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Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria)
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Original article
Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria) Différences de prévalence, de traitement et de contrôle de l’hypertension entre hommes et femmes dans la région de Blida (Algérie) A. Bachir Cherif a,∗ , A. Bouamra b , A. Taleb a , R. Nedjar a , A. Bouraghda a , F. Hamida a , M. Temmar c , M.T. Bouafia a a
Department of internal medicine and cardiology, Blida University Hospital, 09000 Algeria b Department of epidemiology, Blida University Hospital, 09000 Algeria c Center of cardiology and angiology, 47000 Ghardaïa, Algeria Received 17 April 2017; accepted 27 April 2017
Abstract Purpose. – To compare differences in prevalence rates, treatment and control of hypertension (AHT) between males and females in general medicine consultation in the area of Blida (Algeria). Methods. – We included 3622 patients in the study (42% males and 58% females), with a mean age of 48.14 ± 10.11 years, examined between January 2014 and June 2016 in general medicine consultation in the area of Blida (Algeria). Data was collected with individual questionnaires. Measurement of blood pressure was made using validated semi-automatic devices (OMRON HEM model 705CP). Individuals using antihypertensive drugs and/or blood pressure (BP) greater than or equal to 140/90 mmHg were considered as hypertensives. The knowledge about the disease was identified among those who claimed to be aware of the diagnosis before the measurements. The treatment rate was calculated with those who reported using antihypertensive drugs. Controlled blood pressure was considered in individuals with values lower than 140/90 mmHg. Lipid profile (total cholesterol, triglycerides, HDL and LDL cholesterol), and fasting blood sugar were measured. All calculations and statistical analyses are processed by the SPSS 20.0. Results. – The prevalence of hypertension was higher among men (46.2%) than women (31.6%) (P < 0.001), and among aged over 55 years (P< 0.05) and those that have referred hypertensive parents (P < 0.05). Among hypertensive men, 55.7% knew the diagnosis, 63.6% of them were under treatment, and 22% had controlled BP. Among the hypertensive women 69.8% knew the diagnosis, 85.1% were under treatment and 35.6% were with controlled BP (P < 0.001 for the three variables). The most frequent associated risk factors were diabetes mellitus in 36.8% of the patients, obesity in 35.7% of the patients, microalbuminuria in 23.6% of the patients, hypercholesterolemia > 2 g/L in 11.6% of the patients, smoking in 7.7% of them. Presence of controlled AHT was not found to be associated with presence of other risk factors. The likelihood of having AHT was higher among men, diabetics, older subjects and higher BMI. Conclusion. – Our study confirmed the high prevalence of AHT in general medicine consultation in Blida, which is a representative city in the north of Algeria. Although women are better treated, much remains to be done to reach BP goal, much in our countries which have the least financial resources to combat cardiovascular disabilities. © 2017 Elsevier Masson SAS. All rights reserved. Keywords: Hypertension; Sex; Prevalence; Treatment; Control; Risk factors; Blida
Résumé Objectif. – Comparer les différences entre les taux de prévalence, de traitement et de contrôle de l’hypertension (HTA) chez les hommes et les femmes dans une consultation de médecine générale dans la région de Blida (Algérie). ∗
Corresponding author. E-mail address: [email protected] (A. Bachir Cherif).
http://dx.doi.org/10.1016/j.ancard.2017.04.009 0003-3928/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Bachir Cherif A, et al. Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria). Ann Cardiol Angeiol (Paris) (2017), http://dx.doi.org/10.1016/j.ancard.2017.04.009
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Méthodes. – Nous avons inclus 3622 patients (42 % hommes), avec un âge moyen de 48,14 ± 10,11 ans, examinés entre janvier 2014 et juin 2016 en consultation de médecine générale dans la région de Blida (Algérie). Les données ont été recueillies sur un questionnaire individuel. La mesure de la pression artérielle a été réalisée à l’aide de tensiomètres électroniques validés (OMRON HEM modèle 705CP). Les personnes prenant des médicaments antihypertenseurs et/ou ayant une pression artérielle (PA) supérieure ou égale à 140/90 mmHg étaient considérées comme hypertendues. Le taux de traitement a été calculé avec ceux qui ont déclaré prendre des médicaments antihypertenseurs. La PA était considéré comme contrôlée lorsqu’elle était inférieure à 140/90 mmHg. Bilan lipidique (cholestérol total, triglycérides, cholestérol HDL et LDL) et mesure de la glycémie à jeun ont été effectués. Tous les calculs et analyses statistiques sont traités par le logiciel SPSS 20.0. Résultats. – La prévalence de l’hypertension était plus élevée chez les hommes (46,2 %) que chez les femmes (31,6 %) (p < 0,001), et les plus de 55 ans (p < 0,05). Parmi les hommes hypertendus, 55,7 % connaissaient le diagnostic, 63,6 % étaient sous traitement, et la PA était contrôlée chez 22 % d’entre eux. Parmi les femmes hypertendues, 69,8 % connaissaient le diagnostic, 85,1 % étaient sous traitement et 35,6 % étaient contrôlées (p < 0,001 pour les trois variables). Les facteurs de risque associés les plus fréquents étaient le diabète sucré chez 36,8 % des patients, l’obésité chez 35,7 %, micro-albuminurie chez 23,6 %, l’hypercholestérolémie > 2 g/L chez 11,6 %, le tabagisme chez 7,7 % d’entre eux. L’HTA contrôlée n’était associée à la présence ou non de facteurs de risque associés. La probabilité d’avoir une HTA était plus élevée chez les hommes, les diabétiques, les sujets âgés et lorsque l’IMC était élevé. Conclusion. – Notre étude a confirmé la forte prévalence de l’HTA en consultation de médecine générale à Blida, ville représentative du nord de l’Algérie. Bien que les femmes soient mieux traitées, il reste beaucoup à faire pour atteindre l’objectif thérapeutique, surtout dans nos pays qui ont le moins de ressources financières pour lutter contre les complications cardio-vasculaires. © 2017 Elsevier Masson SAS. Tous droits réservés. Mots clés : Hypertension ; Sexes ; Prévalence ; Traitement ; Contrôle ; Facteurs de risque ; Blida
1. Introduction With over one billion people affected, high blood pressure (hypertension) is a global public health problem. Uncontrolled, it causes serious cardiovascular events such as stroke, heart failure and coronary insufficiency, for which it multiplies the risk by nine, five and three, respectively [1]. Three-quarters of hypertensive patients in the world will be in developing countries in 2025, according to epidemiological forecasts [2]. The emergence of many environmental risk factors in the general population due to globalisation, urbanization and rapid change of lifestyle explains this evolution [3]. In the area of Blida (city at 30 km far from the capital Algiers), there is no data on the characteristics of arterial hypertension (AHT), its control, as well as associated cardiovascular risk factors (RFs). It seemed useful to study the profile of our hypertensive subjects. 2. Objective To compare the prevalence rate of arterial hypertension between men and women in general medicine consultations. To evaluate the control rate of hypertensive patients under antihypertensive drugs therapy. And to research the frequency of associated cardiovascular risk factors in the hypertensive population in Blida. 3. Materials and methods It is a retrospective study over two years (between January 2014 and June 2016), on a population followed in general medicine consultations in the department of internal medicine and cardiology of the university hospital centre of Blida
(Algeria); having included 3622 subjects aged 18 years and more, of both sexes. The control consisted of completing a questionnaire which included anthropometric characteristics, life habits, personal and family medical history, supplemented by a clinical examination including: • epidemiological parameters (age, occupation, sex, home, tobacco consuming); • weight, height, waist and hip circumferences were also measured at the same day. The body mass index (BMI) was calculated by the equation: weight (kg)/height2 (m2 ). We define obese subjects (BMI ≥ 30 kg/m2 ), overweight (BMI between 25 and 29.99 kg/m2 ), normal weight (BMI between 18.5 and 24.99 kg/m2 ); • blood pressure (BP) was measured three times at two minutes intervals after five minutes of rest in the sitting position, using a validated electronic tensiometer (Omron705 CP) [4]. The average of the last two measurements was used for the statistical analysis [5].
AHT was defined as systolic BP (SBP) greater than or equal to 140 mm Hg or diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or both, or continuous administration of antihypertensive drug therapy [6]. Blood chemistry, including fasting glucose, total cholesterol (CT), HDL cholesterol, LDL cholesterol, triglycerides, blood creatinine and microalbuminuria, was measured under fasting conditions according to standard techniques. For the diagnosis of metabolic syndrome (MS), we used the definition of NCEP ATP III [7], according to which at least three of the following five criteria must be found:
Please cite this article in press as: Bachir Cherif A, et al. Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria). Ann Cardiol Angeiol (Paris) (2017), http://dx.doi.org/10.1016/j.ancard.2017.04.009
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• the abdominal circumference greater than 102 cm for men and > 88 cm for women; • triglycerides (TG) greater than 1.5 g/L; • HDL-cholesterol less than 0.4 g/L in men and less than 0.5 g/L in women; • BP greater than 130/85 mmHg or antihypertensive drugs therapy; • fasting blood glucose in excess of 1.1 g/L.
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Table 2 Hypertension prevalence according to sex and age. Age (years)
Men (%)
Women (%)
P
All < 40 40–50 50–65 60–70
42.2 6.4 16.8 41.4 35.4
31.6 12.2 20.3 36.9 30.6
< 0.001 0.05 0.05 0.001 0.001
4. Statistical study The analysis of the data was carried out using the SPSS 20.0 software. Only the variables associated with the dependent variable at a threshold of less than 20% were subjected to multivariate analysis using dichotomous logistic regression using the descending step procedure. The trend test (2 of Mantel) was used to choose the optimal threshold for dichotomising the variables with several levels of exposure (classes of a quantitative variable). The Mantel-Haenszel 2 was used as an adjustment test to neutralize the effect of a variable third in the study of the relationship between two variables. The test of the Breslow index was used to demonstrate an interaction introduced by a third variable in the study of the relationship between two variables. The Mann-Whitney test (Kruskal-Wallis test for two groups) was used to compare two averages when the reference to the normal distribution was not possible and/or when the Bartlett test showed that the variance of the two groups differed significantly. 5. Results The anthropometric, clinical and biological characteristics of the population are presented in Table 1. Our study population was composed of more women than men (58% versus 42% for men, P <0.01). Mean age was 48.6 ± 13.5 years. Women were on average overweight (mean BMI at 29.5 ± 5.5kg/m2 ) compared to men (mean BMI at 26.9 ± 4.5 kg/m2 ). Waist and hip circumferences were slightly higher among women than men. There was a higher levels of cholesterolemia and less HDLemia in women, with significant
difference (P <0.01), and higher triglyceridemia among women compared to men, without difference in plasma glucose. Haemodynamically, SBP and DBP were significantly higher in men than in women, without difference in heart rate (HR) between the two genders. According to gender, metabolic syndrome was higher in women than in men, with a very significant difference (21.7% versus 13.2%, P <0.001). Prevalence of hypertension was higher in men than in women (46.2% versus 31.6% in women) with a very significant difference (P <0.001) (Table 2). Depending on the age group, the highest prevalence was observed in the 50 to 65 age group. According to gender, hypertension was predominant among men, also for the age range 50–65 (Table 2). As shown in Fig. 1, the control of hypertension was reached only in 30%. Control of DBP is more important than SBP with a significant difference (P <0.001). According to gender, control of BP is 35% in women and 22% in men with a significant difference (P <0.001). As shown in Table 3, the most common risk factors (RFs) associated with hypertension were diabetes in 36.8% followed by obesity in 35.7%, microalbuminuria in 23.6%, high CT in 11.6% and finally smoking in 7.7%. According to gender, no significant difference was found for high CT between men and women (10.5% versus 11.6%, P = 0.42). Smoking concerned almost exclusively male with a prevalence of 17.5% for men and 0.5% for women, with a very significant difference (P <0.001).
Table 1 General characteristics of the population in the region of Blida. Parameters
Global (n = 3622)
Men (n = 1585)
Women (n = 2037)
P
Repartition (%) Mean age (years) Weight (kg) Height (cm) Waist circumference (cm) Hip circumference (cm) BMI (kg/m2 ) HR (beats/min) SBP (mmHg) DBP (mmHg) Glycemia Total cholesterol (g/L) Triglycerides (g/L) HDL cholesterol (g/L) Metabolic syndrome (%)
100 48.62 ± 13.5 75.5 ± 15.1 163.1 ± 9.1 86.3 ± 12.5 108.5 ± 10.8 28.4 ± 5.28 78.2 ± 14.5 150.7 ± 23.4 90.6 ± 14.1 1.16 ± 0.48 1.84 ±0.5 1.41 ± 0.8 0.45 ± 1.29 17.9
42 50.09 ± 13.2 78.1 ± 14.9 170.1 ± 6.9 84.7 ±12.8 104.9 ± 9.3 26.9 ± 4.5 76.6 ± 14.9 155.5 ± 22.9 92.8 ± 14.4 1.17 ± 0.44 1.77 ± 0.4 1.45 ± 0.8 0.42 ± 1.21 13.2
58 47.78 ± 13.4 73.6 ± 14.9 157 ± 6.7 89.5 ± 12.4 111.1 ± 11.1 29.5 ± 5.5 80.5 ± 15.1 147.2 ± 23.3 89.1 ± 13.5 1.15 ± 0.5 1.90 ± 0.4 1.38 ± 0.8 0.47 ± 1.3 21.7
0.01 0.2 0.2 0.1 0.08 0.01 0.09 0.4 0.04 0.05 0.4 0.01 0.02 0.05 0.001
Please cite this article in press as: Bachir Cherif A, et al. Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria). Ann Cardiol Angeiol (Paris) (2017), http://dx.doi.org/10.1016/j.ancard.2017.04.009
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70%
DBP <90
43
40%
35.6 27.2
SBP<140
52.8
47.9
50%
30%
p< 0.001
59.6
60%
< 140/90
36.3 30
22.2
20% 10% 0%
Men
Women
All
Fig. 1. BP control rate and according to sex. Table 3 Frequency of association of risk factors with hypertension.
Smoking High cholesterol Obesity Diabetes Microalbuminuria
Global (%)
Men (%)
Women (%)
P
7.7 11.6 35.7 36.8 23.6
17.5 10.5 23.1 39.5 24.3
0.5 12.4 44.9 34.7 23.1
0.001 0.13 0.001 0.49 0.81
For diabetes and microalbuminuria, there was no difference between the two sexes in their association with hypertension. For obesity, the predominance was for women in 44.9% versus only 23.1% for men with a very significant difference (P <0.001) (Table 3). In the bivariate analysis of the control of BP, with presence of cardiovascular RFs, all the factors that had an influence on the control of hypertension were selected. Among them were the male sex, age over 40, high CT, smoking status, diabetes mellitus, metabolic syndrome, tachycardia and renal insufficiency, with a very significant difference compared to those without these RFs (P <0.02) (Table 4). In the multivariate analysis, after neutralizing the various parameters, among the risk factors responsible for the noncontrol of BP in our hypertensive population, we found male sex, age over 40 years, renal insufficiency and diabetes, with a very significant difference (P <0.001). There is less influence of the metabolic syndrome and the acceleration of heart rate. No influence of high triglyceridemia and smoking on the BP control rate was found in our study (Table 5). 6. Discussion This survey of the hypertensive population provided important data on the associated cardiovascular risk factors and the rate of control of BP in Blida, Algeria. These data may serve not only for the public health subsequent studies, but also as an effective strategy for the control of hypertension and other RFs to avoid cardiovascular complications. Hypertension was associated with diabetes in 36.8% of patients, obesity in 35.7%, hypercholesterolemia in 11.6% and
7.7% in smoking, results slightly comparable to the ACE study which found a prevalence of diabetes of 24%, obesity of 37%, high CT of 14% and smoking of 14%. The THALES survey (2006 data on general practitioners) indicates that 19% of hypertensive patients are obese, 14% have associated type 2 diabetes and 38% dyslipidemia [8]. In the older PHENOMEN study of 16,358 hypertensive patients, 60% had dyslipidemia, 19% smoking, and 16% diabetes [9]. The prevalence of hypertension was also independently associated with diabetes and waist circumference. These observations have been widely reported by other authors [10–12]. In our study, we have a clear feminine predominance of MS. Other studies in general populations also noted a clear predominance among women. The prevalence of MS in Senegal is 15.7%, predominantly in female patients 20% versus 5.2% in men, P <0.01 [13]. The study of Hamida and al in South Algeria found a prevalence of MS is 38% in the general population of ElMenia. It was significantly higher in women than in men and in black women in particular (P <0.01) [14]. In a previous study, we found that MS frequency was 20.8%, more frequent among women than among men, with a significant difference (28.4% versus 15.1%, P < 0.001) [15]. The control of BP in our study was 30%. These results show an improvement in the management of AHT compared to the principal previous studies in Algeria which were 14% of treated hypertensives in the SAHA (Algerian Society of Hypertension) study in 2004 [16]. 20% in the oasis of El-Menia in 2010 for Hamida and al. In 2014, according to our previous study [14], the control of BP in South Algeria was 28.2%. In Africa, the degree of control of hypertension among those in care is 42.4% in Kisangani. Damasceno et al. reported an average control rate of 33.1% in Mozambique [17]. In USA, the level of blood pressure control was 53% showing a significant progress in the management of hypertension [18,19]. The levels of control varied widely from country to country, and also from region to region. Controlled blood pressure in France, of the order of 40% during the years 2000, has markedly improved, reaching 50% in treated hypertensive patients, but remains below the objective expected for the last 5 years, according to the national nutrition health survey (ENNS) in 2006, and the FLASH survey in 2015 [20,21]. Otherwise, the therapeutic goal is achieved in 63% of patients treated
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Table 4 Relationship of risk factors with the control of blood pressure at the end of the bivariate analysis. Associated factors
All
Controlled HTA
Bivariate analysis OR CI 95%
P value
Sex Women Men
1585 2037
234 529
1 1.31
1.23–1.38
< 0.001
Age (years) < 40 > 40
237 2787
82 673
1 1.05
1.05–1.08
< 0.001
Diabetes No Yes
641 2060
193 560
1 1.08
0.98–1.08
< 0.08
Tobacco No Yes
2482 219
708 45
1 1.45
1.08–2.05
< 0.01
Nephropathy No Yes
2617 73
736 11
1 2.16
1.14–4.09
< 0.01
Cholesterol No Yes
2531 167
695 57
1 1.02
1.02–1.04
< 0.04
821 449
203 138
1 1.35
1.01–1.23
< 0.02
851 1893
261 501
1 1.42
1.09–1.13
< 0.01
Metabolic syndrome No Yes Heart rate < 70 bpm > 70 bpm
Table 5 Characteristics for which the analysis was continued but which were eliminated at the end of the multivariate analysis of the factors finally linked to the poor control of the BP. Associated factors
All
Controlled HTA
Multivariate analysis OR CI 95%
P value
Sex Women Men
1162 1583
234 529
2.08
1.6–3.3
< 0.001
Age (years) < 40 > 40
237 2787
82 673
2.2
1.33–3.6
< 0.02
Diabetes No Yes
641 2060
193 560
1.34
1.01–2
< 0.05
Nephropathy No Yes
2617 73
736 11
3.95
1.1–12.5
< 0.01
821 449
203 138
1.42
1.04–1.75
< 0.06
851 1893
261 501
1.26
1.09–1.67
< 0.08
Metabolic syndrome No Yes Heart rate < 70 bpm > 70 bpm
in England in 2011 [22], and 71.5% in Germany between 2008 and 2011 [23]. In our study, control of BP was better in women than in men (35.6% versus 22% in males, P <0.001). As in most international surveys, blood pressure control in treated hypertensive patients
is more satisfactory in women. On the whole, the women had a better control status than the men in Africa [17]. The same trends were found in the USA according to NHANES 2014 where a higher percentage of women had controlled hypertension (56.3%) comparing to men (50.6%) [19]. For J. Inamo et al.,
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Control is better in women (61.3 vs. 38.6% in men) [1]. In the ENNS study (18–74 years), control of hypertension was more common in women (58%) than for men (42%), and in MONALISA study, 39% for women (35 years–74 years) and 24% for men (35 years–74 years) [24]. The most characteristic feature found in this study is the importance of the disparity between men and women in the treatment and control of hypertension. The presence of cardiovascular RFs (such as diabetes, metabolic syndrome, microalbuminuria and male sex) in our study population has an influence on the non-control of BP except for dyslipidemias which have no effect on the degree of decline of BP. Various RFs were found associated with high prevalence and poor control of BP in South Africa [25]. In the PHARE study [26,27], insufficient control of systolic blood pressure is linked to the prevalence of associated risk cofactors (overweight, dyslipidemia, smoking habits, alcohol consumption, diabetes). In this study, it appears that the risk of these hypertensive patients does not depend solely on the blood pressure figure but above all on the cofactors. The associated risk factors therefore appear both as a factor of non-control and as a determining factor in the risk incurred by the patient. In NHANES 2009 study showed that in hypertensives, the association of other cardiovascular risk factors increases the difficulty of reaching the blood pressure objective [18]. 7. Conclusion Our study confirmed the high prevalence of AHT and associated cardiovascular RFs in Blida (Algeria), which is a representative city in the north of the country. Although women are better treated, much remains to be done to reach BP goal for themselves and also for the rest of the patients. The opening of specialized AHT consultation becomes essential; with training and sensitisation of medical, paramedical and administrative teams, and computerization of patients followup files. Lastly, information and teaching campaigns to patients and general public will certainly improve the results already achieved. The type of study can help public authorities to establish a program of action against public health scourges. In Blida, it becomes urgent to intensify the management of our hypertensive patients to avoid disabilities which still represent a greater financial and social burden. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments The authors are grateful to the resident doctors (Hachemi Amina and Mesbah Ghania) and to the assistant researcher, Mrs Soum Kheira, for participating in this study.
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[23] Falaschetti E, Mindell J, Knott C, Poulter N. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet 2014;383:1912–9. [24] État des lieux de l’hypertension artérielle en France en 2007: l’étude MONALISA. BEH thématique 49–50; 483, 2008. [25] Peltzer K, Phaswana-Mafuy NA. Hypertension and associated factors in older adults in South Africa. Cardiovas J Afr 2013;24(3).
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[26] Chamontin B, Poggi L. Prevalence, treatment and control of hypertension in the French population data from a survey on high BP in general practice in 1994. Am J Hypertens 1998;11:759–62. [27] Chamontin B, Lang T. Hypertension artérielle et facteurs de risques cardiovasculaires associes chez les diabétiques. Arch Mal Coeur Vaiss 2001;94:869–73.
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Original article
Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria) Différences de prévalence, de traitement et de contrôle de l’hypertension entre hommes et femmes dans la région de Blida (Algérie) A. Bachir Cherif a,∗ , A. Bouamra b , A. Taleb a , R. Nedjar a , A. Bouraghda a , F. Hamida a , M. Temmar c , M.T. Bouafia a a
Department of internal medicine and cardiology, Blida University Hospital, 09000 Algeria b Department of epidemiology, Blida University Hospital, 09000 Algeria c Center of cardiology and angiology, 47000 Ghardaïa, Algeria Received 17 April 2017; accepted 27 April 2017
Abstract Purpose. – To compare differences in prevalence rates, treatment and control of hypertension (AHT) between males and females in general medicine consultation in the area of Blida (Algeria). Methods. – We included 3622 patients in the study (42% males and 58% females), with a mean age of 48.14 ± 10.11 years, examined between January 2014 and June 2016 in general medicine consultation in the area of Blida (Algeria). Data was collected with individual questionnaires. Measurement of blood pressure was made using validated semi-automatic devices (OMRON HEM model 705CP). Individuals using antihypertensive drugs and/or blood pressure (BP) greater than or equal to 140/90 mmHg were considered as hypertensives. The knowledge about the disease was identified among those who claimed to be aware of the diagnosis before the measurements. The treatment rate was calculated with those who reported using antihypertensive drugs. Controlled blood pressure was considered in individuals with values lower than 140/90 mmHg. Lipid profile (total cholesterol, triglycerides, HDL and LDL cholesterol), and fasting blood sugar were measured. All calculations and statistical analyses are processed by the SPSS 20.0. Results. – The prevalence of hypertension was higher among men (46.2%) than women (31.6%) (P < 0.001), and among aged over 55 years (P< 0.05) and those that have referred hypertensive parents (P < 0.05). Among hypertensive men, 55.7% knew the diagnosis, 63.6% of them were under treatment, and 22% had controlled BP. Among the hypertensive women 69.8% knew the diagnosis, 85.1% were under treatment and 35.6% were with controlled BP (P < 0.001 for the three variables). The most frequent associated risk factors were diabetes mellitus in 36.8% of the patients, obesity in 35.7% of the patients, microalbuminuria in 23.6% of the patients, hypercholesterolemia > 2 g/L in 11.6% of the patients, smoking in 7.7% of them. Presence of controlled AHT was not found to be associated with presence of other risk factors. The likelihood of having AHT was higher among men, diabetics, older subjects and higher BMI. Conclusion. – Our study confirmed the high prevalence of AHT in general medicine consultation in Blida, which is a representative city in the north of Algeria. Although women are better treated, much remains to be done to reach BP goal, much in our countries which have the least financial resources to combat cardiovascular disabilities. © 2017 Elsevier Masson SAS. All rights reserved. Keywords: Hypertension; Sex; Prevalence; Treatment; Control; Risk factors; Blida
Résumé Objectif. – Comparer les différences entre les taux de prévalence, de traitement et de contrôle de l’hypertension (HTA) chez les hommes et les femmes dans une consultation de médecine générale dans la région de Blida (Algérie). ∗
Corresponding author. E-mail address: [email protected] (A. Bachir Cherif).
http://dx.doi.org/10.1016/j.ancard.2017.04.009 0003-3928/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Bachir Cherif A, et al. Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria). Ann Cardiol Angeiol (Paris) (2017), http://dx.doi.org/10.1016/j.ancard.2017.04.009
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Méthodes. – Nous avons inclus 3622 patients (42 % hommes), avec un âge moyen de 48,14 ± 10,11 ans, examinés entre janvier 2014 et juin 2016 en consultation de médecine générale dans la région de Blida (Algérie). Les données ont été recueillies sur un questionnaire individuel. La mesure de la pression artérielle a été réalisée à l’aide de tensiomètres électroniques validés (OMRON HEM modèle 705CP). Les personnes prenant des médicaments antihypertenseurs et/ou ayant une pression artérielle (PA) supérieure ou égale à 140/90 mmHg étaient considérées comme hypertendues. Le taux de traitement a été calculé avec ceux qui ont déclaré prendre des médicaments antihypertenseurs. La PA était considéré comme contrôlée lorsqu’elle était inférieure à 140/90 mmHg. Bilan lipidique (cholestérol total, triglycérides, cholestérol HDL et LDL) et mesure de la glycémie à jeun ont été effectués. Tous les calculs et analyses statistiques sont traités par le logiciel SPSS 20.0. Résultats. – La prévalence de l’hypertension était plus élevée chez les hommes (46,2 %) que chez les femmes (31,6 %) (p < 0,001), et les plus de 55 ans (p < 0,05). Parmi les hommes hypertendus, 55,7 % connaissaient le diagnostic, 63,6 % étaient sous traitement, et la PA était contrôlée chez 22 % d’entre eux. Parmi les femmes hypertendues, 69,8 % connaissaient le diagnostic, 85,1 % étaient sous traitement et 35,6 % étaient contrôlées (p < 0,001 pour les trois variables). Les facteurs de risque associés les plus fréquents étaient le diabète sucré chez 36,8 % des patients, l’obésité chez 35,7 %, micro-albuminurie chez 23,6 %, l’hypercholestérolémie > 2 g/L chez 11,6 %, le tabagisme chez 7,7 % d’entre eux. L’HTA contrôlée n’était associée à la présence ou non de facteurs de risque associés. La probabilité d’avoir une HTA était plus élevée chez les hommes, les diabétiques, les sujets âgés et lorsque l’IMC était élevé. Conclusion. – Notre étude a confirmé la forte prévalence de l’HTA en consultation de médecine générale à Blida, ville représentative du nord de l’Algérie. Bien que les femmes soient mieux traitées, il reste beaucoup à faire pour atteindre l’objectif thérapeutique, surtout dans nos pays qui ont le moins de ressources financières pour lutter contre les complications cardio-vasculaires. © 2017 Elsevier Masson SAS. Tous droits réservés. Mots clés : Hypertension ; Sexes ; Prévalence ; Traitement ; Contrôle ; Facteurs de risque ; Blida
1. Introduction With over one billion people affected, high blood pressure (hypertension) is a global public health problem. Uncontrolled, it causes serious cardiovascular events such as stroke, heart failure and coronary insufficiency, for which it multiplies the risk by nine, five and three, respectively [1]. Three-quarters of hypertensive patients in the world will be in developing countries in 2025, according to epidemiological forecasts [2]. The emergence of many environmental risk factors in the general population due to globalisation, urbanization and rapid change of lifestyle explains this evolution [3]. In the area of Blida (city at 30 km far from the capital Algiers), there is no data on the characteristics of arterial hypertension (AHT), its control, as well as associated cardiovascular risk factors (RFs). It seemed useful to study the profile of our hypertensive subjects. 2. Objective To compare the prevalence rate of arterial hypertension between men and women in general medicine consultations. To evaluate the control rate of hypertensive patients under antihypertensive drugs therapy. And to research the frequency of associated cardiovascular risk factors in the hypertensive population in Blida. 3. Materials and methods It is a retrospective study over two years (between January 2014 and June 2016), on a population followed in general medicine consultations in the department of internal medicine and cardiology of the university hospital centre of Blida
(Algeria); having included 3622 subjects aged 18 years and more, of both sexes. The control consisted of completing a questionnaire which included anthropometric characteristics, life habits, personal and family medical history, supplemented by a clinical examination including: • epidemiological parameters (age, occupation, sex, home, tobacco consuming); • weight, height, waist and hip circumferences were also measured at the same day. The body mass index (BMI) was calculated by the equation: weight (kg)/height2 (m2 ). We define obese subjects (BMI ≥ 30 kg/m2 ), overweight (BMI between 25 and 29.99 kg/m2 ), normal weight (BMI between 18.5 and 24.99 kg/m2 ); • blood pressure (BP) was measured three times at two minutes intervals after five minutes of rest in the sitting position, using a validated electronic tensiometer (Omron705 CP) [4]. The average of the last two measurements was used for the statistical analysis [5].
AHT was defined as systolic BP (SBP) greater than or equal to 140 mm Hg or diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or both, or continuous administration of antihypertensive drug therapy [6]. Blood chemistry, including fasting glucose, total cholesterol (CT), HDL cholesterol, LDL cholesterol, triglycerides, blood creatinine and microalbuminuria, was measured under fasting conditions according to standard techniques. For the diagnosis of metabolic syndrome (MS), we used the definition of NCEP ATP III [7], according to which at least three of the following five criteria must be found:
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• the abdominal circumference greater than 102 cm for men and > 88 cm for women; • triglycerides (TG) greater than 1.5 g/L; • HDL-cholesterol less than 0.4 g/L in men and less than 0.5 g/L in women; • BP greater than 130/85 mmHg or antihypertensive drugs therapy; • fasting blood glucose in excess of 1.1 g/L.
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Table 2 Hypertension prevalence according to sex and age. Age (years)
Men (%)
Women (%)
P
All < 40 40–50 50–65 60–70
42.2 6.4 16.8 41.4 35.4
31.6 12.2 20.3 36.9 30.6
< 0.001 0.05 0.05 0.001 0.001
4. Statistical study The analysis of the data was carried out using the SPSS 20.0 software. Only the variables associated with the dependent variable at a threshold of less than 20% were subjected to multivariate analysis using dichotomous logistic regression using the descending step procedure. The trend test (2 of Mantel) was used to choose the optimal threshold for dichotomising the variables with several levels of exposure (classes of a quantitative variable). The Mantel-Haenszel 2 was used as an adjustment test to neutralize the effect of a variable third in the study of the relationship between two variables. The test of the Breslow index was used to demonstrate an interaction introduced by a third variable in the study of the relationship between two variables. The Mann-Whitney test (Kruskal-Wallis test for two groups) was used to compare two averages when the reference to the normal distribution was not possible and/or when the Bartlett test showed that the variance of the two groups differed significantly. 5. Results The anthropometric, clinical and biological characteristics of the population are presented in Table 1. Our study population was composed of more women than men (58% versus 42% for men, P <0.01). Mean age was 48.6 ± 13.5 years. Women were on average overweight (mean BMI at 29.5 ± 5.5kg/m2 ) compared to men (mean BMI at 26.9 ± 4.5 kg/m2 ). Waist and hip circumferences were slightly higher among women than men. There was a higher levels of cholesterolemia and less HDLemia in women, with significant
difference (P <0.01), and higher triglyceridemia among women compared to men, without difference in plasma glucose. Haemodynamically, SBP and DBP were significantly higher in men than in women, without difference in heart rate (HR) between the two genders. According to gender, metabolic syndrome was higher in women than in men, with a very significant difference (21.7% versus 13.2%, P <0.001). Prevalence of hypertension was higher in men than in women (46.2% versus 31.6% in women) with a very significant difference (P <0.001) (Table 2). Depending on the age group, the highest prevalence was observed in the 50 to 65 age group. According to gender, hypertension was predominant among men, also for the age range 50–65 (Table 2). As shown in Fig. 1, the control of hypertension was reached only in 30%. Control of DBP is more important than SBP with a significant difference (P <0.001). According to gender, control of BP is 35% in women and 22% in men with a significant difference (P <0.001). As shown in Table 3, the most common risk factors (RFs) associated with hypertension were diabetes in 36.8% followed by obesity in 35.7%, microalbuminuria in 23.6%, high CT in 11.6% and finally smoking in 7.7%. According to gender, no significant difference was found for high CT between men and women (10.5% versus 11.6%, P = 0.42). Smoking concerned almost exclusively male with a prevalence of 17.5% for men and 0.5% for women, with a very significant difference (P <0.001).
Table 1 General characteristics of the population in the region of Blida. Parameters
Global (n = 3622)
Men (n = 1585)
Women (n = 2037)
P
Repartition (%) Mean age (years) Weight (kg) Height (cm) Waist circumference (cm) Hip circumference (cm) BMI (kg/m2 ) HR (beats/min) SBP (mmHg) DBP (mmHg) Glycemia Total cholesterol (g/L) Triglycerides (g/L) HDL cholesterol (g/L) Metabolic syndrome (%)
100 48.62 ± 13.5 75.5 ± 15.1 163.1 ± 9.1 86.3 ± 12.5 108.5 ± 10.8 28.4 ± 5.28 78.2 ± 14.5 150.7 ± 23.4 90.6 ± 14.1 1.16 ± 0.48 1.84 ±0.5 1.41 ± 0.8 0.45 ± 1.29 17.9
42 50.09 ± 13.2 78.1 ± 14.9 170.1 ± 6.9 84.7 ±12.8 104.9 ± 9.3 26.9 ± 4.5 76.6 ± 14.9 155.5 ± 22.9 92.8 ± 14.4 1.17 ± 0.44 1.77 ± 0.4 1.45 ± 0.8 0.42 ± 1.21 13.2
58 47.78 ± 13.4 73.6 ± 14.9 157 ± 6.7 89.5 ± 12.4 111.1 ± 11.1 29.5 ± 5.5 80.5 ± 15.1 147.2 ± 23.3 89.1 ± 13.5 1.15 ± 0.5 1.90 ± 0.4 1.38 ± 0.8 0.47 ± 1.3 21.7
0.01 0.2 0.2 0.1 0.08 0.01 0.09 0.4 0.04 0.05 0.4 0.01 0.02 0.05 0.001
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70%
DBP <90
43
40%
35.6 27.2
SBP<140
52.8
47.9
50%
30%
p< 0.001
59.6
60%
< 140/90
36.3 30
22.2
20% 10% 0%
Men
Women
All
Fig. 1. BP control rate and according to sex. Table 3 Frequency of association of risk factors with hypertension.
Smoking High cholesterol Obesity Diabetes Microalbuminuria
Global (%)
Men (%)
Women (%)
P
7.7 11.6 35.7 36.8 23.6
17.5 10.5 23.1 39.5 24.3
0.5 12.4 44.9 34.7 23.1
0.001 0.13 0.001 0.49 0.81
For diabetes and microalbuminuria, there was no difference between the two sexes in their association with hypertension. For obesity, the predominance was for women in 44.9% versus only 23.1% for men with a very significant difference (P <0.001) (Table 3). In the bivariate analysis of the control of BP, with presence of cardiovascular RFs, all the factors that had an influence on the control of hypertension were selected. Among them were the male sex, age over 40, high CT, smoking status, diabetes mellitus, metabolic syndrome, tachycardia and renal insufficiency, with a very significant difference compared to those without these RFs (P <0.02) (Table 4). In the multivariate analysis, after neutralizing the various parameters, among the risk factors responsible for the noncontrol of BP in our hypertensive population, we found male sex, age over 40 years, renal insufficiency and diabetes, with a very significant difference (P <0.001). There is less influence of the metabolic syndrome and the acceleration of heart rate. No influence of high triglyceridemia and smoking on the BP control rate was found in our study (Table 5). 6. Discussion This survey of the hypertensive population provided important data on the associated cardiovascular risk factors and the rate of control of BP in Blida, Algeria. These data may serve not only for the public health subsequent studies, but also as an effective strategy for the control of hypertension and other RFs to avoid cardiovascular complications. Hypertension was associated with diabetes in 36.8% of patients, obesity in 35.7%, hypercholesterolemia in 11.6% and
7.7% in smoking, results slightly comparable to the ACE study which found a prevalence of diabetes of 24%, obesity of 37%, high CT of 14% and smoking of 14%. The THALES survey (2006 data on general practitioners) indicates that 19% of hypertensive patients are obese, 14% have associated type 2 diabetes and 38% dyslipidemia [8]. In the older PHENOMEN study of 16,358 hypertensive patients, 60% had dyslipidemia, 19% smoking, and 16% diabetes [9]. The prevalence of hypertension was also independently associated with diabetes and waist circumference. These observations have been widely reported by other authors [10–12]. In our study, we have a clear feminine predominance of MS. Other studies in general populations also noted a clear predominance among women. The prevalence of MS in Senegal is 15.7%, predominantly in female patients 20% versus 5.2% in men, P <0.01 [13]. The study of Hamida and al in South Algeria found a prevalence of MS is 38% in the general population of ElMenia. It was significantly higher in women than in men and in black women in particular (P <0.01) [14]. In a previous study, we found that MS frequency was 20.8%, more frequent among women than among men, with a significant difference (28.4% versus 15.1%, P < 0.001) [15]. The control of BP in our study was 30%. These results show an improvement in the management of AHT compared to the principal previous studies in Algeria which were 14% of treated hypertensives in the SAHA (Algerian Society of Hypertension) study in 2004 [16]. 20% in the oasis of El-Menia in 2010 for Hamida and al. In 2014, according to our previous study [14], the control of BP in South Algeria was 28.2%. In Africa, the degree of control of hypertension among those in care is 42.4% in Kisangani. Damasceno et al. reported an average control rate of 33.1% in Mozambique [17]. In USA, the level of blood pressure control was 53% showing a significant progress in the management of hypertension [18,19]. The levels of control varied widely from country to country, and also from region to region. Controlled blood pressure in France, of the order of 40% during the years 2000, has markedly improved, reaching 50% in treated hypertensive patients, but remains below the objective expected for the last 5 years, according to the national nutrition health survey (ENNS) in 2006, and the FLASH survey in 2015 [20,21]. Otherwise, the therapeutic goal is achieved in 63% of patients treated
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Table 4 Relationship of risk factors with the control of blood pressure at the end of the bivariate analysis. Associated factors
All
Controlled HTA
Bivariate analysis OR CI 95%
P value
Sex Women Men
1585 2037
234 529
1 1.31
1.23–1.38
< 0.001
Age (years) < 40 > 40
237 2787
82 673
1 1.05
1.05–1.08
< 0.001
Diabetes No Yes
641 2060
193 560
1 1.08
0.98–1.08
< 0.08
Tobacco No Yes
2482 219
708 45
1 1.45
1.08–2.05
< 0.01
Nephropathy No Yes
2617 73
736 11
1 2.16
1.14–4.09
< 0.01
Cholesterol No Yes
2531 167
695 57
1 1.02
1.02–1.04
< 0.04
821 449
203 138
1 1.35
1.01–1.23
< 0.02
851 1893
261 501
1 1.42
1.09–1.13
< 0.01
Metabolic syndrome No Yes Heart rate < 70 bpm > 70 bpm
Table 5 Characteristics for which the analysis was continued but which were eliminated at the end of the multivariate analysis of the factors finally linked to the poor control of the BP. Associated factors
All
Controlled HTA
Multivariate analysis OR CI 95%
P value
Sex Women Men
1162 1583
234 529
2.08
1.6–3.3
< 0.001
Age (years) < 40 > 40
237 2787
82 673
2.2
1.33–3.6
< 0.02
Diabetes No Yes
641 2060
193 560
1.34
1.01–2
< 0.05
Nephropathy No Yes
2617 73
736 11
3.95
1.1–12.5
< 0.01
821 449
203 138
1.42
1.04–1.75
< 0.06
851 1893
261 501
1.26
1.09–1.67
< 0.08
Metabolic syndrome No Yes Heart rate < 70 bpm > 70 bpm
in England in 2011 [22], and 71.5% in Germany between 2008 and 2011 [23]. In our study, control of BP was better in women than in men (35.6% versus 22% in males, P <0.001). As in most international surveys, blood pressure control in treated hypertensive patients
is more satisfactory in women. On the whole, the women had a better control status than the men in Africa [17]. The same trends were found in the USA according to NHANES 2014 where a higher percentage of women had controlled hypertension (56.3%) comparing to men (50.6%) [19]. For J. Inamo et al.,
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Control is better in women (61.3 vs. 38.6% in men) [1]. In the ENNS study (18–74 years), control of hypertension was more common in women (58%) than for men (42%), and in MONALISA study, 39% for women (35 years–74 years) and 24% for men (35 years–74 years) [24]. The most characteristic feature found in this study is the importance of the disparity between men and women in the treatment and control of hypertension. The presence of cardiovascular RFs (such as diabetes, metabolic syndrome, microalbuminuria and male sex) in our study population has an influence on the non-control of BP except for dyslipidemias which have no effect on the degree of decline of BP. Various RFs were found associated with high prevalence and poor control of BP in South Africa [25]. In the PHARE study [26,27], insufficient control of systolic blood pressure is linked to the prevalence of associated risk cofactors (overweight, dyslipidemia, smoking habits, alcohol consumption, diabetes). In this study, it appears that the risk of these hypertensive patients does not depend solely on the blood pressure figure but above all on the cofactors. The associated risk factors therefore appear both as a factor of non-control and as a determining factor in the risk incurred by the patient. In NHANES 2009 study showed that in hypertensives, the association of other cardiovascular risk factors increases the difficulty of reaching the blood pressure objective [18]. 7. Conclusion Our study confirmed the high prevalence of AHT and associated cardiovascular RFs in Blida (Algeria), which is a representative city in the north of the country. Although women are better treated, much remains to be done to reach BP goal for themselves and also for the rest of the patients. The opening of specialized AHT consultation becomes essential; with training and sensitisation of medical, paramedical and administrative teams, and computerization of patients followup files. Lastly, information and teaching campaigns to patients and general public will certainly improve the results already achieved. The type of study can help public authorities to establish a program of action against public health scourges. In Blida, it becomes urgent to intensify the management of our hypertensive patients to avoid disabilities which still represent a greater financial and social burden. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments The authors are grateful to the resident doctors (Hachemi Amina and Mesbah Ghania) and to the assistant researcher, Mrs Soum Kheira, for participating in this study.
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Please cite this article in press as: Bachir Cherif A, et al. Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria). Ann Cardiol Angeiol (Paris) (2017), http://dx.doi.org/10.1016/j.ancard.2017.04.009
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Please cite this article in press as: Bachir Cherif A, et al. Differences in prevalence, treatment and control rates of hypertension between male and female in the area of Blida (Algeria). Ann Cardiol Angeiol (Paris) (2017), http://dx.doi.org/10.1016/j.ancard.2017.04.009