383 Hypertension control in small but well-characterised
urban and rural populations in Varna region
Krassimira
1
Stoeva ,
1
Dokova ,
1
Feschieva ,
Klara
Nevijana
Philip
4
5
6
Ioto Iotov , Adela Sanz , John Powles
2
Kirov ,
3
Petrova ,
Stefka
(1) Dept of Social Medicine, Medical University, Varna, Bulgaria, (2) Stroke Unit, University Hospital, Varna, Bulgaria, (3) National Centre for Hygiene, Medical Ecology and
Nutrition, Sofia, (4) Cardiology Department, Medical University , Varna, Bulgaria, (5) Department of Preventive Medicine and Public Health, University of the Basque Country, Bilbao,
Spain, (6) Dept of Public Health and Primary Care, University of Cambridge
Results (cont)
Introduction
Methods (cont)
About 67% of all deaths in Bulgaria are officially
criteria proved co-extensive.)
attributed to vascular causes and the rates for deaths
attributed to stroke are very high relative to those of
Anti-hypertensive medications by frequency of
mention (generic names, n=138)
‘Controlled’ if their usual pressures were in the
normotensive range.
west European populations [1].
Stroke incidence and case fatality in rural areas near
residents[2].
Few studies have reported on the effectiveness with
which hypertension is controlled in Bulgarian
populations.
20
Verapamil
Varna are amongst the highest yet reported for an
European population but are less elevated in city
38
Enalapril
18
Nifedipin
Results
8
Propranol
pressures from urban females to rural males, the gradient
6
Diltiazem
in proportions classified as hypertensive was heavily
5
Clonidine
affected by treatment proportions.
Atenolol
4
Indapamide
4
We present here data on the levels of ‘awareness,
treatment and control’ of hypertension in small, but well
79%
79% 79%
3
Erposit
72%
70%
9
Chlortalidone
Although there was an increasing gradient in mean blood
characterised populations in Varna region gathered as
14
Captopril
Furosemide
Comb.
/Triamterene,
Metoprolol
part of the Varna Diet and Stroke Study[3].
55%
50%
33%
Methods
2
2
2
Bromazepam
1
Isosorbide dinitras
1
Diazepam
1
81 rural residents and 78 urban residents aged 45 to 74,
took part in ‘Varna Diet and Stroke Study’ in 2000.
Blood pressure was measured in the subject’s home, on
Urban females
Rural females
Urban males
Rural males
% hypertensive by pressure and medication
% hypertensive by pressure criteria only
days 1 and 8 of the two (winter and summer) data
collection cycles. Two measurements were made, on
each occasion, after 5 minutes rest in a sitting position.
When hypertensive subjects were classified as ‘aware’,
Standard mercury sphygmomanometers were used.
‘treated’ or ‘controlled’, there was again a marked gradient
Ambient temperature was recorded on each occasion
from urban females to rural males.
Conclusions
immediately after the measurements of blood pressure
Caution is needed in generalising from these findings due to
were made.
95
‘Usual’ blood pressures are defined as the mean of the
US (NHANES III) [5]
90
summer and winter readings. Because the data were
Varna urban
unbalanced, ‘usual winter (and summer) pressures’ were
79
calculated as least square means using proc glm in SAS
8.2.
populations as, for example, in the USA.
The proportion able to produce evidence of current medication
(‘treated’) is also comparable to western levels (though the poor
64
Individuals were classified as normotensive if usual
studied.
Hypertension appears to be as frequently detected in these
Sofia tranport
workers [6]
Varna rural
73
uncertainty about the representativeness of the subjects
level of achieved control raises questions about compliance with
systolic blood pressure (SBP) was less than 140 mmHg
55
and usual diastolic blood pressure (DBP) was less than
recommended doses).
90 mmHg and the subject did not report current
The failure in hypertension control is mainly manifest in the
treatment for hypertension; otherwise subjects were
failure to achieve target blood pressure levels in the rural
41
classified as hypertensive[4].
36
population.
32
29
Subjects classified as hypertensive were deemed:
Thiazide diuretics, which are cheap but effective medications
(and recommended, semi-officially, in the US for ‘most patients
‘Aware’ if they answered yes to the question: “Have
with uncomplicated hyptertension’ [7]) were rarely used. (A
you ever been told by a doctor or other health worker
related observation was that none of these subjects, many of
that you have high blood pressure?” ‘Treated’ if the
7
answer to the question “Are you taking drugs now for
4
hypertension” was ‘yes’ or ‘not sure’ and the respondent
was able to produce a container of antihypertensive
Aware
Treated
Controlled
medication. (In practice, these 2
whom are at high risk of vascular disease, reported taking low
dose aspirin.)
In summary:
 In these populations at high risk of stroke, the main failure lies
in the inadequate control of blood pressures in rural
populations.
 Cheap effective drugs were under-used whilst more expensive
Receptionist in a rural polyclinic operating under
the former dispensation (mid 1990s)
References
drugs were used ineffectively – a pattern that presents
[1] WHO Regional Office for Europe. Health for all database [computer program].
Copenhagen, WHO Regional Office for Europe; updated June, 2002
(http://www.who.dk/country/country.htm)
opportunities for enhancing the cost-effectiveness of hyper-
[2] Powles J, Kirov P, Feschieva N, et al. Stroke in urban and rural populations in north-east
Bulgaria: incidence and case fatality findings from a 'hot pursuit' study . BMC-Public
Health 2002;2(1):24.
 Risk factor surveys in Bulgaria should evaluate the
[3] See http://www.phpc.cam.ac.uk/varna/stroke/index.html for background
populations.
[4] The sixth report of the Joint National Committee on Prevention, Detection, Evaluation
and Treatment of high blood pressure. NIH Publication No 98 40-80, 11. 1997.
 Trials are urgently needed of the best means for enhancing the
[5] Burt VL, Culter JA, Higgins M, Horan MJ, Labarthe D, Whelton P, Brown C, Roccella EJ.
Trends in the prevalence, awareness, treatment, and control of hypertension in the adult
US population. Data from the health examination surveys, 1960 to 1991 Hypertension 1995;
26 (1) : 60-9.
[6] Stein AD, Stoyanovsky V, Mincheva V, Dimitrov E, Hodjeva D, Petkov A, Tsanova V.
Prevalence, awareness, treatment and control of hypertension in a working Bulgarian
population. Eur J Epidemiol 2000; 16 (3) : 265-70.
[7] Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr., Jones DW,
Materson BJ, Oparil S, Wright JT, Jr., Roccella EJ. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure:
The JNC 7 Report. JAMA: The Journal of the American Medical Association 2003; 289 (19) :
2560.
Web address: http://www.phpc.cam.ac.uk/varna/stroke/index.html
tension control in these economically disadvantaged groups.
effectiveness of hypertension control in large representative
cost-effectiveness of hypertension control in Bulgaria,
especially in rural areas.
Funding source