levels of morbidity, mortality, and health care expenditure. The negative effects of hypertension and its complications are preventable if those at risk are appropriately treated and controlled. Continually monitoring the epidemiological trends of hypertension is essential to formulate and evaluate public health measures to limit its negative effects. The herein presented Elieth-HIFARI study sought to estimate the prevalence of hypertension, as well as the prevalence of related awareness, treatment, and control in a small town in Central America.

METHODS

A population survey to assess cardiovascular risk was conducted (n = 577, 55.3% women, mean age 42.4 years) in the municipality of San Rafael del Norte in northern Nicaragua, between November 2016 and March 2017, based on the STEPwise method by the World Health Organization and the recommendations by the World Hypertension League.

RESULTS

The overall prevalence of hypertension, awareness, treatment, and control was 28.1%, 72.2%, 68.5%, and 36.4%, respectively. Men had a lower prevalence of all indicators (22.5%, 60.3%, 53.4%, and 24.1%, respectively) compared with women (32.6%, 78.8%, 76.9%, and 43.3%, respectively). The median systolic blood pressure was 118.5 mm Hg (20.5 interquartile range [IQR]) (men: 123.0 mm Hg vs women: 115.5 mm Hg, Mann-Whitney U test P < .001), and the mean diastolic blood pressure was 78.0 mm Hg (13 IQR) (men: 77.0, women: 78.0).

CONCLUSION

Hypertension is highly prevalent in San Rafael del Norte, while control rates are low despite the relatively higher levels of awareness and treatment. Furthermore, women have much higher prevalence of hypertension than men, along with higher awareness, treatment, and control. However, the control rate for those treated for hypertension was low, irrespective of sex.

HbA1c AND BLOOD PRESSURE MEASUREMENTS: RELATION WITH GENDER, BODY MASS INDEX, STUDY FIELD, AND LIFESTYLE IN LEBANESE STUDENTS

Objective: The purpose of this study is to determine the prevalence of prediabetes/diabetes in Lebanese university students and to examine the relationship between both hemoglobin A1c (HbA1c) and blood pressure (BP) and gender, body mass index (BMI), study field, and lifestyle factors. Methods: This cross-sectional study was carried out at the Saint-Joseph University of Beirut. A total of 603 students aged 18 to 25 years were recruited from both the medical science campus (MSC) and the social science campus (SSC) between January, 2016, and May, 2018. Waist circumference (WC), BMI, and BP were determined for each student and HbA1c was measured using the Siemens vintage DCA device. Participants completed a self-administered questionnaire about their eating habits and level of physical activity. Results: The mean age of the population was 20.31 ± 1.76 years. The percentage of participants recruited from the MSC was 59.2%. The prevalence of prediabetes was 2.5%. Lower BMI, WC, and HbA1c values, and higher diastolic BP (DBP) were found in MSC students compared to SSC ones. HbA1c, systolic BP (SBP), and DBP were correlated with BMI (P = .02, P<.0001, and P = .017, respectively). HbA1c was not associated with eating habits or physical activity. DBP was inversely associated with physical activity (P = .002), while SBP was positively associated with fast food consumption (P = .003). Conclusion: The present study shows a low prevalence of prediabetes in Lebanese students. BMI and the study field are the main factors predicting HbA1c and BP. Further studies are needed to extrapolate our results to the overall young Lebanese population. Abbreviations: ADA = American Diabetes Association; BMI = body mass index; BP = blood pressure; DBP = diastolic blood pressure; HbA1c = hemoglobin A1c; HTN = hypertension; MSC = medical science campus; SBP = systolic blood pressure; SSC = social science campus; T2D = type 2 diabetes; US = United States; USJ = Saint-Joseph University; WC = waist circumference.

Hypertension in Jordan: Prevalence, Awareness, Control, and Its Associated Factors

Objectives

Determine the prevalence, awareness, and control rates of hypertension and their associated factors among Jordanian adults.

Methods

A multistage sampling technique was used to select a nationally representative sample of adults from the population of Jordan. Trained interviewers collected data using a comprehensive structured questionnaire, measured anthropometric parameters, and collected blood samples.

Results

This study included a total of 1193 men and 2863 women aged ranged from 18 to 90 year with a mean (SD) of 43.8 (14.2) year. The age-standardized prevalence was 33.8% among men and 29.4% among women. Of those with hypertnsion, 57.7% of men and 62.5% of women were aware of hypertension. Only 30.7% of men and 35.1% of women who were on antihypertensive medications had their blood pressure controlled. From 2009 to 2017, there was nonsignificant decrease in hypertension prevalence of 2.7% among men and 1.1% among women. However, the rate of hypertension awareness increased significantly among men and among women.

Discussion

Almost one-third of Jordanian adults had hypertension. Interventions that target modifiable risk factors of hypertension, might decrease blood pressure, and even prevent the development of hypertension should be implemnted.

Prevalence, Awareness, and Control of Hypertension in Greater Beirut Area, Lebanon

Background

Hypertension (HTN) has been identified as the leading risk factor for mortality and the third cause of disability worldwide. Lebanon has witnessed a threefold increase in the prevalence of HTN in the past decade. The timely exploration and detection of the factors contributing to a higher prevalence of the disease among the Lebanese population is fundamental. The objectives of this study were to assess the prevalence, awareness, and control rates of HTN in Greater Beirut Area in Lebanon and to identify their respective predictors.

Methods

A representative sample of 501 participants aged 18-79 years residing in Greater Beirut Area was examined. Data collection form was filled up, through interviews, physical exams, and lab tests. The analysis was done for three defined outcomes: blood pressure status (normotensive, prehypertension, and hypertension), unaware HTN, and uncontrolled HTN. These were compared for the various associated predictors.

Results

The sample consisted of 64.3% women and mean age 45.4 ± 15 years and the subjects were predominantly from low educational income levels. The results showed that 36.4% of the study participants were hypertensive, 25.3% were prehypertensive, and 38.2% had optimal blood pressure, while the awareness rate was 65.4% and control rate was 61%. The independent predictors of HTN were age, gender, marital status, T2D, body fat, triglyceride (positive correlates), and income level (negative correlate). Moreover, unawareness of HTN was common among older age, men, single participants, and the obese. We could not identify any factor related to uncontrolled HTN.

Conclusion

The trend in the prevalence of HTN in Greater Beirut Area is found to be consistent and relatively high, yet there was an observed improvement in the awareness and control of the disease. Public health measures on a national level are urgently needed to curb the increasing prevalence of HTN, achieve primary prevention, and better control the disease.

Noncardiac Lebanese hospitalized adult patients' awareness of their coronary artery disease risk factors

BACKGROUND

Noncommunicable diseases are the leading cause of death in Lebanon, with cardiovascular diseases accounting for almost half of the annual deaths.

PURPOSE

We aimed to determine awareness of noncardiac Lebanese hospitalized patients for their coronary artery disease risk factors, their level of adherence to medications or lifestyle modifications, and assess factors associated with awareness.

MATERIALS AND METHODS

A cross-sectional study was conducted in 14 hospitals with a total of 382 patients. Levels of awareness were evaluated by the comparison of self-report with measurements and laboratory test results. Healthy behaviors and adherence to treatment were evaluated. Factors associated with better awareness were studied using multivariate regressions, while adherence to treatments and healthy lifestyle were described for the different risk factors and in the Framingham Risk Score categories.

RESULTS

Our work revealed a moderate-to-high level of awareness (58.7% for overweight/obesity, 75% for hypertension, 85.7% for diabetes, and 86.4% for dyslipidemia) among patients for most cardiovascular risk factors, but a low-to-moderate level of adherence for some interventions such as physical exercise, weight loss, and smoking cessation.

CONCLUSION

The results emphasize on the importance of educational campaigns on healthy habits and screening to improve early diagnosis, increase patients' awareness of their risk factors, and, therefore, optimize primary prevention.

Care and Discharge Outcome of Acute Stroke in Lebanon: A Hospital-Based Study

The present study was conducted to assess stroke care and outcomes in two Lebanese hospitals. Patients admitted in 2012 and 2013 were retrospectively selected. Data were extracted from medical records for time to hospital arrival, stroke severity, management, and discharge outcomes. A Cox regression analysis was then conducted to predict time to in-hospital death. A total of 201 patients were included (mean age = 69.2 years), among whom 50% arrived within a delay of 3.75 hours. Half underwent brain imaging in the first hour, and nine patients received an acute intervention. Forty-four patients died at the hospital; 142 were discharged home, among whom 98 patients were dependent in their daily activities. Stroke severity on admission and time from onset to arrival were found to be significantly associated to the time to in-hospital death (adjusted hazard ratio [HRa] = 1.13 and HRa = 0.98 respectively; p < 0.05). The study sheds light on high case fatality and dependency rates at discharge among stroke patients in Lebanese hospitals.

Correlations between health-promoting lifestyle and health-related quality of life among elderly people with hypertension in Hengyang, Hunan, China

Hypertension is considered as an important public health problem in developed and developing countries. The disease is closely associated with health-promoting lifestyle (HPL), and it seems that HPL plays an important role in improving health-related quality of life (HRQOL). This cross-sectional study is to investigate the effects of health-promoting lifestyle (HPL) on health-related quality of life in elderly people with hypertension from a community health service center in Hengyang, Hunan, PR China.Totally 530 elderly patients with hypertension from the community health service center were included in this study, who were asked to fill in a questionnaire (504 patients responded). HPL was assessed by the health-promoting lifestyle profile II (HPLP-II), and HRQOL was measured by the Short Form Health Survey Questionnaire (SF-36).HPL among these elderly people with hypertension was at moderate level (125.02 ± 21), with the highest score for nutrition and the lowest score for health responsibility. Moreover, HRQOL among these elderly hypertensive people was at moderate level (54.36 ± 21.18). Role-emotional domain score was far below average, vitality domain was a little below average, social functioning and general health domains were a little above average, and other domains were far above average. Furthermore, HPL and HRQOL were positively correlated (P < .01). According to the standardized regression coefficients, the influencing factors for HRQOL included (in a descending order) the health responsibility, physical activity, interpersonal relationships, stress management, spiritual growth, and nutrition.HPL and HRQOL were both relatively poor in the elderly people with hypertension from the community health service center. HPL represents an important factor affecting HRQOL of elderly people with hypertension. HRQOL could be improved through promoting HPL (such as health responsibility and physical activity).

A New Lebanese Medication Adherence Scale: Validation in Lebanese Hypertensive Adults

BACKGROUND

A new Lebanese scale measuring medication adherence considered socioeconomic and cultural factors not taken into account by the eight-item Morisky Medication Adherence Scale (MMAS-8). Objectives were to validate the new adherence scale and its prediction of hypertension control, compared to MMAS-8, and to assess adherence rates and factors.

METHODOLOGY

A cross-sectional study, including 405 patients, was performed in outpatient cardiology clinics of three hospitals in Beirut. Blood pressure was measured, a questionnaire filled, and sodium intake estimated by a urine test. Logistic regression defined predictors of hypertension control and adherence.

RESULTS

54.9% had controlled hypertension. 82.4% were adherent by the new scale, which showed good internal consistency, adequate questions (KMO coefficient = 0.743), and four factors. It predicted hypertension control (OR = 1.217; p value = 0.003), unlike MMAS-8, but the scores were correlated (ICC average measure = 0.651; p value < 0.001). Stress and smoking predicted nonadherence.

CONCLUSION

This study elaborated a validated, practical, and useful tool measuring adherence to medications in Lebanese hypertensive patients.

Prevalence and risk factors of hypertension: A nationwide cross-sectional study in Lebanon

There is limited epidemiologic data on hypertension (HTN) in Lebanon. This study aimed to determine the prevalence and associated risk factors of HTN in the adult Lebanese population and evaluate the association between dietary and psychological factors on systolic blood pressure (SBP). Cross-sectional analyses were conducted using a multistage cluster sample across Lebanon. A total of 2014 participants were included. The prevalence and control rates of HTN were 31.2% and 28.7%, respectively. In women, educational level and physical activity were negatively associated with HTN (P < .05 for both) and adherence to the Lebanese Mediterranean diet was associated with a lower SBP. Other factors were associated with HTN in men. There was no relationship with SBP and psychological distress. Of the modifiable risk factors, body mass index persisted as the only contributory factor in both sexes (P < .01). Accordingly, prevention of HTN at the population level should focus mainly on overweight prevention.

Prevalence, awareness, treatment, control and risk factors associated with hypertension in Lebanese adults: A cross sectional study

Background: The prevention and control of hypertension is an essential component for reducing cardiovascular disease burden. Hypertension is an important public health issue, yet few studies have examined its current status among the Lebanese population. Objective: To examine the prevalence, awareness, treatment and control of hypertension and its associated risk factors among Lebanese adults. Methods: A cross-sectional study was conducted between December 2014, and May 2015, on adults from the five districts of Lebanon. Multistage sampling was used to enroll participants. Hypertension was defined as an average of two blood pressure (BP) measurements with systolic/diastolic blood pressure of at least 140/90 mm Hg, using an automated digital device, or the use of antihypertensive medication. A questionnaire was used to assess hypertension risk factors, awareness, treatment and control. Results: Of the 1362 Lebanese adults interviewed, 399 (29.3%) had hypertension. Of these, 106 (26.5%) were aware of their condition. Sixty-nine patients (65%) of those aware, were receiving treatment, and 38 (55%) participants from those treated were controlled. The significant risk factors were sex, gender, age, family history of hypertension, obesity, and a low level of education. Conclusions: Hypertension is prevalent among the Lebanese adult population and is multifactorial, but remains incompletely recognized, leading to insufficient control. Hypertension was highly prevalent in males in the age category 18-29 years. These findings show that improvements in detection, treatment, and control of hypertension among Lebanese adults, is much needed.

Gender disparities in midlife hypertension: a review of the evidence on the Arab region

Objective

While gender differences in hypertension and increased prevalence rates among women at midlife have been documented in multiple settings, the evidence on the Arab world has not been systematically examined. This review summarizes the evidence related to gender disparities in midlife hypertension in this region.

Methods

We searched MEDLINE and Social Sciences Citation Index (SSCI) databases for studies, published between January 2000 and August 2015, on hypertension in the 22 countries of the Arab region. We abstracted information on the prevalence of hypertension among women and men, in general populations during midlife.

Results

Nineteen studies provided data on the prevalence of hypertension by gender and age in the Arab world. Higher rates of hypertension were found among Arab women at midlife in most countries. In studies that included subjects younger than 35 years old, a decrease in sex ratios (M/F) at midlife was observed in all countries except Palestine. Higher female prevalence rates are observed in the 4^th decade of life in most countries of the region, almost two decades earlier than in other parts of the world.

Conclusions

This review highlights the need for more systematic examinations of hypertension in the Arab region, its risk factors, and the reasons for the particular patterns of gender differences that are observed. Such research would have considerable implications for prevention, treatment, and improved well-being.

Adherence to treatment and evaluation of disease and therapy knowledge in Lebanese hypertensive patients

BACKGROUND

Adherence to treatment, healthy lifestyle, physical activities, smoking, diet, and salt intake are important factors to control for an effective decrease in blood pressure (BP) values for patients diagnosed with essential hypertension (HT). The aim of this work was to study the adherence to antihypertensive treatment and factors predicting this behavior in Lebanese patients. In addition, we evaluated the extent of patient's knowledge and perceptions about HT, risk factors, and medication side effects.

METHODS

The cross-sectional study was conducted between May and September 2015 among 249 participants randomly recruited from community and hospital pharmacies (56.6%), private cardiology clinics (37%), and outpatient clinics located in hospitals (6.4%) in Baabda region of Lebanon. The questionnaire was prepared after reviewing published literature. Data were collected by trained and certified interviewers and analyzed by Statistical Package for the Social Sciences program. p-value less than 0.05 was considered to determine the statistical significance.

RESULTS

Among the 249 patients interviewed, 48% were females with a mean age of 62±17.2 years. Overweight and obesity was declared in 42.2% and 35.3%, respectively. Only 52.6% of participants reported visiting their physicians for regular checkups, and 72% claimed checking their BP routinely at home. Awareness of complications related to HT was very high (97%). However, our results showed that 89.2% of the participants were found to be adherent to treatment, and forgetfulness was cited as the main reason for non-adherence to therapy. Only health coverage showed statistical significance (p=0.01) between adherent and non-adherent participants.

CONCLUSION

A better communication between patients and their physicians, the use of a special container for medication packaging, and reminder to refill prescriptions are important parameters to enhance adherence to treatment. HT can be better managed if an educational system is implemented to increase awareness.

The epidemiology of stroke in the Middle East

Purpose

The purpose of this paper is to review and synthesize data from different countries in the Middle East on stroke and its potential risk factors.

Method

A systematic review of all published stroke articles in the Middle East between 1980 and May 2015 was conducted.

Findings

Sixty-four papers were included in the review. The incidence rate for all strokes ranged between 22.7 and 250 per 100,000 population per year. The prevalence rate for stroke ranged between 508 and 777 per 100,000 population. Among studies reporting gender differences, 75% reported a high male-to-female ratio among stroke patients. The mean age of stroke was within the sixth and the seventh decade. Ischemic stroke was the most reported type followed by intracerebral hemorrhage and subarachnoid hemorrhage. Hypertension was the most reported risk factor followed by diabetes. The overall case-fatality rate within one month was 12-32%.

Discussion

During the last decades, there was an increase in stroke incidence and mortality rates in the Middle East. The Middle East faces low rates of self-awareness and control of noncommunicable diseases and also lacks knowledge for stroke risk factors, awareness, causes, and symptoms.

Conclusion

There is an urgent need to develop more efficient and accurate methods to measure stroke in the Middle East. There is also a significant call to increase public awareness and implement interventions on stroke and its risk factors and symptoms to help people understand the negative impact of stroke on quality of life and potentially prevent this disease.

Pre-hypertension, pre-diabetes or both: which is best at predicting cardiovascular events in the long term?

The present study aimed to assess the value of pre-diabetes and pre-hypertension in predicting cardiovascular events. A population-based, cross-sectional survey was conducted, representing a large sample of the general Iranian population aged 35 years and older from the Isfahan Province and determined using a random, multistage cluster-sampling 10-year cohort. The five end points considered as study outcome were unstable angina (UA), acute occurrence of myocardial infarction (MI), sudden cardiac death (SCD), brain stroke and cardiovascular disease (CVD). Of the 6323 subjects scheduled for assessment of diabetes state 617 were diabetics and 712 were pre-diabetic. In addition, of these subjects, 1754 had hypertension and 2500 had pre-hypertension. Analysing only pre-hypertension, pre-diabetes and its combination and adjusted for gender and age variables, pre-hypertension and pre-diabetes status together, could only effectively predict occurrence of MI (hazard ratio (HR)=3.21, 95% confidence interval (CI): 1.06-9.76, P=0.04). In the same COX regression models, pre-hypertension status could predict UA and CVD occurrence (HR=2.94, 95% CI: 1.68-5.14, P<0.001 and HR=1.74, 95% CI: 1.23-2.47, P=0.002, respectively). However, pre-diabetes status could not predict any of these events after adjustment for gender and age. Our data provide valuable evidence of the triggering role of pre-hypertension and pre-diabetes together, on appearance and progression of MI even in healthy individuals and the significant predicting value of pre-hypertension on the occurrence of UA and CVD. In this regard, the value of pre-hypertension and pre-diabetes together, and the pre-hypertension state alone, are clearly superior to pre-diabetes state alone in predicting cardiovascular events.

Prevalence of Hypertension in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

We aimed to obtain overall and regional estimates of hypertension prevalence, and to examine the pattern of this disease condition across different socio-demographic characteristics in low-and middle-income countries. We searched electronic databases from inception to August 2015. We included population-based studies that reported hypertension prevalence using the current definition of blood pressure ≥140/90 mm Hg or self-reported use of antihypertensive medication. We used random-effects meta-analyses to pool prevalence estimates of hypertension, overall, by World Bank region and country income group. Meta-regression analyses were performed to explore sources of heterogeneity across the included studies. A total of 242 studies, comprising data on 1,494,609 adults from 45 countries, met our inclusion criteria. The overall prevalence of hypertension was 32.3% (95% confidence interval [CI] 29.4-35.3), with the Latin America and Caribbean region reporting the highest estimates (39.1%, 95% CI 33.1-45.2). Pooled prevalence estimate was also highest across upper middle income countries (37.8%, 95% CI 35.0-40.6) and lowest across low-income countries (23.1%, 95% CI 20.1-26.2). Prevalence estimates were significantly higher in the elderly (≥65 years) compared with younger adults (<65 years) overall and across the geographical regions; however, there was no significant sex-difference in hypertension prevalence (31.9% vs 30.8%, P = 0.6). Persons without formal education (49.0% vs 24.9%, P < 0.00001), overweight/obese (46.4% vs 26.3%, P < 0.00001), and urban settlers (32.7% vs 25.2%, P = 0.0005) were also more likely to be hypertensive, compared with those who were educated, normal weight, and rural settlers respectively. This study provides contemporary and up-to-date estimates that reflect the significant burden of hypertension in low- and middle-income countries, as well as evidence that hypertension remains a major public health issue across the various socio-demographic subgroups. On average, about 1 in 3 adults in the developing world is hypertensive. The findings of this study will be useful for the design of hypertension screening and treatment programmes in low- and middle-income countries.

Prevalence of Lebanese stroke survivors: A comparative pilot study

Stroke is a leading cause of morbidity and mortality worldwide and its late burden has mainly been attributable to developing countries. Lebanon is one of these countries where epidemiological studies on stroke burden are scarce but necessary. Thus, the present study was conducted to assess the prevalence of stroke survivors among Lebanese inhabitants. A cross-sectional survey was carried out using randomly selected landline phone numbers on all governorates to retrieve data on stroke survivors and their sociodemographic characteristics. Results were then standardized over the Lebanese and the World Health Organization (WHO) world populations. A total of 6963 Lebanese inhabitants were included in the study; among these were 56 stroke survivors. This led to an adjusted stroke prevalence of 0.50% [95% confidence interval (CI) = 0.33–0.66%] and a world-standardized prevalence of 0.60% (95% CI = 0.42–0.78%). A significantly higher stroke prevalence was found among older age groups and more socioeconomically privileged areas. Overall, the study showed a relatively higher prevalence of stroke in this sample of Lebanese inhabitants when compared to other developing countries. However, larger community-based studies with a clinical assessment of stroke cases are needed to confirm our findings.