ANNALS OF IBADAN POSTGRADUATE MEDICINE
A. Abdu1, A.B. Lawrence2, A.T. Shuaibu2 and T. Sani2
Background: High blood pressure is an independent risk factor for cerebrovascular, renal and cardiovascular disease. According to World Health Organization treatment to target Blood Pressure (BP) of <140/90 mmHg has been associated with decrease in morbidity and mortality. Despite this BP control has been very poor even in developed economies.
Objective: We set to assess level of BP control among hypertensive patients on treatment in Dutse, Jigawa state, and to identify treatable causes of failure to achieve target for better management.
Methods: It is a cross sectional study of all hypertensives for more than one year attending medical out patients clinic who have consented. An interviewer administered questionnaire was used to obtain information from the patients.
Results: A total of 123 patients of which 45% were females with mean age, duration of hypertension of 51.9 and 5.9 years respectively and BMI of 40.9Kg/m2. Eighty-three per cent, 91% and 94% were aware of salt restriction, cessation of smoking and alcohol moderation as lifestyle modifications respectively. The mean Systolic and Diastolic BP were 142mmHg and 86mmHg respectively. Fifty-two per cent were on two drugs combination including a diuretic while 4.87% were on three drugs or more. Less than a third (27.6%) had their BP controlled at <140/90mmHg. There was no significant difference in the demographic and clinical data between patients with controlled and uncontrolled BP.
Conclusion: This study found that control of BP is still poor in our setting. This could be due to physician inertia in the treatment, use of inappropriate combination of anti hypertensives or failure to reinforce lifestyle modifications.
Keywords: Blood pressure, Hypertensives, Control, Blacks
Dr. A. Abdu
Department of Internal Medicine,
Rasheed Shekoni Specialist Hospital,
P.M.B. 7200, Dutse,
According to the 2016 global status report, there were 40.5 million deaths due to non-communicable diseases, and about 31.5 million occurred in low- and middle-income countries.1 Cardiovascular diseases accounted for 44% (17.9 million) of the total NCDs mortality. Hypertension is an important modifiable risk factor for cerebrovascular, renal and cardiovascular diseases. Hypertension affects about 44% of Western Europe and 28% of the United States population.2,3 The overall hospital-based prevalence is about 10% to 15%, higher prevalence rates have been reported in middle-income urban and rural areas.4 Despite availability of effective treatment for hypertension, treatment to target BP is a universal problem in both developing and developed countries.
Uncontrolled BP is responsible for 62% of death from cerebrovascular diseases (CVD) and 49% of death from Ischemic Heart Disease (IHD). These increased risks are present in individuals ranging from 40 to 89 years. For every 20 mmHg systolic or 10 mmHg diastolic increase in B.P, there is doubling of mortality from both IHD and CVD.3 The Higher the BP the greater the chance of heart attack, Heart Failure (HF), Stroke and kidney diseases. According to the National Health and Nutrition Examination survey (NHANES) between the year 1999 to 2000 about 34% of Hypertensive Americans achieved controlled blood pressure (less than 140/90mmHg).2,3 Mansia G et al reviewed 2775 hypertensives aged 60.6±16.1 years followed up in 131 specialist centers in Italy and found that only 37.5% achieved optimal blood pressure (defined according to ESH/ESC 2003 guideline as BP less than 140/90mmHg).5 In an extensive review of 8001 hypertensive patients in Japan, Nakado K et al observed achievement rate for treatment goals (as defined by JSH 2014) of 60.2% among young and early phase elderly without Diabetes and chronic kidney disease (CKD).6
In a community survey conducted between October and December 2015 in a town of Aksum northern Ethiopia, Teklay AG et al studied 521 patients and found a control rate of 18.2%.7 In an urban hospital in Nairobi Kenya Achieng’ and colleagues studied 575 hypertensives attending outpatient clinic and found a control rate of 24% which they attributed largely to non-adherence.8 In Ghana a community survey conducted between June 2001 and June 2002 showed that only 22% of the respondents were aware of their hypertension status out of which 11.3% were on treatment with only 2.8% having controlled BP.9 In a clinic-based assessment of BP control in Port Harcourt, Nigeria, Akpa MR and colleagues found a control rate of 33.3% among 207 hypertensive/diabetics reviewed attending cardiology clinic.10 A control rate of 34.5% was found by Igbis et al among 200 randomly selected patients attending Hypertension clinic in Kano.11
This study was conducted to assess the level of blood pressure control, pattern of anti- hypertensive prescription and to determine factors that affect blood pressure control in Rasheed Shekoni Specialist hospital (RSSH Dutse), Northwest Nigeria.
MATERIALS AND METHODS
This is a cross sectional study of Hypertensive patients attending Cardiology clinic of Rasheed Shekoni Specialist Hospital (RSSH) Dutse, Jigawa state in North West Nigeria. It is a state-owned tertiary health institution that is a major referral center from all parts of Jigawa state, some parts of Kano, Bauchi, yobe states and occasionally from Niger republic. The study was conducted from 2nd May 2016 to 2nd November 2016.
The study participants were all patients attending the cardiology clinic of RSSH Dutse who were receiving treatment for hypertension. Patients who gave informed consent were recruited consecutively as subjects. Patients who refused consent, or admitted to non-compliance with anti hypertensives were excluded from the study. Subjects were seen at least three times during the course of the study.
Using a structured questionnaire, biodata, as well duration of hypertension, circumstances leading to the diagnosis and current anti-hypertensive medications were recorded. Likewise, complications of Hypertension such as Heart failure, retinopathy, cerebrovascular disease, nephropathy and encephalopathy were also recorded. Knowledge of lifestyle modification and its application were also recorded. Height was measured to the nearest meter with a stadiometer barefooted while weight was measured in kilogram using a standard weighing scale with light clothing. Body mass index (BMI) was calculated as weight (Kg) divided by the square of the height (m) as defined by world health organization (WHO).12
Blood pressure was measured during first visit with an Accouson’s mercury sphygmomanometer with a standard cuff size (12-13cm wide and 35cm long) on both arms after the subject has rested for at least 5 minutes. The cuff was maintained at heart level and Korotkoff phase I and V were used as the systolic and diastolic BP respectively.13 The arm with the higher reading was used subsequently. On each visit 2 BP measurements separated by at least 2 minutes were taken and the average used. Control was considered adequate when the BP based on the JNC 8 criteria was less than or equals 140/80 mmHg.3 Five milliliter (5ml) of blood was collected in the fasting state for the estimation of fasting blood glucose, lipid profile and electrolytes, creatinine and urea. Hyperglycemia was defined according to WHO criteria14, while lipid abnormalities were defined based on the NCEP criteria.15 Urine was also collected for urinalysis. Proteinuria, and hematuria were graded according to combi-9 urine dipstick test and proteinuria was as 1+ (300mg/L), 2+ (1.5g/L), 3+ (3g/L) and 4+ (20g/L) and hematuria defined as >1+ blood.
Data was analyzed using statistical package for social sciences version 20 (SPSS V20), numerical data were reported as means ±SD, while student t-test was used to compare means. Pearson correlation was used to compare relationship between variables and multiple regression analysis was applied to identify independent predictors of uncontrolled hypertension. Chi square test was used to compare categorical variables. A P value of <0.05 was considered statistical significance. Ethical approval was obtained from the ethics committee of RSSH Dutse and each participant gave an informed consent after proper explanation of the study.
A total of 123 hypertensives were seen during the study period. Fifty five (44.7%) were males and 68 (55.3%) were females, with a female to male ratio of 1.2 to 1, table 1 summarizes the demographic and clinical characteristics of the respondents. The mean age of the respondents was 51.99(±12.49) years with a range from 25 to 85 years. Male respondents were statistically older than females (P =0.03). The mean duration of hypertension was 5.9 (±5.1) years with a range from 1 year to 30 years. Twenty nine (23.6%) were diagnosed following routine medical check, 37 (30.1%) were diagnosed secondary to persistent headache while 12.2%, 8.1% and 4.1% were diagnosed following pregnancy, heart failure and stroke respectively.