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2006; 19:53– 60

Prevalence, Awareness, Treatment and Control of Hypertension in Hellas, Greece The Hypertension Study in General Practice in Hellas (HYPERTENSHELL) National Study Aris D. Efstratopoulos, Sofia M. Voyaki, Athanasios A. Baltas, Filippos A. Vratsistas, Dimitrios-Eteoklis P. Kirlas, John T. Kontoyannis, John G. Sakellariou, George B. Triantaphyllou, Gregorios A. Alokrios, Dimitrios N. Lianas, Emanuel A. Vasilakis, Kyriakos N. Fotiadis, and Evangelia E. Kastritsea, for the Hypertenshell Investigators Background: The Hypertension Study in General Practice in Hellas (Hypertenshell) is a cross-sectional study (much like the National Health and Nutrition Examination Study) for assessing the prevalence, level of awareness, treatment, and control of hypertension in Greece. Methods: The study was conducted with the collaboration of physicians in 98 Health Centers across Greece. Participants were interviewed about lifestyle, and blood pressure (BP) measurements were taken on two clinical visits for verification of diagnosis and control of hypertension. Hypertension was defined as systolic BP ⱖ140 mm Hg or diastolic BP ⱖ90 mm Hg, or current treatment with antihypertensive drugs; the same threshold was used for assessing control of hypertension. Results: A total of 11,950 individuals participated and data for 11,540 were analyzed, comprising 0.1% of the Greek population. The prevalence of hypertension was 31.1% (men 33.6%, women 28.4%); among elderly individuals (⬎65 years) the prevalence was higher (65.4%).

Of the hypertensive individuals, 39.8% did not know that had hypertension, yielding an awareness of 60.2%; in addition, 12.4% were aware but not treated (men 13.1%, women 11.8%). In all, 51.2% (1838) of hypertensive subjects were treated; 67.2% (1235) were treated but not controlled (men 66.7%, women 67.7%); and 32.8% (603) were treated and controlled (men 33.3%, women 32.3%). Conclusions: The results of the Hypertenshell Study indicate that hypertension is a common risk factor for cardiovascular disease in the Greek population. Awareness, treatment, and control of hypertension are comparable to the best rates of control of hypertension given for the problem, but there is a considerable potential for further improvement in the control of this disease. Am J Hypertens 2006;19:53– 60 © 2006 American Journal of Hypertension, Ltd. Key Words: Hypertension, prevalence, awareness, treatment, control, Hellas (Greece).

ypertension is one of the most important and modifiable risk factors for cardiovascular and cerebrovascular morbidity and mortality.1,2 Epidemiologic studies demonstrate that cardiovascular events are correlated

H

linearly over a wide range of blood pressures (BP). This correlation is continuous and independent of other risk factors.3 In individuals 40 to 70 years of age, for every increase in systolic BP (SBP) of 20 mm Hg or an increase in diastolic

Received December 2, 2004. First decision July 14, 2005. Accepted July 14, 2005. From the Hypertension Unit (ADE, AAB, SMV), General Hospital of Athens “G. Gennimatas,” Athens, Greece; Health Center of Mouzaki (FAV), Karditsa, Greece; Health Center of Thesprotiko (D-EPK), Preveza, Greece; Health Center of Goumenitsa (JTK), Kilkis, Greece; Health Center of Farkadona, Trikala, Greece; Health Center of Skopelos (GBT), Skopelos, Greece; Health Center of Chalandritsa (GAA), Axaia, Greece; Health Center of Erymanthia (DNL), Achaia, Greece; Health Center of Dervinaki (EAV), Ioannina, Greece; Health Center of Lito-

horon (KNF), Pieria, Greece; and Health Center of Areopolis, Lakonia, Greece. This study was supported by grants from Boehringer-Ingelheim Hellas, AstraZeneca SA, Hellas, Sanofi-Synthelabo, Hellas, and BristolMyers Squibb, Hellas, Greece. A list of participants in the Hypertenshell study is given in the Appendix. Address correspondence and reprint requests to Prof. Aris D. Efstratopoulos, 20, Vasileos Irakliou Street, 10682 Athens, Greece; e-mail: [email protected]

© 2006 by the American Journal of Hypertension, Ltd. Published by Elsevier Inc.

0895-7061/06/$30.00 doi:10.1016/j.amjhyper.2005.07.011

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BP (DBP) of 10 mm Hg, the risk for CVD doubles along the whole spectrum of BP from 115/75 to 185/115 mm Hg.4 It is estimated that in patients with a BP of 140 to 159/90 to 99 mm Hg and at least one additional risk factor, the steady reduction of SBP by 12 mm Hg for 10 years will prevent one death for every 11 treated hypertensive patients.5 According to the seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7),6 individuals with a SBP of 120 to 139 mm Hg and a DBP of 80 to 89 mm Hg must be evaluated as prehypertensive and must undergo treatment with lifestyle modification to prevent a steady increase of BP with resultant CVD. However some 25% of the approximately 50 million individuals in the United States do not know that they have hypertension.7 The problem is even greater in the rest of the world, where ⬎800 million individuals or ⬎20% of adults are hypertensive with a very poor rate of control, averaging about 18% achieving the BP goal of ⬍140/90 mm Hg. According to the most recent data from the National Health and Nutrition Examination Survey (NHANES) (1999 –2000), only one third (⬃34%) of hypertensive patients who have been treated achieve satisfactory BP control (ie, ⱕ140/90 mm Hg).8 In a recent systematic review of the worldwide prevalence, awareness, treatment and control of hypertension,9 the lowest prevalence of hypertension was found to be 3.4% (for men in rural India) and the highest 72.5% (in women in Poland). In Europe, the worst control of hypertension (using a threshold of ⱕ140/90 mm Hg to designate adequate control) was found in Poland (4%) and the highest score was noted in France (33%). In Greece, knowledge about the prevalence, awareness, treatment, and control of hypertension is inadequate and is limited to a few regional studies.10 –13 Therefore the aim of the present study was to investigate the current status of hypertension in Greece and to estimate the current prevalence, awareness, treatment, and control of hypertension in the adult population of Greece. The study was also intended to provide an estimate of the absolute number of persons with hypertension (the so-called hypertension burden).14 This information is vitally important for health policy, medical care, and public health strategy as well as for resource allocation.

Methods The Hypertension Study in General Practice in Hellas (Hypertenshell) was conducted from September 2002 to April 2004. The target population comprised 11,950 subjects in the 98 participating health centers (HC) throughout Greece. Study Population The present study used a cross-sectional survey that was carried out in 98 HC across Greece (see Appendix). The survey included all individuals ⱖ17 years of age who were

permanent inhabitants of each area served by the specific HC. All participants were previously enrolled in and attended the Health Center of their area. A total of 15,000 invitations to participate in this survey were sent out and 11,950 individuals (⬃75%) agreed to participate. The main reason given for refusal to participate was difficulty with work. The study protocol was evaluated and approved by the Ethics Committee of our hospital and the Ministry of Health in Greece. Subject Evaluation In each collaborating HC, a well-trained investigator evaluated all participants from the area in the HC office. The initial visit involved an interview to collect information on demographic and lifestyle data (salt intake, alcohol consumption, smoking, and exercise), which included history of hypertension, previous drug treatment for hypertension (as well as medication adherence and tolerability with regard to side effects), smoking and alcohol consumption, and concurrent medication for conditions other than hypertension. Information was also obtained regarding blood pressure (BP) measurements (self-measurements, measurements at the clinic or pharmacy, and frequency of measurements). In addition, information was collected for coexisting diseases and complications such as previous stroke, ischemic heart disease, renal dysfunction, diabetes mellitus, hyperlipidemia, and any other condition mentioned by the participant. Measurement of BP Clinic BP was measured by a physician in each HC according to guidelines of the International Society of Hypertension (ISH)/World Health Organization (WHO; 1999) and the JNC-VI.16,17 Measurements were taken using a standard mercury sphygmomanometer Baumomanometer, W.A. Baum, NY) with a bladder size of 12 ⫻ 35 cm (for obese persons a sphygmomanometer with a larger bladder size was used). Triplicate BP measurements were taken using the subject’s left arm with the subject in the sitting position after 5 min of rest, with 1 min between measurements (Korotkoff phase V for DBP); the mean of three measurements was used as the final value. Participants with an elevated BP measurement were invited to attend a second clinic visit after 1 to 2 weeks to have their BP measured again; the average BP of the second visit was used as a criterion for the diagnosis and control of hypertension. In addition, all treated hypertensive patients were asked to return for a second visit after 1 to 2 weeks to have their BP measured. Twelve-lead electrocardiograpy was performed in subjects diagnosed as hypertensive, and echocardiography was also performed in those with signs of left ventricular hypertrophy. Left ventricular mass index (LVMI) was evaluated using M-mode echocardiography and the Penn

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Table 1. Comparison of normotensive and hypertensive participants by body mass index (BMI) and age All subjects (n ⴝ 11,540) Age: 57.5 ⴞ 0.16

Normotensive subjects N ⴝ 7,951 (68.9%) Age: 49 ⴞ 0.32

Overweight subjects (BMI 25–29.9 kg/m2) All Men Women Obese subjects (BMI ⬎30) All Men Women

Hypertensive subjects N ⴝ 3,589 (31.1%) P Age: 67.1 ⴞ 0.14