Racial differences in blood pressure control rates in the VA medical center

AJH–May 2004 –VOL. 17, NO. 5, PART 2

between mercury in blood and 24 hours blood pressure has never been studied. We studied four groups of healthy subjects stratified according to food intake, ethnicity and living place based on a structured interview, medical history, clinical examination, and a laboratory screening of blood and urine samples. Group 1 comprised Danes living in Denmark consuming European food, Group 2 comprised Greenlanders living in Denmark consuming European food, Group 3 comprised Greenlanders living in Greenland consuming European food, and Group 4 comprised Greenlanders living in Greenland consuming mainly traditional Greenlandic food. Mercury was determined in peripheral blood, and a 24 hours blood pressure measurement was performed. Mercury in blood was highest in Greenlanders and increased when they lived in Greenland and consumed traditional Greenlandic food ( Group 1: 0.0022 mg/kg, Group 2: 0.0071 mg/kg, Group 3: 0.0142 mg/kg, and Group 4: 0.0303 mg/kg ). 24 hours blood pressure was the same in all three groups of Greenlanders. However, 24 hours diastolic blood pressure was lower among Greenlanders than Danes ( 71 versus 76 mm Hg, P⬍ 0.000 ) and pulse pressure was higher ( 54 versus 50 mm Hg, P⬍0.000 ), whereas systolic blood pressure was the same. Mercury in blood was significantly and negatively correlated to diastolic blood pressure and significantly and positively to pulse pressure. The results support the hypothesis that mercury intake from maritime food is involved in cardiovascular disease. It is suggested that long-term mercury intake induces degenerative changes in aorta and thereby increases the pulse pressure and cardiovascular risk Key Words: Mercury in blood, 24 Hours Blood Pressure, Greenlanders

P-465 CURRENT PREVALENCE AND CONTROL OF HYPERTENSION IN THE PRIMARY CARE SETTING Robert J Petrella, Elizabeth Merikle, Farzad Ali. Family Medicine, University of Western Ontario, London, ON, Canada; Outcomes Research, Pfizer Canada Inc, Kirkland, QC, Canada. The substantial burden of cardiovascular disease and associated risk factors are seen in the primary care setting. The most recent prevalence and control estimates of hypertension in Canada (1986 –1992) may not be reflective of more recent clinical evidence and practice guidelines. The objective of this study was to describe the prevalence, treatment and control of hypertension in Canada using data from a large population-based prospective cohort of ⬎ 150,000 patients in 35 family practice clinics in Southwestern Ontario (SWO). Clinic record and measurement of all chronic diseases including for example date of onset, prescribed medications, blood pressure, procedures/interventions and laboratory results are collected on a quarterly basis. In this study hypertension was defined as at least one of: a recorded prescription of antihypertensive medication, a chart entry and billable record of a diagnosis of hypertension, or a recorded blood pressure exceeding target values on at least 2 visits. Patients with at least 4 quarters of data to allow for corroboration of our definition of hypertension were included (N⫽42,496). The overall prevalence of hypertension was 16.0% (68.6% untreated, 12.8% treated but uncontrolled, and 15.0% treated and controlled). For patients ⬎ 65 years the prevalence of hypertension was 42% (63.6% untreated, 15.5% treated but uncontrolled and 16.7% treated and controlled). For patients ⬍ 65 years the prevalence of hypertension was 9.6% (73.9% untreated, 10.0% treated but uncontrolled and 13.2% treated and controlled). Despite new pivotal clinical evidence and recent novel treatment guidelines, hypertension is largely untreated in primary care. Educational supports to improve awareness, detection, diagnosis and treatment to recommended targets are needed. Key Words: Prevalence, Treatment and Control, Age

POSTERS: Epidemiology/Special Populations

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P-466 MICROALBUMINURIA DETECTION AND ITS ASSOCIATION WITH CARDIOVASCULAR RISK MARKERS IN NON_DIABETIC HYPERTENSIVE PATIENTS EVALUATED BY GENERAL PRACTITIONERS Jorge J Polonia, Jose P Carmona, Luis Pisco, Grant Support. Portuguese Association of Hypertension, Portuguese Society of Gardiology, Lisboa, Portugal; Portuguese Society of General Practitioners, Lisbon, Portugal; Sanofi & BMS, , Portugal. The study aim was to examine the presence of microalbuminuria in non-diabetic hypertensive patients (HTs) observed by a cohort of urban and rural general practitioners (GP). Between May and October 2003, 531 GPs randomly selected the first 3 HTs patients observed in a week. In average GPs observed 26.1⫹18.1 HTs patients out of a total of 121.5⫹57 patients /week.. A total of 1582 HTs patients were studied, 58% female, mean age 59.,8 yrs. From the total population studied 67% were sedentary and 85% overweight. Mean hypertension duration was 9.7⫾7.4 yrs. Casual BP was 150/87 (18/11) mm Hg. Drugs used: ACEin (40%), diuretics (38%), ARBs (8%), calcium blockers (17%), beta blockers 13%. Fixed dose combinations were used in 24%. Statins were used in 44%, aspirin in 19%, oral contraceptives in 8% and HTR in 5%. Smokers were 10% and 14% former smokers. Hypercholesterolemia and hyper trigliceridemia were present in 55% and 26% respectively. Abnormally high creatinine levels occurred in 6% Abnormal levels of C reactive protein occurred in 2%. Associated pathologies were angina (8%), myocardial infarction (4%), left ventricular hypertrophy (10%), previous stroke or TIA (6%) and peripheral vascular disease (12%). Microalbuminuria (positive micral test) was found in 30% and proteinuria occurred in 1% of the patients. According to the 2003 ESH-ESC guidelines cardiovascular risk, 6% had moderate added risk, 67% high added risk and 26% very high added risk. Overall cardiovascular risk was greater in women v men. Comparing with other risk groups and for similar age and gender subjects with very high risk were more sedentary, had significantly (p⬍0.01) higher (double) prevalence of microalbuminuria in spot urine collection and higher (2-3 times) prevalence of associated disease and target organ damage. Despite treatments, prevalence of microalbuminuria in HTs non diabetics is high and associates with greater CV risk and prevalence of cardiovascular disease. Key Words: Albuminuria, Cardiovascular Risk, Non-Diabetic Hypertensives

P-467 RACIAL DIFFERENCES IN BLOOD PRESSURE CONTROL RATES IN THE VA MEDICAL CENTER Shakaib U Rehman, Brent M Egan, Florence N Hutchison. Primary Care, Ralph H. Johnson V.A. Medical Center, Charleston, SC; Medicine, Medical University of South Carolina, Charleston, SC. African Americans (AA) have lower rates of hypertension control and more adverse outcomes than Caucasians. The explanation for ethnic variations in hypertension control and outcomes has not been fully understood but includes differential access to care and medications. Ethnic differences in hypertension control rates in the Veterans Administration healthcare system, which minimizes access barriers, could be instructive. Therefore, we compared blood pressure (BP) control rates in AA and Caucasian hypertensive patients in a large V.A. Medical center using computerized medical records during the previous year. 25871 hypertensive veterans were identified (97% male, mean age 64.6 years, 50% Caucasian, 28% AA, ethnicity unknown 21.5%). Caucasian hypertensives (N⫽12,917) were older than AA hypertensives ([N⫽7215) 66.2 vs 61.2 years, p⬍0.05). BP was 137.3/75.5 in Caucasian hypertensives and 137.9/80.1 mmHg in AA hypertensives (p⫽NS/⬍0.05). Among Caucasians, 54.3% had a BP ⬍140/90 mmHg on their last visit compared to 48.4% among AA (p⬍0.05). AA and Caucasian hypertensive patients received a similar number of BP drugs 2.4 and 2.0

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POSTERS: Epidemiology/Special Populations

AJH–May 2004 –VOL. 17, NO. 5, PART 2

respectively, p⫽NS. AA were more likely than Caucasians to receive diuretics (58% vs 49%, p⬍0.01) and calcium channel blockers (39% vs 32%, p⬍0.01) and less likely to receive beta-blockers (22% vs 31%, p⬍0.01). The two groups were equally likely to receive ACE inhibitors (54% vs 52%). A very high proportion of both AA (67.8%) and Caucasians (75.4%) hypertensives met criteria for JNC VI Risk Group C. The findings indicate that BP control is lower among AA than Caucasian hypertensive patients in a large VA Medical Center. The lower control rates in AA appear to reflect differences in diastolic rather than systolic BP and do not represent a less intensive therapeutic effort or more comorbidities in AA than C hypertensives. The ethnic differences in BP control in this VA patient population are less than those in a recent national survey and may point to advantages of the VA healthcare system for reducing health disparities.

P-469 THE ASSOCIATION OF HYPERTENSION AWARENESS, ANTIHYPERTENSIVE DRUG TREATMENT, AND LIFESTYLE MODIFICATION RECOMMENDED BY THE PHYSICIAN WITH QUALITY OF LIFE AMONG OLDER ADULTS

Key Words: Hypertension, Racial Differences, Department of Veterans Affair

This study examines the relationship of elevated blood pressure, hypertension awareness and treatment with quality of life among communityliving older adults. We carried out a cross-sectional household survey among 3368 subjects representative of the population aged 60 years and older in Spain. Data were collected through personal interview, and physical examination to determine blood pressure and anthropometric measures. Quality of life was assessed with the SF-36 questionnaire, which comprises eight dimensions of quality of life, while blood pressure was obtained from six readings with mercury sphygmomanometer in standardized conditions. Analyses were done with linear regression adjusted for predictors of quality of life, such as age, sex, number of chronic diseases, tobacco, alcohol, body mass index, physical activity, level of education and social support. Neither hypertension (over 140/90 mmHg or under antihypertensive treatment), nor its pharmacological treatment or control were associated with poorer quality of life in any of the eight dimensions of the SF-36, among men or women. These results also held for hypertension awareness among men. For women, hypertension awareness was associated with an statistically significant (p⬍0.01) and clinically relevant reduction (a 4 to 7 lower score) in all the dimensions of quality of life. The unfavourable effect of hypertension awareness on quality of life among women remained after further adjustment for medical advice to lose weight, to reduce salt, to increase physical activity and to moderate alcohol intake. However, after additional adjustment for prescription of antihypertensive drugs, the association of hypertension awareness with quality of life was reduced for the physical role, vitality and social function scales. We conclude that uncomplicated hypertension or its pharmacological treatment does not seem to alter quality of life. Among women, however, hypertension labelling reduces quality of life, independently of the nature of lifestyle modification recommended by the physician. The impact of hypertension labelling on quality of life could be partially explained by drug prescription. This study has been funded by FIS grant PI020563, FIS-RCESP and by an unrestricted educational grant from ASTRAZENECA.

P-468 BLOOD PRESSURE CONTROL AND ANTIHYPERTENSIVE MEDICATIONS IN A POPULATION OF DIABETIC HYPERTENSIVES IN THE SOUTHEASTERN UNITED STATES Jessica E Riehle, Daniel T Lackland, Brent M Egan. Biometry and Epidemiology, Medical University of South Carolina, Charleston, SC; General Internal Medicine, Medical University of South Carolina, Charleston, SC. The purpose of this study is to determine the state of blood pressure control and use of anti-hypertensive medications among diabetics with hypertension in the Southeastern U.S. The data were obtained on 72,351 hypertensive patients receiving medical care from 80 practice sites in the Southeast. Data concerning risk factor levels, medications, and co-morbidities were collected either from data cards completed and mailed by the provider or from downloaded electronic medical records. Among 22,263 diabetics in the database, a quarter have achieved a blood pressure below 130/80 as recommended by JNC-VII guidelines. African Americans were less likely to have a blood pressure below this level (p ⬍ 0.001), as were females (p ⬍ 0.001). The average number of blood pressure medications is lower for females than it is for males (p ⬍ 0.001). African American males are on more anti-hypertensive medications than their Caucasian counterparts. A similar racial gradient also exists among females. In this population, ACE Inhibitors are the most common anti-hypertensive medications prescribed, followed by diuretics. African Americans are more likely to be on ACE Inhibitors, and more likely to be on Diuretics than their Caucasian counterparts. The average number of BP meds is also higher for African Americans than it is for Caucasians, but lower for females than it is for males. Disparities in medications between males and females may reflect the fact that approximately 40 percent of the data is from the Veteran’s Administration, which serves predominantly males and has unique prescriptive practices. These results highlight the need for continued efforts toward controlling the blood pressure of diabetics. In particular, African Americans are less likely to achieve appropriate control of their blood pressure, despite the fact that they tend to be on more medications. Females have lower rates of blood pressure control than males, and may benefit from the addition of more medications to their regimens.

BP ⬍ 140/90 BP ⬍ 130/80 % on ACE-Is % on ARBs % on Diuretics % on CCBs (dihydropyridine) BP meds (avg. ⫹/⫺ s.d.)

All

Afr. Caucasian Amer. Males Males

Afr. Caucasian Amer. Females Females

50.3% 25.1% 66.0% 12.1% 57.5% 30.3%

55.9% 31.2% 68.4% 5.4% 53.6% 25.8%

53.3% 24.9% 56.4% 19.8% 59.1% 26.1%

48.0% 23.7% 75.1% 6.4% 61.4% 24.4%

44.7% 19.5% 69.3% 23.0% 65.6% 41.3%

3.4⫹/⫺2.3 3.4⫹/⫺2.3 3.5⫹/⫺2.4 3.1⫹/⫺2.3 3.2⫹/⫺2.3

Key Words: Diabetes, Hypertension, Southeastern United States

Pilar Guallar-Castillon, Jose R. Banegas-Banegas, Esther LopezGarcia, Luz Leon, Ana Tabuenca, Fernando Rodriguez-Artalejo. Department of Preventive Medicine and Public Health, School of Mecicine. Universidad Autonoma de Madrid, Madrid, Madrid, Spain; Department of Nutrition, Harvard School of Public Health, Boston, MA.

Key Words: Quality of Life, Older Adults, Population-Based

P-470 CARDIOVASCULAR RISK FACTORS IN THE ELDERLY. ACCURACY OF ATTENTION IN PRIMARY CARE Meritxell Sa´ nchez-Amat, Alejandra Valero Suau, Me`ncia Benı´tezCamps, Antoni Dalfo´ Baque´ , Ma Anto`nia Vila Coll, Susana Pe´ rezZamora. ABS Go`tic, Barcelona, Catalonia, Spain; ABS Nova Lloreda, Badalona, Catalonia, Spain. To evaluate high blood pressure (HBP) control and cardiovascular risk factors of individuals aged 65 and older receiving medical attention in Catalonia. To compare the accuracy of control with results obtained five years ago. Descriptive cross-sectional study. Primary care. External auditing of 990 medical histories of hypertensive patients receiving medical attention