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Valmore J. Bermdez, MD, MPH, PhD1*, Joselyn Rojas, MD, Msc1, Roberto Aez, MD1, Juan Salazar, MD1, Mara Sofa Martnez, BSc1, Mara Jos Calvo, BSc1,
Robys Gonzlez, BSc1, Vanessa Apruzzese, BSc1, Luis Carlos Olivar, BSc1, Luis Miguel Bello, MD1, Edward R. Rojas, MD1, Alexandra C. Toledo, MD1,
Adonas Lubo, MD, MgSc, PhD2, Mara Corina Gmez, MgSc, PhD3, Maricarmen Chacn, MD1, Marjorie Villalobos, MD1, Miguel Aguirre, MD, MSc1,
Manuel Velasco, MD, PhD4, Zafar H. Israili, MD, PhD5, Jos Lpez-Miranda, MD, PhD6
Endocrine and Metabolic Diseases Research Center. University of Zulia, Maracaibo Venezuela.
2.
Works Medicine Institute. School of Medicine, University of Zulia, Maracaibo Venezuela.
3.
Nutrition School. University of Zulia, Maracaibo - Venezuela
4.
Central University of Venezuela. Clinical Pharmacology Unit of Jos Mara Vargas School of Medicine, Caracas Venezuela.
5.
Department of Medicine. Emory University School of Medicine, Atlanta, GA, USA.
6.
Lipid and Atherosclerosis Unit. Department of Medicine. IMIBIC/Reina Sofia University Hospital/University of Cordoba, and CIBER Fisiopatologa Obesidad y Nutricin
(CIBEROBN), Instituto de Salud Carlos III, Spain.
1.
Recibido: 16/04/2012
Abstract
71
Aceptado: 20/06/2012
ypertension (HT) is one of the most prevalent modifiable risk factor for the development of coronary artery disease (CAD),
cerebrovascular disease, and end-stage
kidney disease (ESRD) in the industrialized
countries1. The Framingham study reported that the risk
to develop CAD increases progressively as the levels of systolic and diastolic blood pressure (BP) rise2. Approximately
75% of the American adults with CAD, congestive heart
failure, CvD, or type 2 diabetes mellitus (T2DM) also suffer
from HT3. This pattern is observed not only in developed
countries, but it is also seen in developing countries4. Currently, HT is considered one of the most important public
health problems worldwide5, contributing to an estimated
7.5 million deaths per year6.
According to the World Health Organization (WHO), the
global prevalence of HT in adults over 25 years of age in
2008 was about 40%6. In a systematic review, Kearny et
al.7 reported that the global prevalence of HT in 2000 was
26.4%, equivalent to 972 million people, and this number
is projected to rise to about 1.54 billion people (29.2%)
in 2025. In the majority of the epidemiological studies,
an association has been found between increasing age
and a rise in BP and the prevalence of HT8. However, this
relationship was not observed in populations where there
is low prevalence of obesity, salt consumption, and stress
level, in association with increased physical activity8, suggesting that the increase in BP during the aging process
depends on the level of modernization of the populace
being analyzed9.
A relationship between obesity and BP has been reported10. In addition, elevated BP and the risk of developing
HT appear to vary inversely with socioeconomic indicators,
such as education and household income11. Furthermore,
it has also been reported that HT prevalence differs between countries, and also amongst regions within a given
country, due to the different environmental and genetic
factors10. Although, several investigations have been carried out in Venezuela and some local regions which have
focused on HT, these studies are limited in regard to the
analysis of risk factors surrounding this disease. The purpose of the present study was to determine the prevalence, awareness, treatment and control of HT, and factors associated with its pathology in the municipality of
Maracaibo, State of Zulia, Venezuela.
Introduccin
Population Sample
The sampling method has previously been described in
the Maracaibo City Metabolic Syndrome Prevalence Study
(MMSPS) cross-sectional proposal12. Briefly, using the
population estimates from the National Institute of Statistics (NIS), Venezuela, (1,428,043 in 2007), the sample
was calculated to be 1,986 individuals with 244 subjects
(12.0%) added because of the oversampling method, to
give an overall number of 2,230 individuals from both
sexes, 18 years of age12. The city of Maracaibo is divided into 18 parishes and each of these was proportionally sampled. The sampling was done using a 2-phase
method: during the first phase, the sorting was random
and stratified, where each stratus was represented by sectors from each of the 18 parishes, finally selecting 4 from
each parish. The second phase was stratified to represent
a city block, in which they were selected using a random
number generation tool. All the individuals enrolled in the
study signed an informed written consent before physical examination and blood collection. All procedures were
approved by the Ethics Committee of the Endocrine and
Metabolic Diseases Research Center of The University of
Zulia, Maracaibo, Venezuela.
Physical Examination and Blood
Pressure Measurement
Each individual was subjected to a complete medical history. BP was measured by the auscultatory method using
calibrated mercury sphygmomanometer, appropriate cuff
size, and employing Korotkoff`s phase I and V as systolic
and diastolic BP, respectively. BP was monitored in subjects sitting down with feet resting on the ground. After
a resting period of 15 minutes, the pressure was taken 3
times, with 15 minutes in between each take on two different days. Those subjects with BP above 140/90 mmHg
on more than two occasions, without previous diagnosis
of HT or taking antihypertensive medication were categorized as Newly-Diagnosed Hypertensives, unaware of
the presence of the disease. On the other hand, those
who were referred to having previously been diagnosed
with HT or to taking treatment for it were considered as
Known-Hypertensives. The classification of HT was done
using the criteria reported in the Seventh Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC-7)13. Those with
known history of HT (or taking antihypertensive medications) were classified as controlled or uncontrolled
subjects, according to the classification of JNC-814: a)
<140/90 mmHg in those 18 years with T2DM or chronic
kidney disease; b) <140/90 mmHg in those <60 years; c)
<150/90 mmHg in those 60 years.
Anthropometric Evaluation
A bioelectric scale was used to obtain weight (Tanita,
TBF-310 GS Body Composition Analyzer, Tokyo Japan).
Height was determined by using a calibrated metric measurement tape. For body mass index (BMI) the formula
72
73
Laboratory Analysis
Blood samples were collected after 8 hours of fasting,
and serum/plasma was obtained by centrifugation and
stored at 200C prior to analysis. Serum levels of glucose
total cholesterol, triglycerides, high density lipoproteincholesterol (HDL-C) were determined using computerized
equipment (Human Gesellschoft Biochemica and Diagnostica MBH, Magdeburg, Germany. Fasting insulin levels
were determined with Drug International Inc (New Jersey,
USA) insulin kit.
Glycemic status and Metabolic Syndrome
Glycemic status was classified as follows17: a) Type 2 Diabetes (T2DM) was diagnosed when any individual obtained
126 mg/dL in 2 different blood sample measurements
(T2DM Newly Diagnosed), or those with previous diagnosis of the disease (Known T2DM); b) Impaired Fasting
Glucose (IFG) those with fasting glycemia between 100
- <126 mg/dL; and c) Normoglycemic, those with fasting
glucose <100 mg/dL. For the calculation of insulin resistance (IR), the homeostatic model assessment formula
was applied using the HOMA Calculator v2.2.2 available
at https://www.dtu.ox.ac.uk/homacalculator/download.
php, obtaining HOMA-IR, HOMA2--cell and HOMA2-S.
The diagnosis of metabolic syndrome was made by using
the consensus criteria of IDF/NHLBI/AHA-200918.
Statistical Analysis
Qualitative variables are expressed as absolute or relative
frequencies, applying Z Test for Proportions and c2 test
for further analysis. Quantitative variables were subjected
to logarithmic transformation observing a normal distribution after Geary test; results are expressed as mean
SD.To determine differences between means, Student
t-test was applied between the logarithms of the corresponding variables. Data were analyzed with the Statistical Package for Social Sciences (SPSS) v.19 for Windows
(SPSS IBM Chicago, IL). The results were considered statistically significant when p<0.05.
Results
increased gradually to 20% and 12% respectively, in individuals with abdominal circumference in the 5th quintile.
Treatment and Control of Hypertension
According to JNC-8, there were 216 BP-controlled individuals, 44.7% (n=109) treated and 56.6% (n=107)
untreated. Women obtained higher results among the
controlled group, with 48.6% (n=72) treated and 67.3%
(n=66) untreated, compared with the mens group which
resulted in 38.5% (n=37) treated and 45.1% (n=41) untreated achieving BP goals (p<0.05). Age was associated
with proper BP control (c2=16.621, p=0.01), while factors
such as BMI (c2=6.014, p=0.198), waist circumference
(c2=4.933, p=0.294) and type of medication used for control (c2=4.933, p=0.294) were not. The most prescribed
anti-hypertensive drug class was Angiotensin Converting
Enzyme Inhibitor (ACEI) with 24.2.0% (n=105), followed
by Beta-Blockers with 8.5% (n=37), and Angiotensin receptor II Blockers with 7.4% (n=32); Table 3. Regarding
BP control, there were ethnic differences where Hispanic
Whites had the highest control rates (34.2%), followed
by Mixed Race (28.4%), Afro-Venezuelans (25.0%), and
Amerindians (16.7%).
Table 1. General characteristics of the adult population from the Maracaibo Municipality. Zulia State.
Female
n
Male
%
Total
%
7.6
31.4
18.8
18.2
15.5
5.8
2.7
181
581
396
462
368
163
79
8.1
26.1
17.8
20.7
16.5
7.3
3.5
77.1
15.2
3.4
4.2
0.1
1692
352
66
106
14
75.9
15.8
3.0
4.8
0.6
1.4
24.6
39.2
21.8
8.8
4.2
45
650
786
457
197
95
2.0
29.1
35.2
20.5
8.8
4.3
19.6
18.1
21.1
20.0
21.2
425
439
458
446
462
19.1
19.7
20.5
20.0
20.7
69.6
22.0
5.8
2.6
1606
435
130
57
72.1
19.5
5.8
2.6
55.3
44.7
100.0
1284
946
2230
57.6
42.4
100.0
74
Table 2. Prevalence of known history of Hypertension according to age groups and metabolic alterations. Maracaibo Municipality.
Zulia state.
Female
n
75
Male
%
Total
0.0
4.8
10.2
32.6
32.6
13.4
6.4
0
18
36
117
130
84
45
0.5
4.2
8.3
27.0
30.3
19.4
10.4
82,4
14,4
2,1
1,1
0.0
337
69
12
11
4
77,8
15,9
2,8
2,5
0,9
0.0
10.7
36.4
29.4
16.0
7.5
0
61
148
126
66
32
0.0
14.1
34.2
29.1
15.2
7.4
2.7
9.0
23.4
27.1
37.8
14
52
94
122
151
3.2
12.0
21.7
28.2
34.9
50.3
26.2
17.1
6.4
230
109
71
23
53.1
25.2
16.4
5.3
19.8
80.2
43.1
79
354
433
18.2
81.8
100
No prescription
ACEI
BB
ARB
Diuretic
ACEI+BB
CCB
ACEI+ARB
ACEI+Diuretic
BB+ARB
ACEI+CCB
BB+Diuretic
Diuretic+ARB
BB+CCB
CCB+ARB
Diuretic+CCB
ACEI+CCB+Diuretic
ARB+CCB+Diuretic
Total
Mixed Race
n
%
147
43.6
83
24.6
27
8.0
24
7.1
0
0
4
1.2
20
5.9
1
0.3
3
0.9
0
0
1
0.3
7
2.1
12
3.6
3
0.9
2
0.6
1
0.3
1
0.3
1
0.3
337
100.0
Hispanic White
n
%
33
47.8
11
15.9
9
13.0
8
11.6
0
0
0
0
2
2.9
1
1.4
1
1.4
0
0
0
0
3
4.3
1
1.4
0
0
0
0
0
0
0
0
0
0
69
100.0
Ethnic groups
Afro-Venezuelan
Amerindian
n
%
n
%
2
16.7
6
54.5
6
50.0
4
36.4
1
8.3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
16.7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
8.3
0
0
0
0
1
9.1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
12
100.0
11
100.0
n
1
1
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
4
Others
%
25.0
25.0
0
0
0
0
0
0
0
0
0
25.0
25.0
0
0
0
0
0
100.0
n
189
105
37
32
0
4
24
2
4
0
1
11
15
4
2
1
1
1
433
Total
ACEI= Angiotensin Converting Enzyme Inhibitors; BB= -Blockers; ARB= Angiotensin Receptor II Blockers; CCB= Calcium Channel Blockers; HCT= Hydrochlorothiazide
%
43.6
24.2
8.5
7.4
0
0.9
5.5
0.5
0.9
0
0.2
2.5
3.5
0.9
0.5
0.2
0.2
0.2
100.0
76
Figure 2. Distribution according to blood pressure, age group, HOMA2-IR and glycemic status in individuals without previous
history of hypertension, Maracaibo Municipality, Zulia State.
Figure 3. Distribution according to blood pressure and anthropometric parameters in individuals without previous history of
hypertension, Maracaibo Municipality, Zulia State.
Discussion
77
It is a global agreement that HT is a fundamental modifiable cardiovascular risk factor1,2, making imperative its appropriate identification and treatment to ameliorate deleterious effects1,2,5. International guidelines propose that
BP control in hypertensive patients must show a steady
and sustained decline in their BP, to values <140 mmHg
for systolic BP and <90 mmHg for diastolic BP, including
in those with diabetes and target organ damage14. In the
United States, HT has remained constant over the past decade, but it is higher in patients with obesity, diabetes and
those with physical disabilities34; however, in these groups,
HT is better controlled due to closer medical observation
and proper medication35. In the present study, 50.6% of
the hypertensive individuals were controlled; higher in
women (56.1%) than in men (41.7%). In a previous investigation in Maracaibo by Sulbarn et al.26, the percentage
of controlled subjects in a sample from 1997 was 4.5%, a
rate far lower than in the present study, possibly as a result
of improved medical care, promotion of healthy lifestyle,
access to better primary care personnel training and more
efficacious antihypertensive medications.
Acknowledgments
This work was supported by research grant N CC-0437-1021-09-10 from CONDES - University of Zulia, and research
grant N FZ-0058-2007 from Fundacite-Zulia, Venezuela.
Disclosure
The authors have are no conflicts of interest to disclose.
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