Summary
Background
Elevated blood pressure is one of the most important modifiable risk factors for cardiovascular diseases.
Aim
To evaluate blood pressure management in Côte d’Ivoire.
Methods
A retrospective study was conducted among 2575 hypertensive patients from the Institute of Cardiology of Abidjan, who were followed for at least 10 years, between January 2000 and December 2009.
Results
The patients’ mean age ± standard deviation was 59.1 ± 12.5 years; 54.3% were women. At first presentation, hypertension was stage 1 in 21.7%, stage 2 in 32.3% and stage 3 in 46.0% of patients. According to the European guidelines’ stratification of the cardiovascular risk-excess attributable to high blood pressure, 46.7% had a very high added risk, 37.8% had a high added risk and 14.9% had a low-to-moderate added risk. Pharmacological therapy was prescribed in 97.8% of patients; more than 66% were receiving at least two antihypertensive drugs, including fixed-dose combination drugs. The most common agents used were diuretics (59.7%) followed by angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (59.6%). The most common agents for monotherapy were calcium antagonists. When two or more drugs were used, diuretics and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were most commonly used. Blood pressure control was achieved in 43.7% of cases.
Conclusion
In our series, severe hypertension with high added risk or very high added risk was very common. Treatment – mostly diuretics and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers – required at least two antihypertensive drugs to meet the recommended blood pressure target.
Résumé
Introduction
L’hypertension artérielle constitue un des principaux facteurs de risque cardiovasculaires. Cette étude a été entreprise pour évaluer sa prise en charge en consultation externe de l’Institut de cardiologie d’Abidjan.
Méthodes
Il s’agissait d’une étude rétrospective, incluant les hypertendus ayant au moins un an de suivi.
Résultats
Il s’agissait de 2575 patients ayant un âge moyen de 59,1 ± 12,5 ans et dont 54,3 % étaient de sexe féminin. À la consultation initiale, l’hypertension artérielle était de grade 1 dans 21,7 %, de grade 2 dans 32,3 % et de grade 3 dans 46,0 %. Le risque cardiovasculaire évalué selon les recommandations de la Société européenne de cardiologie et la Société européenne d’hypertension artérielle était très élevé dans 46,7 %, élevé dans 37,8 % et faible ou modéré dans 14,9 %. Un traitement médicamenteux a été prescrit dans 97,8 %. Plus de 66 % des patients avaient au moins deux antihypertenseurs incluant les associations fixes. Les antihypertenseurs les plus prescrits étaient les diurétiques (59,7 %) suivis des inhibiteurs de l’enzyme de conversion ou de l’angiotensine 2 (59,6 %). Quand il s’agissait d’une monothérapie, les antagonistes calciques étaient les plus utilisés. En revanche, les associations médicamenteuses ont pris en compte surtout les diurétiques et les inhibiteurs de l’enzyme de conversion ou de l’angiotensine 2. La tension artérielle a été équilibrée chez 43,7 % des patients.
Conclusion
Il s’agissait surtout d’hypertension artérielle sévère avec un risque cardiovasculaire élevé. Pour atteindre l’objectif tensionnel recommandé, une polythérapie a été nécessaire, utilisant surtout les diurétiques et les inhibiteurs de l’enzyme de conversion ou de l’angiotensine 2.
Background
Hypertension is an important worldwide public health challenge because it is one of the most common chronic conditions . In a worldwide survey, 26.4% of the adult population in 2000 had hypertension and 29.2% were projected to have this condition by 2025. The estimated total number of adults with hypertension in 2000 was 972 million and 639 million in economically developing countries . The prevalence of hypertension in Sub-Saharan Africa (SSA) is between 12.5% and 26.9% . In 2005 the World Health Organization’s stepwise approach to the surveillance of non-communicable disease risk factors established a prevalence of hypertension in Côte d’Ivoire of 21.7% .
Hypertension is a major risk factor for cardiovascular disease ; it remains an important cause of coronary heart disease, cerebrovascular disease, peripheral artery disease and heart failure . The 2002 World Health Report estimated that around 11% of the entire disease burden in developed countries was caused by raised blood pressure, and that more than 50% of coronary heart diseases and almost 75% of strokes arose as a result of elevated systolic blood pressure . In SSA, the mortality among patients hospitalized for hypertension-related disorders is over 20% . Unfortunately the particular context of SSA, with its poverty and illiteracy, contributes to the low awareness and suboptimal control and treatment of hypertension . These facts underscore that screening and effective treatment for hypertension should be given higher priority in health policies in this region. It was in this context that we undertook this study at the Institute of Cardiology of Abidjan (ICA), the single university hospital managing cardiovascular diseases in Côte d’Ivoire. The study aimed to describe characteristics, risk factors, treatment and blood pressure control in adult hypertensive patients.
Methods
We undertook a retrospective descriptive study involving patients seen in outpatient clinics at the ICA. The study period spans 10 years, between January 2000 and December 2009. The study population comprised hypertensive adults (aged at least 18 years) with a regular follow-up at the ICA within 1 year. This series included patients who had been receiving initial treatment upon referral to our centre.
We used the standard definition and classification of hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) . The data collected were age, sex and level of blood pressure at initial presentation and, during follow-up, the coexistence of other cardiovascular risk factors, the impact of hypertension and treatment modalities. The following additional cardiovascular risk factors were documented when present: current smoking, dyslipidaemia, diabetes and obesity. Obesity was defined as body mass index greater than 30 kg/m 2 . Waist circumference was recorded when available. Dyslipidaemia was defined according to our biochemistry laboratory standard (total cholesterol > 200 mg/dL or low-density lipoprotein cholesterol > 140 mg/dL or high-density lipoprotein cholesterol < 40 g/L). Diabetic patients were informed and treated for diabetes according to standard clinical practice. New diabetic patients detected at the ICA were diagnosed based on the standard value in our laboratory (fasting plasma glucose > 126 mg/dL on repeated measurement). The overall management of diabetes was coordinated by the individual patient’s physician and not by the cardiology staff of the ICA.
Assessment of the impact of hypertension systematically included electrocardiography and plasma creatinine measurement. All strokes were documented by a brain computerized tomography scan. Echocardiography was frequently performed and the results were included in the data collection. Finally, if other tests were seldom performed (e.g. albuminuria, microalbuminuria, fundoscopy and 24-hour ambulatory blood pressure) they were not used for analysis.
The ESH/ESC categorization of total risk as low, moderate, high and very high added risk has the merit of simplicity and was therefore chosen for risk stratification . In addition, we focused on the evolution of blood pressure during follow-up. Blood pressure control was defined as a treated systolic blood pressure less than 140 mmHg and diastolic blood pressure less than 90 mmHg, and was ascertained by direct measurement of blood pressure.
Data analysis was conducted using Statistical Package for Social Sciences (SPSS) software, version 17. Univariate analysis was performed for significant associations. A P value ≤ 0.05 was considered for statistical significance.
Results
There were 2575 patients (54.3% women) with a mean age ± standard deviation (SD) of 59.1 ± 12.5 years (range: 18–89 years). At first presentation, mean blood pressure was 169/102 mmHg (range: 120/80 to 250/130 mmHg), with inappropriate control in 90.5% of patients. The hypertension was classified as stage 1 in 21.7%, stage 2 in 32.3% and stage 3 in 46.0% of patients. Blood pressure levels were similar in all age groups ( P = 0.18). Stage 3 hypertension was the most common in all age categories ( Fig. 1 ).
Overall, patients had been diagnosed with hypertension for a mean duration ± SD of 8.8 ± 5.3 years (range: 1–15 years) at the time of their initial assessment in our clinics. The mean follow-up duration ± SD in the ICA was 3.3 ± 4.1 years (range: 1–18 years). Other risk factors and organ damage are reported in Table 1 . Cardiovascular complications were left ventricular hypertrophy (44.4%, n = 1144), heart failure (16.2%, n = 417), coronary artery disease (5.2%, n = 133), arrhythmia (4.9%, n = 127) and peripheral arterial disease (0.5%, n = 13). Echocardiography was performed in 1182 patients (45.9%) and was normal in 227 (19.2%). The recorded anomalies were left ventricular diastolic dysfunction (35.6%, n = 421), hypertensive cardiomyopathy (29.7%, n = 351) and minor lesions (slight valve regurgitation, sclerosis, valvular calcification) (11.2%, n = 133). Cardiovascular risk stratification according to the European guideline for the management of arterial hypertension is reported in Table 2 . The very high added risk and high added risk categories were predominant at presentation in 46.7% and 37.8% of patients, respectively.
| % of patients | |
|---|---|
| Other cardiovascular risk factors | |
| Dyslipidaemia | 31.7 |
| Diabetes mellitus | 12.2 |
| Current smoking | 9.1 |
| Obesity | 12.7 |
| Organ damage | |
| None ( n = 665) | 25.8 |
| One organ (58.7%, n = 1512) | |
| Cardiovascular | 48.9 |
| Kidney | 7.0 |
| Cerebral | 2.8 |
| More than one organ (15.5%, n = 398) | |
| Cardiovascular + kidney | 10.8 |
| Cardiovascular + cerebral | 3.4 |
| Kidney + cerebral | 0.4 |
| Cardiovascular + kidney + cerebral | 0.9 |
| Other risk factors, OD or disease | Blood pressure (mmHg) | Total | ||||
|---|---|---|---|---|---|---|
| Normal | High normal | Grade 1 HT | Grade 2 HT | Grade 3 HT | ||
| SBP 120–129 or DBP 80–84 | SBP 130–139 or DBP 85–89 | SBP 140–159 or DBP 90–99 | SBP 160–179 or DBP 100–109 | SBP ≥ 180 or DBP ≥ 110 | ||
| No risk factor | 7 (0.3) | 8 (0.3) | 30 (1.2) | 41 (1.6) | 35 (1.4) | 121 (4.7) |
| 1–2 risk factors | 34 (1.3) | 43 (1.7) | 78 (3.0) | 77 (3.0) | 211 (8.2) | 443 (17.2) |
| 3 or more risk factors, MS, OD or diabetes | 81 (3.1) | 66 (2.6) | 351 (13.6) | 522 (20.3) | 499 (19.4) | 1519 (59.0) |
| Established cardiovascular or renal disease | 2 (0.1) | 4 (0.2) | 47 (1.8) | 113 (4.4) | 326 (12.7) | 492 (19.1) |
| Total | 124 (4.8) | 121 (4.7) | 506 (19.7) | 753 (29.2) | 1071 (41.6) | 2575 (100) |
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