Prevalence, awareness, treatment, and control of hypertension among very elderly Chinese: results of a community-based study

Accepted Manuscript Prevalence, awareness, treatment and control of hypertension among very elderly Chinese: results of a community-based study Gang Huang, MD, Jun-bo Xu, MD, Ting-jie Zhang, MD, Qiu Li, MD, Xiao-li Nie, MD, M.D. Ya liu, Shun-rong Peng, BN, Jian-kang Liu, MD, Xing-tang Liu, MD, Xiao-ling Kang, MD PII:

S1933-1711(17)30186-9

DOI:

10.1016/j.jash.2017.05.008

Reference:

JASH 1041

To appear in:

Journal of the American Society of Hypertension

Received Date: 18 February 2017 Revised Date:

26 May 2017

Accepted Date: 29 May 2017

Please cite this article as: Huang G, Xu J-b, Zhang T-j, Li Q, Nie X-l, Ya liu M, Peng S-r, Liu J-k, Liu Xt, Kang X-l, Prevalence, awareness, treatment and control of hypertension among very elderly Chinese: results of a community-based study, Journal of the American Society of Hypertension (2017), doi: 10.1016/j.jash.2017.05.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title page Title: Prevalence, awareness, treatment and control of hypertension among very elderly Chinese: results of a community-based study

RI PT

Short Title: Hypertension prevalence among very elderly Chinese Word count: Abstract: 196 words, Text: 2790 words; Number of tables and figures: 3 tables, 2 supplemental tables, 4 figures

SC

Funding: This study was supported by the Science and Technology Bureau of Chengdu (contract: 11PPYB034SF).

M AN U

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Authors: Gang Huang, MD;1,2 Jun-bo Xu, MD;1,2 Ting-jie Zhang, MD;1 Qiu Li, MD;1,2 Xiao-li Nie, MD;1,2 Ya liu, MD;1 Shun-rong Peng, BN;2 Jian-kang Liu,

TE D

MD;3 Xing-tang Liu, MD;4 Xiao-ling Kang, MD 5

From Cardiovascular and Metabolic Disease Center, The Second People’s Hospital of Chengdu, Chengdu, China;1 Department of Cardiology, The Second

EP

People’s Hospital of Chengdu, Chengdu, China;2 Jianshelu community hospital, Chengdu, China;3 Linchuan community hospital, Chengdu, China.4 Bali

AC C

community hospital, Chengdu, China. 5 Gang Huang and Jun-bo Xu contribute equally and are co-first authors. Corresponding author: Ting-jie Zhang, MD. Cardiovascular and Metabolic Disease Center, The Second People’s Hospital of Chengdu, Chengdu 610017, China.

Tel:

(86)

28-65108064,

Fax:

(86)

28-65108064,

E-mail:

[email protected]

1

ACCEPTED MANUSCRIPT Abstract The epidemiological distribution of hypertension among very elderly Chinese is still not clear. This study aimed to investigate the prevalence, awareness,

RI PT

treatment and control rate of hypertension among very elderly in Chengdu. From May 2013 to May 2015, a total of 1056 participants from 20 residential communities were sampled. Standard face to face interviews, physical

SC

examinations and biochemical analysis were undertaken. Participants had a mean age of 83.6 ± 3.4 years (range: 80-100), and 49.8% were men. Mean

M AN U

systolic blood pressure (BP) and diastolic BP were 146.4 ± 20.6 and 74.1 ± 11.9 mmHg, respectively, and both of the highest BP levels were among participants aged 80 - 84 years. Mean pulse pressure (PP) was 72.5 ± 17.1 mmHg. And the highest PP level was among participants aged 90 years and older. The overall

TE D

estimated hypertension prevalence was 75.3% (95% CI: 72.6-77.9%) and among overall participants, 51.9% were aware of their hypertensive condition and 45.5% were treated. However, only 18.1% of hypertensive participants

EP

were controlled (BP < 140/90 mmHg). Among very elderly Chinese in Chengdu, the prevalence of hypertension is predominantly high, while awareness,

AC C

treatment and control rates are considerably low. Effective primary and secondary prevention strategies are needed. Keywords: Awareness, Chinese, control, hypertension, prevalence, very elderly.

2

ACCEPTED MANUSCRIPT Text Introduction Hypertension is believed as one of the most important disease burdens not only

increases with aging gradually.2

RI PT

in western countries but also in China.1 The prevalence of hypertension In China, cardiovascular diseases(CVD)

account for more than one-third of all adult deaths.3 Moreover, hypertension

SC

accounts for about one-third of deaths due to CVD at age 35 to 79 years.4

During past few decades, epidemiological surveys have reported updated 5-7

and regional distribution

M AN U

epidemiological data of hypertension prevalence

variance in China.8 However, few of these surveys enrolled individuals older than 80 years, even as subgroup subjects. While according to data in 2012 from World Health Organization, the average life expectancy at birth for Chinese is

TE D

currently already about 75 years.9 Therefore, with a rapidly increasing incidence of hypertension in China, it becomes urgent to examine the epidemiological distribution of hypertension among population aged 80 years and older in real

EP

world. As a part of the community-based epidemiological cardiovascular diseases survey among very elderly in Chengdu, we report the blood pressure

AC C

(BP) levels, prevalence, awareness, treatment and control rate of hypertension among very elderly residents in Chengdu. Methods

Study Participants

From May 2013 to May 2015, participants were recruited by use of a stratified three-stage cluster sampling design.10 Firstly, five districts in Chengdu were randomly selected. Secondly, four neighborhoods were randomly selected from

3

ACCEPTED MANUSCRIPT each district. Thirdly, from each neighborhood, one residential community was randomly

selected.

Finally,

twenty

residential

communities

and

1056

participants were sampled according to house registration data from Chengdu

RI PT

government (Figure 1). Study participants were invited into this survey aiming to investigate epidemiological situation of cardiovascular diseases among very elderly in

SC

Chengdu. They were explained to the importance and necessity of this survey for both individuals and public policy formulating in detail. Participants were

M AN U

defined as permanent residents of households with a record in the household registration of Chengdu (by identity card or permanent residence booklet checking). Individuals with any secondary hypertension, severe frailty, neurological and psychological diseases (dementia, Alzheimer's disease or

TE D

schizophrenia, etc.), and disabilities or other problems who could not fully participate in this survey were excluded. Ethics approval was obtained from the Ethics Committee of the Second People’s Hospital of Chengdu. All participants

EP

gave informed consent. Study Methods

AC C

All participants were assessed at a survey site in each community accompanying by their family members living with (to insure full information collecting). All participants completed a questionnaire-based interview, a physical examination, a venous blood sample collection for biochemical analysis, and other measurements. The physical examination involved measurements of height, weight, waist circumference (WC), and BP.

4

ACCEPTED MANUSCRIPT All study investigators were successfully trained for study questionnaire administration, correct cuff size selecting, BP measurement and other techniques needed in this study with standard techniques. All participants had

RI PT

their BP measurements with validated, automatic oscillometric BP measuring device (HEM - 7300, Omron, Kyoto, Japan) by well-trained researchers. Three consecutive readings of BP were taken on the right arm with a cuff size of 22 to

SC

26 cm long and 12 to 14 cm wide with participants in a seated position after at least 10 minutes of rest and at 2 minute intervals according to the Chinese

M AN U

guidelines for the management of hypertension and the seventh joint national committee on prevention, detection, evaluation, and treatment of high blood pressure guidelines.11,12 All participants with BP ≥ 140/90 mmHg at the first visit were visited twice more subsequently to confirm the final diagnosis of

TE D

hypertension. The mean value of the last two of three BP measures at each visit was used for analysis. Thirty minutes before BP measurements, participants were not allowed to smoke cigarettes, drink tee / coffee, and do any physical

EP

exercise. The room temperature was required to be between 18°C and 25°C for survey measurements.

AC C

Definitions

Hypertension was defined as systolic BP (SBP) ≥ 140 mmHg, diastolic BP (DBP) ≥ 90 mmHg , and / or self-reported treatment of hypertension (medical records checked) with antihypertensive medication within 2 weeks prior to the interview.11,12 Hypertension subtypes in this survey include: isolated systolic hypertension (ISH), defined as SBP ≥ 140 mmHg and DBP < 90 mmHg; isolated diastolic hypertension (IDH), defined as DBP ≥ 90 mmHg and SBP ≤

5

ACCEPTED MANUSCRIPT 140 mmHg; systolic-diastolic hypertension (SDH), defined as SBP ≥ 140 mmHg and DBP ≥ 90 mmHg.11,12 Awareness of hypertension was defined as any self-reported previous diagnosis

RI PT

of hypertension by a healthcare professional physician (medical records checked).11,12 Treatment of hypertension was defined as self-reported use of a prescription medication for hypertension management within the 2 weeks

SC

preceding the participant’s interview (medical records checked). Control of hypertension was defined as pharmacological treatment of hypertension

M AN U

associated with an average SBP < 140 mmHg and an average DBP < 90 mmHg during previous 2 weeks (medical records checked).11,12 Diabetes mellitus (DM) was diagnosed if fast glucose (FG) ≥ 7.0 mmol/L, or FG < 7.0 mmol/L

with

a

past

history

of

DM

(medical

records

checked).13

Hypercholesterolemia was defined as total cholesterol ≥ 5.2 mmol/L according

TE D

to the guidelines of Chinese adult dyslipidemia prevention and control.14 Hypertrigleicemiea was defined as total triglyceride ≥ 1.7 mmol/L. Obesity was

EP

defined as body mass index at least 28.0 kg/m2 and visceral obesity as WC at least 85 cm in women and at least 90 cm in men.15,

16

All self-reported

AC C

information was confirmed by available medical records checking. Statistical analysis

Continuous variables are expressed as mean ± standard deviation, and their normality was checked by the Shapiro-Wilk test. Frequencies are presented as percentages with 95% confidence interval (95% CI). Statistical comparison of means between men and women was conducted by using Student’s t-test or Wilcoxon signed-rank test. And x2 test was applied to compare proportions.

6

ACCEPTED MANUSCRIPT Multiple logistic regression models were used to determine the effect of other cardiovascular risk factors such as smoking, visceral obesity, DM, and hypercholesterolemia on hypertension prevalence and control. The receiver

RI PT

operating characteristic (ROC) curve analysis was used to evaluate the efficiency of potential risk factors in predicting hypertension prevalence and control. Results for the overall population of elderly adults have been

SC

standardized for age and sex. Analyses were performed by using SPSS software (Version 17.0, SPSS Inc, Chicago, IL). A two-sided P value < 0.05 was

Results Demographic characteristics

M AN U

considered statistically significant.

Totally, 1056 participants from twenty residential communities were enrolled in

TE D

this study. The overall response rate was 92.6%. Finally, 1038 participants (49.8% men) were included in final analysis (Figure 1). The mean age of participants was 83.6 ± 3.4 years (age range: 80-100 years ) and the median

EP

age was 83 years. Men were slightly older than women (P = 0.342). Among all participants, more than 10% were current smokers and 8% of them were

AC C

current alcohol drinker (Table 1). Mean level of BP

The mean levels of SBP, DBP, and pulse pressure (PP) among overall participants were 146.4 ± 20.6, 74.1 ± 11.9, and 72.5 ± 17.1 mmHg, respectively (Figure 2). And the mean level of heart rate was 70.0 ± 9.0 beats per minute. In women, there were a relatively higher mean SBP (P = 0.038), PP (P < 0.001) and heart rate (P = 0.003), while a lower mean DBP (P = 0.006),

7

ACCEPTED MANUSCRIPT respectively. Not only in women and men but also among overall participants, there was a decrease trend of SBP, DBP and heart rate with aging, while an increase trend of PP with aging (Supplemental table 1).

RI PT

Constituent ratio of hypertension Among hypertensive participants, 82.2% of them were ISH, 17.7% were SDH and only 0.1% were IDH. Among hypertensive men, 82.6% of them were ISH,

SC

17.1% were SDH and 0.1% were IDH. While compared with men, there were a lower percentage of ISH (81.9%, P = 0.834) and a higher percentage of SDH

M AN U

(18.1%, P = 0.756) among hypertensive women.

Estimated prevalence, awareness, treatment, and control of hypertension Based on the strategies used in this study, the estimated prevalence should be a point prevalence. The overall estimated prevalence of hypertension was 75.3% (95% CI: 72.6 - 77.9%). Hypertension prevalence in women was a bit

TE D

higher than in men (75.7% vs 74.9%, P = 0.774). And the overall estimated prevalence of ISH was 51.2% (95% CI: 48.1 - 54.2%). The ISH prevalence in

EP

women was also higher than in men (52.0% vs 50.2%, P = 0.578). The highest prevalence of hypertension was in participants aged 80-84 years among overall

AC C

participants (77.9%), women (79.1%) and men (76.6%). ISH was most prevalent in participants aged 85-89 years both among overall participants and women (52.3% in overall participants , 54.5% in women), and among men aged 90 years and older (51.5%) (Table 2, Supplemental table 2). The overall awareness of hypertension was 51.9% (95% CI: 48.7 - 54.8%). It was higher in women (53.8%, 95% CI: 49.5 - 58.0%) than in men (49.7%, 95% CI: 45.4 - 54.0%)(P = 0.194). The overall treatment rate was 45.5% (95% CI:

8

ACCEPTED MANUSCRIPT 42.2 - 48.2%). It was significantly 10% higher in women (50.6%, 95% CI: 46.4 55.0%) than in men (39.7%, 95% CI: 35.4 - 43.9%)(P < 0.001). Among hypertensive participants, awareness decreased with aging gradually in

RI PT

overall participants and men, while increased in women. Similarly, the highest percentage of study participants on antihypertensive treatment was among participants aged 80-84 years. Moreover, treatment rate also decreased with

SC

aging. Moreover, it was significantly higher in women than in men (65.4% vs 53.0%, P < 0.001)(Table 2, Supplemental table 2).

M AN U

Among participants with hypertension, there was only 18.1% of them with an optimal controlled BP ( BP < 140 / 90 mmHg). The percentage of participants with an optimal controlled BP was higher in men than in women (19.9% vs 16.5%, P = 0.218), and the highest control rate was in participants aged 80-84

TE D

years both among women and men. Among hypertensive participants treated, only about 25% of them had an optimal controlled BP. However, BP was better controlled in men than in women (28.0% vs. 22.4%,p=0.188)(Table 2,

EP

Supplemental table 2). Moreover, hypertensive participants comorbid with DM had a higher control rate than hypertensive participants without DM (23.2%

AC C

vs.17.4%, p=0.092). Hypertensive comorbid with hypercholesterolemia had a lower control rate than hypertensive participants without hypercholesterolemia (13.2% vs. 21.8%, p=0.003). Overall hypertension prevalence, awareness, treatment and control by sex and age were showed in Figure 3. Hypertension and other cardiovascular risk factors

9

ACCEPTED MANUSCRIPT Among overall participants, there were 20.0% (95%CI:17.6-22.5%) participants with DM, 35.8% (95%CI:32.9-38.8%) with hypercholesterolemia, 21.6% (95%CI:18.9-23.9%) with hypertrigleicemiea, 54.5% (95%CI:51.5-57.6%) with

RI PT

visceral obesity, and 9.4% (95%CI:7.6-11.1%) with obesity, respectively. Meanwhile, 83.1% (95%CI: 78.0-88.2%) participants with DM, 79.2% (95% CI: 75.0-83.4%) participants with hypercholesterolemia, 78.6% (95%CI: 73.2-

SC

84.0%) participants with hypertrigleicemiea, 81.7% (95%CI: 78.5-84.9%) visceral obese participants, and 89.6% (95%CI: 83.5-95.7%) obese participants

M AN U

suffered from hypertension.

In multiple logistic regression models, the risk of hypertension in participants aged 85-89 years was threefold (odds ratio (OR): 3.12, 95%CI:1.72-5.65) of those aged 80-84 years. Moreover, in visceral obese very elderly, the risk of

TE D

hypertension was 68% higher (OR: 1.68, 95%CI:1.18-2.40). And hypertensive participants comorbid with DM (OR: 2.04, 95%CI: 1.284-3.27) were more likely to have an optimal BP control, while hypertensive participants comorbid with

EP

hypercholesterolemia may achieve the target BP more difficultly (Table 3), which were in accordance with comparisons of control rate. Results of ROC

AC C

analysis estimating WC predicting hypertension prevalence, TC predicting hypertension control and FG predicting uncontrolled hypertension were showed in Figure 4.

Discussion

Among very elderly in Chengdu, the hypertension prevalence and ISH prevalence is extremely high, while the control rate is considerably low.

10

ACCEPTED MANUSCRIPT Moreover, hypertension and ISH prevalence are higher among very elderly women. The mean SBP level among very elderly Chinese in this study is consistent with

RI PT

the level in Americans 80 years and older during 1988-1994 and 1999-2004 17, very elderly Israel 18 and Polish.19 Moreover, the mean DBP level in our study is almost the same as among very elderly American during 1988-1994 and Israel.

SC

However, it is about 10 mmHg lower than in very elderly Polish.19 The mean PP level in this survey is also in constant with which in very elderly Americans

M AN U

during 1988-1994 and Israel.18,19 As expected, DBP decreases and PP increases gradually with aging in our study, while SBP also decreases surprisingly with aging. Progressive cardiac dysfunction, severe artery wall stiffness

20,21

and vascular remodeling

among elderly could be possible

TE D

explanations.

22

Estimated prevalence of hypertension and ISH in this survey is also almost the same as those among very elderly Americans17 during 1999-2004 and

EP

Japanese.23 While surprisingly, ISH prevalence is almost twofold than in very elderly Polish.19 Control rates among both very elderly hypertensive and treated

AC C

hypertensives are only half of very elderly Americans during 2005-2010.17 As well, they are unfortunately lower than in very elderly Japanese23 and Israel.18 Moreover, the control rate among treated hypertensives is even lower than in very elderly Americans during 1988-1994.17 Both the treatment and control rates in very elderly Chinese in this survey are lower than in Japanese, while the awareness rate is relatively higher.23 This study shows that current hypertension epidemiological situation in very elderly in Chengdu is somewhat

11

ACCEPTED MANUSCRIPT like which in American two decades ago. Obviously, it is still a big challenge to improve the control in very elderly in order to decrease cardiovascular events and mortality. It is already known that little knowledge is a barrier of medication

RI PT

adherence in elderly.24 In this study, less than half of the participants completed a middle school or a higher education. Moreover, prescribed medication for other comorbidities may decrease the antihypertensive medication adherence. Among hypertensive patients with low persistence to medication leads to

SC

suboptimal treatment and poorer BP control in elderly patients.24,25 Therefore,

M AN U

non-adherence to antihypertensive medication could be a reason for low control rate in this study.

It has been reported that obesity is related with the development of hypertension among elderly.26 Among elderly Chinese, abdominal obesity adds

TE D

predictive information on atherosclerotic CVD.27 Our analysis finds that visceral obesity is associated with increased hypertension prevalence among very elderly. A previous study in Chinese also shows BP is better controlled among

EP

persons aware of their hypertension diagnosis and those who undertake lifestyle modification.

28

Our study shows that there is a better BP control rate in

AC C

hypertensives comorbid with DM (compared with hypertensives without DM) and a poorer control in hypertensives comorbid with hypercholesterolemia (compared with hypertensives without hypercholesterolemia). One possible explanation may be that hypertensive patients with DM receive a more intensive antihypertensive therapy or attach more importance to their diseases and therefore have a better compliance. While a high level of cholesterol is often associated with unhealthy lifestyle choices，especially inappropriate patterns of

12

ACCEPTED MANUSCRIPT food intake, including the habit of eating too much oily food (typical local food in Sichuan). And there may be less motivations for very elderly to change their habitual dietary habit. Therefore, it could also be one reason for poorer BP

RI PT

control in hypertensives with hypercholesterolemia. Compared with very elderly men, very elderly women have a higher mean BP level, especially higher SBP and PP levels in this study. Therefore, it is not a

SC

surprise that hypertension prevalence and ISH prevalence are relatively higher in very elderly women. Similarly, studies also report a higher hypertension

M AN U

prevalence in Japanese women older than 70 years, very elderly American women and very elderly Polish women.19,23,29 It still needs further population based studies to clarify whether there is a sex difference of pathophysiological process of artery stiffness and vascular remodeling in very elderly.

TE D

Results of this study should be interpreted with caution. This cross-sectional study focused on very elderly residents only in Chengdu. Most of the study participants are Han, therefore, results in this study should not be applied to

EP

other minorities Chinese. Moreover, there might be potential bias from participant selection and self-reporting information. And data about artery

AC C

stiffness, physiological diseases, cardiac function, mental and neurological function and health related quality of life in this study is not available. In conclusion, this is the first community based study, to our knowledge, to report hypertension epidemiological distribution among very elderly Chinese in Chengdu. Among very elderly Chinese in Chengdu, the prevalence of hypertension is high, while the control rate is considerably low. Effective primary and secondary prevention strategies are still urgently needed.

13

ACCEPTED MANUSCRIPT Conflict of interest The authors declare that there is no conflict of interest. Acknowledgments

RI PT

We appreciate all study participants for their participation and collaborators for their efforts which made the survey possible. We also thank Miss. Hui-xing Yang for secretarial contribution and Ms. Qiong Wang for organizational support

AC C

EP

TE D

M AN U

SC

for this survey.

14

ACCEPTED MANUSCRIPT REFERENCES 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in

RI PT

1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095-2128.

2. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global

SC

burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217-223. 3. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health

M AN U

transition in China,1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2013; 381: 1987-2015.

4. Lewington S, Lacey B, Clarke R, Guo Y, Kong XL, Yang L, et al. The Burden of Hypertension and Associated Risk for Cardiovascular Mortality in China.

TE D

JAMA Intern Med 2016; 176: 524-532.

5. Li W, Gu H, Teo KK, Bo J, Wang Y, Yang J, et al. Hypertension prevalence, awareness, treatment, and control in115 rural and urban communities involving

EP

47000 people from China. J Hypertens 2016; 34: 39-46. 6. Li D, Lv J, Liu F, Liu P, Yang X, Feng Y, et al. Hypertension burden and

AC C

control in mainland China Analysis of nationwide data 2003-2012. Int J Cardiol 2015; 184: 637-644.

7. Yang ZJ, Liu J, Ge JP, Chen L, Zhao ZG, Yang WY; China National Diabetes and Metabolic Disorders Study Group. Prevalence of cardiovascular disease risk factor in the Chinese population The 2007-2008 china national diabetes and metabolic disorders study. Eur Heart J 2012; 33: 213-220. 8. Wang X, Bots ML, Yang F, Hoes AW, Vaartjes I. Prevalence of hypertension

15

ACCEPTED MANUSCRIPT in China: a systematic review and meta-regression analysis of trends and regional differences. J Hypertens. 2014 32: 1919-1927 9.

World

Health

Organization.

China:

WHO

statistical

profile.

RI PT

http://www.who.int/gho/countries/chn.pdf?ua=1. Accessed February 7, 2017. 10. Huang G, Xu JB, Zhang TJ, Nie XL, Li Q, liu Y, et al. Hyperuricemia is associated with cardiovascular diseases clustering among very elderly women-

SC

a community based study in Chengdu, China. Scientific Reports 2017; 7: 996. 11. Liu LS, Writing Group of 2010 Chinese Guidelines for the Management of

M AN U

Hypertension. 2010 Chinese guidelines for the management of hypertension [in Chinese]. Zhonghua Xin Xue Guan Bing Za Zhi 2011; 39: 579-615. 12. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection,

TE D

Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42: 1206-1252.

13. Chinese Diabetes Society. China Guideline for Type 2 Diabetes. Beijing:

EP

Beijing University Medical Publication House; 2011. 14. Joint Committee for Developing Chinese guidelines on Prevention and

AC C

Treatment of Dyslipidemia in Adults. Chinese guidelines on prevention and treatment of dyslipidemia in adults [in Chinese]. Zhonghua Xin Xue Guan Bing Za Zhi 2007; 35: 390-419. 15. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363: 157-163. 16. Disease control, Ministry of Health of the People's Republic of China. The

16

ACCEPTED MANUSCRIPT guidelines of Chinese adult overweight and obesity prevention and control. Beijing: People's Medical Publishing House; 2006. 17. Bromfield SG, Bowling CB, Tanner RM, Peralta CA, Odden MC, Oparil S,

RI PT

Muntner P. Trends in hypertension prevalence, awareness, treatment and control among US adults 80 years and older, 1988-2010. J Clin Hypertens 2014; 16: 270-276.

SC

18. Jacobs JM, Stessman J, Ein-Mor E, Bursztyn M. Hypertension and 5-Year Mortality among 85-Year-Olds. J Am Med Dir Assoc 2012; 13: 759.e1-6.

M AN U

19. Zdrojewski T, Wizner B, Więcek A, Ślusarczyk P, Chudek J, Mossakowska M, et al. Prevalence, awareness, and control of hypertension in elderly and very elderly in Poland results of a cross-sectional representative survey. J Hypertens 2016; 34: 532-538.

TE D

20. Humphrey JD, Harrison DG, Figueroa CA, Lacolley P, Laurent S. Central Artery Stiffness in Hypertension and Aging: A Problem With Cause and Consequence. Circ Res 2016;118:379-381.

EP

21. Kaess BM, Rong J, Larson MG, Hamburg NM, Vita JA, Levy D, et al. Aortic stiffness, blood pressure progression, and incident hypertension. JAMA

AC C

2012;308:875-881.

22. Safar ME. Arterial aging-hemodynamic changes and therapeutic options. Nat Rev Cardiol 2010;7:442-449. 23. Ishine M, Okumiya K, Hirosaki M, Sakamoto R, Fujisawa M, Hotta N, et al. Prevalence of hypertension and its awareness, treatment, and satisfactory control through treatment in elderly Japanese [Letter]. J Am Geriatr Soc 2008; 56: 374-375.

17

ACCEPTED MANUSCRIPT 24. Turner BJ, Hollenbeak C, Weiner MG, Ten Have T, Roberts C. Barriers to adherence and hypertension control in a racially diverse representative sample of elderly primary care patients. Pharmacoepidemiol Drug Saf 2009;18:672-681.

RI PT

25. Erkens JA, Panneman MM, Klungel OH, van den Boom G, Prescott MF, Herings RM. Differences in antihypertensive drug persistence associated with drug class and gender: a PHARMO study. Pharmacoepidemiol Drug Saf

SC

2005;14:795-803.

26. Rahmouni K, Correia ML, Haynes WG, Mark AL. Obesity-associated

M AN U

hypertension: new insights into mechanisms. Hypertension 2005;45:9-14. 27. Fan H, Li X, Zheng L, Chen X, Lan Q, Wu H, et al. Abdominal obesity is strongly associated with Cardiovascular Disease and its Risk Factors in Elderly and very Elderly Community-dwelling Chinese. Sci Rep 2016; 6: 21521.

TE D

28. Muntner P, Gu D, Wu X, Duan X, Wenqi G, Whelton PK et al. Factors Associated With Hypertension Awareness, Treatment, and Control in a Representative Sample of the Chinese Population. Hypertension 2004;43:578-

EP

585.

29. Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age

AC C

spectrum current outcomes and control in the community. JAMA 2005; 294: 466-472.

18

ACCEPTED MANUSCRIPT Figure legends Figure 1. Flow chart of the study. Figure 2. Density curves representing the distributions of BPs among very

SBP, systolic blood pressure; PP, pulse pressure.

RI PT

elderly Chinese in Chengdu. BP, blood pressure; DBP, diastolic blood pressure;

Figure 3. Overall prevalence, awareness, treatment and control rate by sex (A) and age group (B) among very elderly Chinese in Chengdu. Comparison were

SC

by x2 test .

M AN U

Figure 4. Receiver operating characteristic (ROC) curves. A. WC predicting hypertension prevalence. The area under the ROC curve (AUC) was 0.605 (95% CI: 0.561-0.649, P<0.001). B. TC level predicting hypertension control. The AUC was 0.579 (95% CI: 0.525-0.633, P=0.005) C. FG level predicting

TE D

uncontrolled hypertension. The AUC was 0.584 (95% CI: 0.522-0.645,

AC C

EP

P=0.008). FG, fasting glucose; TC, total cholesterol. WC, waist circumference.

19

ACCEPTED MANUSCRIPT

Tables

Table 1. Characteristics of study participants Overall

Men

Women

(N=1038)

(N=517)

(N= 521)

83.6±3.4

83.6±3.3

83.5±3.4

Han Ethnicity n,(%)

1029(99.1)

513(99.2)

Current Smoker n,(%)

116(11.2)

93(18.0)

Current Drinking n,(%)

87(8.4)

78(15.1)

P value

RI PT

0.342

516(99.0)

1.000

23(4.4)

< .001

9(1.7)

< .001

SC

Age, years

M AN U

Education 249(24.0)

60(11.6)

189(36.3)

< .001

Primary School n,(%)

312(30.0)

154(29.8)

158(30.3)

.913

Middle/High School n,(%)

336(32.4)

210(40.6)

126(24.1)

< .001

College/University n,(%)

141(13.6)

93(18.0)

48(9.3)

< .001

123(11.8)

58(11.2)

65(12.5)

0.039

53(5.1)

24(4.6)

29(5.6)

0.499

70(6.7)

32(6.2)

38(7.3)

0.478

ACEI/ARB n,(%)

121(11.7)

62(12.0)

59(11.3)

0.737

CCB n,(%)

271(26.1)

124(24.0)

147(28.2)

0.121

β-receptor blocker n,(%)

81(7.8)

36(7.0)

45(8.6)

0.315

Centrally acting drugs n,(%)

32(3.1)

14(2.7)

18(3.5)

0.486

Diuretics n,(%)

79(7.6)

36(7.0)

45(8.6)

0.315

TE D

Illiterate n,(%)

Medical history

Heart disease n,(%)

AC C

Stroke n,(%)

EP

DM n,(%)

Antihypertension Medication n,(%)

ACCEPTED MANUSCRIPT 272(26.2)

121(23.4)

151(29.0)

0.041

Combined treatment

204(19.7)

89(17.2)

115(22.1)

0.049

WC, cm

87.5±10.6

87.7±10.2

87.4±10.9

0.684

23.1±3.7

23.0±3.5

23.2±4.0

0.484

FG, mmol/L

5.53±1.35

5.65±1.45

5.40±1.22

0.004

TC, mmol/L

4.87±0.99

4.67±0.94

5.09±1.00

< 0.001

TG, mmol/L

1.34±0.57

1.30±0.57

1.38±0.56

0.005

2

SC

BMI, kg/m

RI PT

Single treatment

M AN U

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BMI, body mass index; CAD, Coronary artery disease; CCB, calcium channel blockers; DM, diabetes mellitus; FG, fasting glucose; TC, total cholesterol; TG, triglycerides; WC, waist circumference; Data are presented as mean±standard deviation for continuous variables and as frequencies (percentages) for categorical variables. P

AC C

EP

TE D

value is for comparison between men and women.

ACCEPTED MANUSCRIPT

Table 2. Prevalence, awareness, treatment and control of hypertension Overall *

Men **

Women **

% (95% CI)

% (95% CI)

% (95% CI)

75.3 (72.6–77.9)

74.9 (71.1–78.6)

75.7 (71.9–79.3)

0.774

51.2 (48.1–54.2)

50.2 (46.0–54.6)

52.0 (47.7–56.3)

0.578

Awareness

68.8 (65.5-72.0)

66.3 (61.7-71.1)

71.0 (66.6-75.5)

0.160

Treatment

59.7 (56.3-63.1)

53.0 (48.0-57.9)

65.4 (60.8-70.0)

<0.001

Control

18.1 (15.5–20.9)

19.9 (15.9–23.9)

16.5 (12.8–20.2)

0.218

28.0 (21.7–33.9)

22.4 (17.4–27.6)

0.188

P value

Hypertension ISH

24.7 (20.9–28.8)

TE D

Control

M AN U

Among treated hypertensives

SC

Among Hypertensives

RI PT

Prevalence

Abbreviations: CI, confidence interval; ISH, Isolated systolic hypertension. Data are presented as percentage (95% CI); Isolated systolic hypertension defined as SBP≥140

EP

and DBP<90mmHg. Hypertension defined as antihypertensive treatment or blood pressure ≥140 and/or 90mmHg; P value is for comparison between men and women. * Overall rates

AC C

are adjusted by age and sex. ** Rates are adjusted by age.

ACCEPTED MANUSCRIPT

Table 3. Multiple logistic regression models for hypertension prevalence and control Prevalence (N=1038) OR (95% CI) Ref.

80-84

3.12(1.72-5.65)

< 0.001

≥ 90

2.33(1.23-4.43)

0.011

Ref.

Women

Ref.

No

0.67(0.40-1.12)

Yes DM

1.68(1.18-2.40)

No

1.44(0.91-2.26)

0.003

0.122

Ref.

1.32(0.91-1.92)

0.090

2.11(0.46-9.67)

0.337

0.96(0.62-1.50)

0.866

Ref.

1.30(0.65-2.59)

0.488

Ref. 0.74(0.48-1.16)

0.201

Ref.

2.04(1.284-3.27)

0.003

Ref. 0.125

0.55(0.347-0.88)

0.014

EP

Yes

TE D

Hypercholesterolemia

0.103

Ref.

No Yes

0.558

Ref.

No

3.56(0.82-15.46)

Ref.

M AN U

Yes Visceral obesity

0.89(0.62-1.30)

P value

Ref.

85-89

Men

Current smoking

OR (95% CI)

RI PT

Sex

P value

SC

Age (years)

Control (N=1038)

Abbreviations: CI, confidence interval; BMI, body mass index; DM, diabetes mellitus; OR,

AC C

odds ratio; Ref., reference category. Data are presented as odds ratio (95% CI). Diabetes defined as fast glucose ≥ 7.0 mmol/L, or with a past history. Hypercholesterolemia defined as total cholesterol ≥ 5.2 mmol/L. Visceral obesity was defined as waist circumference ≥ 85 cm in women and ≥ 90 cm in men. P<0.05 versus reference category.

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT

Highlights

• This study provides first hand information about the epidemiological distribution of

RI PT

hypertension among very elderly population in Southwest China-Chengdu.

• Among very elderly in Chengdu, the prevalence of hypertension is predominantly high, while awareness, treatment and control rates are considerably low.

AC C

EP

TE D

M AN U

SC

• The hypertension prevalence among very elderly women is higher than in men.

ACCEPTED MANUSCRIPT Prevalence, awareness, treatment and control of hypertension among very elderly Chinese: results of a community-based study

SC

Supplemental Materials

RI PT

Short Title: Hypertension prevalence among very elderly Chinese

M AN U

Authors: Gang Huang, MD;1,2 Jun-bo Xu, MD;1,2 Ting-jie Zhang, MD;1 Qiu Li, MD;1,2 Xiaoli Nie, MD;1,2 Ya liu, MD;1 Shun-rong Peng, BN;2 Jian-kang Liu, MD;3 Xing-tang Liu, MD;4 Xiao-ling Kang, MD 5

From Cardiovascular and Metabolic Disease Center, The Second People’s Hospital of Chengdu, Chengdu, China;1 Department of Cardiology, The Second People’s Hospital of

TE D

Chengdu, Chengdu, China;2 Jianshelu community hospital, Chengdu, China;3 Linchuan community hospital, Chengdu, China.4 Bali community hospital, Chengdu, China. 5

EP

Gang Huang and Jun-bo Xu contribute equally to this manuscript and are co-first authors.

AC C

Corresponding author:

Ting-jie Zhang, MD. Cardiovascular and Metabolic Disease Center, The Second People’s Hospital of Chengdu, Chengdu 610017, Sichuan, China. Tel.: (86) 28-65108064, Fax: (86) 28-65108064, E-mail: [email protected]

ACCEPTED MANUSCRIPT

Supplemental table 1. Blood pressure and heart rate

Overall

Men

Women

(N=1038)

(N=517)

(N= 521)

146.4±20.6

145.0±20.0

148.0±21.0

80–84 years

147.0±20.9

145.9±20.3

148.3±21.4

0.231

85–89 years

145.4±20.9

144.0±21.4

147.3±20.1

0.004

≥90 years

143.8±22.8

141.2±19.2

146.0±25.6

0.410

74.1±11.9

75.0±11.6

80–84 years

74.8±11.7

75.9±11.6

85–89 years

73.3±11.8

≥90 years

71.4±12.8

P value

72.5±17.1

RI PT

SC

0.006

73.5±11.7

0.005

73.5±11.7

73.1±11.9

0.392

72.9±11.9

70.0±13.5

0.347

70.2±16.8

75.2±17.1

< 0.001

80–84 years

72.3±17.1

70.0±16.6

74.8±17.3

< 0.001

85–89 years

74.4±19.0

71.5±19.4

77.9±18.0

0.002

≥90 years

76.2±22.7

73.4±19.7

78.8±25.2

0.294

EP

PP mmHg

0.038

73.1±12.1

M AN U

DBP mmHg

TE D

SBP mmHg

68.4±9.5

71.3±8.3

0.003

70.0±9.0

AC C

Heart rate, bpm 80–84 years

70.7±9.1

68.7±9.6

71.2±8.4

0.193

85–89 years

69.6±9.1

68.3±9.8

71.3±8.2

0.193

≥90 years

69.4±9.2

67.6±9.4

72.0±8.8

0.071

Abbreviations: DBP, diastolic blood pressure; PP, pulse pressure; SBP, systolic blood pressure. Data are presented as mean±standard deviation for continuous variables and as frequencies (percentages) for categorical variables. P value is for comparison between men and women.

ACCEPTED MANUSCRIPT

Supplemental table 2. Prevalence, awareness, treatment and control of hypertension by age Overall *

Men

Women

% (95% CI)

% (95% CI)

% (95% CI)

80–84 years

77.9 (74.9–81.0)

76.6 (72.2—81.0)

85–89 years

76.1 (70.9–81.5)

73.3 (65.6–81.0)

≥90 years

59.5 (47.8–71.0)

67.6 (51.4–83.8)

P value

Hypertension

51.9 (48.2–55.5)

85–89 years

52.3 (46.2–58.6)

≥90 years

44.5 (32.2–56.7)

Among Hypertensives Awareness 80–84 years

78.3 (71.0–85.6)

0.366

54.3 (38.2–70.4)

0.256

50.3 (45.1–55.5)

53.4 (48.3–58.5)

0.401

49.6 (40.9–58.3)

54.5 (45.6–63.4)

0.450

51.5 (34.2–68.8)

40.0 (24.2–55.8)

0.341

SC

0.432

TE D

80–84 years

79.1 (74.9–83.3)

M AN U

ISH

RI PT

Prevalence

69.2 (63.7-74.7)

70.6 (65.3-75.9)

0.715

67.8 (61.1-73.4)

63.6 (53.8-73.4)

71.1 (62.0-80.2)

0.274

64.1 (48.7-78.2)

52.2 (31.3-73.1)

73.7 (54.4-93.0)

0.153

80–84 years

61.3 (57.4-65.4)

56.8 (50.9-62.7)

65.4 (59.9-70.9)

0.037

85–89 years

56.6 (49.5-63.7)

46.4 (36.3-56.5)

64.5 (54.9-74.1)

0.013

≥90 years

57.3 (40.9-71.3)

43.5 (22.8-64.2)

68.4 (48.0-88.8)

0.106

AC C

85–89 years

EP

69.9 (66.1-73.7)

≥90 years Treatment

Control

ACCEPTED MANUSCRIPT

80–84 years

20.5 (17.1–23.8)

21.2 (16.4–26.0)

19.9 (15.3–24.5)

0.685

85–89 years

15.0 (9.8–19.9)

20.2 (12.0–28.4)

11.1 (4.8–17.4)

0.088

≥90 years

9.7 (0.7–18.8)

8.7 (-3.1–20.5)

10.5 (-2.9–23.9)

1.000

80–84 years

27.9 (23.1–32.6)

28.3 (21.2–35.4)

85–89 years

20.5 (12.9–28.2)

32.6 (18.6–46.6)

≥90 years

13.6 (-0.7–26.8)

10.0 (-9.6–29.6)

27.5 (21.1–33.9)

0.871

13.8 (5.1–22.5)

0.022

M AN U

SC

Control

RI PT

Among treated hypertensives

15.4 (-3.5–34.3)

1.000

Abbreviations: CI, confidence interval; ISH, Isolated systolic hypertension. Data are presented as percentage (95% CI); Isolated systolic hypertension defined as SBP≥140 and DBP<90mmHg. Hypertension defined as antihypertensive treatment or blood pressure ≥140 and/or 90mmHg; P value is for comparison between men and women. * Overall rates

AC C

EP

TE D

are adjusted by age and sex.