July 2008.indd Control and Management of Hypertension at a University Health Centre in Oman Abdulaziz Almahrezi,1 *Ibrahim Al-Zakwani,2 Ayman Al-Aamri,3 Samia Al-Khaldi,3 Nisrin Al-Zadjali,3 Mohammed Al-Hatali,3 Abdullah Al-Shukeili3 SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JULY 2008, VOLUME 8, ISSUE 2, P. 179-184 SULTAN QABOOS UNIVERSITY© SUBMITTED - 4TH MARCH 2008 ACCEPTED - 21ST APRIL 2008 جامعي صحي وعالجه مبركز ضغط الدم ارتفاع مرض على السيطرة عمان في عبداهللا ، الهطالي محمد ، الزدجالي ، نسرين اخلالدي ، ساميه العامري الزكواني ، أمين ، إبراهيم احملرزي عبدالعزيز الشكيلي عمان. في قابوس في مركز صحي بجامعة السلطان عالجه وطرق عليه والسيطرة الدم ضغط ارتفاع مرض انتشار معدل امللخص: الهدف: تقييم والذين ، أكثر أو ــنة 18 س الدم البالغة أعمارهم ارتفاع ضغط املصابني مبرض املرضى جميع ــتعادية االس املقطعية ــة الدراس هذه ــملت الطريقة: ش ــاطي الدم االنقباضي واالنبس ضغط قيم حتليل مت .2002 1998 و بني عامي ما الفترة خالل قابوس ــلطان الس بجامعة الصحي املركز مبراجعة قاموا (التقرير الدم ضغط ارتفاع وعالج وتقييم ــف وكش ملنع املشتركة الوطنية اللجنة معايير ــتخدام اس مت للمركز. األخيرة الثالثة الزيارات في ــجلة املس البيانات حتليل مت االنبساطي. للضغط زئبقي و90 مليمتر االنقباضي للضغط زئبقي 140 مليمتر ,أقل من بالضغط التحكم درجة لتعريف السابع) ) هو الدم ضغط ارتفاع ــار مرض انتش معدل أن وجد ، طبيا ــجال 7702 س مراجعة النتائج: بعد األحادي. املتغير اإلحصائي ذو التحليل ــتخدام باس العمانيني من كانوا املرضى أغلب %54 - 101 مريضة). ) بلغت النساء ــبة نس ــنة. 55±11 س للعينة العمر ــط متوس كان %2.4 - 187 مريضا). على ضغط ــيطرة الس درجة أن لوحظ (41 % - 77 مريضا). ــت كان ــيطرة الس املصابني بضغط الدم حتت ــى املرض ــبة نس ــا). (66 % - 123 مريض كانوا املرضى معظم .(P= 0.017 , % 53 ــع م (35 % مقارنة إحصائيا معتدة ــورة بص العمانيني مع غير مقارنة العمانيني ــدى ل أقل ــت ــدم كان ال حتويل ومثبطات البيتا محصرات أدوية كانت . ــن بدواءي يعاجلون %27 - 50 مريضا) ) بينما كان هناك %70 - 131 مريضا). ) ــد ــدواء واح ب ــون يعاجل أدوية كانت املزدوج العالج أدوية فيما يخص . التوالي على %25 - 47 مريضا) و %34 - 64 مريضا ) أحادية كأدوية شيوعا األكثر األجنيوتينسن أنزمي األكثر هي %24 - 12 مريضا) ) للبول املدرة األدوية مع البيتا ومحصرات %28 - 14 مريضا) ) البيتا محصرات مع األجنيوتينسن انزمي حتويل مثبطات أن الدراسة هذه أظهرت الوطني. املتوسط مع منخفضا باملقارنة يعد العينة هذه في الدم ارتفاع ضغط مرض ــار انتش معدل اخلالصة: إن ــيوعا. ش دول أخرى. في املسجلة النسب ولكنه أعلى من األمثل ليس هو الدم ارتفاع ضغط على السيطرة درجة عمان. املرض ، ، عالج الوقاية والسيطرة ، ضغط الدم ارتفاع الكلمات: مفتاح Departments of 1Family Medicine & Public Health; 2Pharmacy, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman; 3Medical Students College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman *To whom correspondence should be addressed. Email: ial_zakwani@yahoo.com ABSTRACT Objectives: To evaluate the prevalence of hypertension, its control and management at Sultan Qaboos University (SQU) Health Centre, Oman. Methods: This was a retrospective cross-sectional study, in which were enrolled all the subjects (≥8 years), with the diagnosis of essential hypertension, who attended the SQU Health Centre between 998 and 2002. The systolic and diastolic blood pressure (BP) values of the last three visits were used for analysis. BP control was defined using the Joint National Committee (JNC-7) criteria, <40 mmHg and <90 mmHg for systolic and diastolic BPs, respectively. Analyses were performed using univariate statistics. Results: Among the 7,702 medical records reviewed, the prevalence of hypertension was 2.4% (n = 87). The overall mean age of the cohort was 55± years, 54% (n = 0) were females, and majority of the subjects were Omanis (n = 23; 66%). The proportion of subjects who had their BP controlled was 4% (n = 77) with Omanis significantly less likely to have their BP controlled compared to non-Omanis (53% versus 35%; p = 0.07). The majority of the subjects were on mono (n = 3; 70%) followed by dual (n = 50; 27%) anti-hypertensive therapies. The most frequent mono anti-hypertensive therapies were B-blockers (n = 64; 34%) and angiotensin-con- verting enzyme (ACE) inhibitors (n = 47; 25%). Among the dual combination therapies, the most common prescribed regimens were ACE inhibitor plus B-blocker (n = 4; 28%) and B-blocker plus diuretic (n = 2; 24%). Conclusion: The prevalence of hypertension in this patient population was low compared to the national average. This study shows that control of hypertension is not optimal, but higher than those reported elsewhere. Key words: Hypertension; Prevention and control; Disease management; Oman. C L I N I C A L A N D B A S I C R E S E A R C H A B D U L A Z I Z A L M A H R E Z I , I B R A H I M A L - Z A K WA N I , AY M A N A L - A A M R I , S A M I A A L - K H A L D I , N I S R I N A L - Z A D J A L I , M O H A M M E D A L - H ATA L I A N D A B D U L L A H A L -S H U K E I L I 180 HYPERTENSION IS A COMMON DISEASE WITH significant morbidity and mortality. It is theleading diagnosis made in physician offices in the United States.1 Twenty-six percent of the world adult population has hypertension.2 Moreover, the proportion is expected to rise further in 2025 to 29.2% with an estimated total number of 1.56 billion affected adults.2 The reported prevalence varies around the world with the lowest prevalence in rural India (3.4% in men and 6.8% in women) and the highest preva- lence in Poland (68.9% in men and 72.5% in women).3 In Oman, a community based survey conducted in 2000 estimated the prevalence of hypertension to be 33%.4 High blood pressure (BP) leads to an increasing risk of stroke, myocardial infarction and cardiovascu- lar disease, all of which cause mortality.5, 6, 7 Further- more, hypertension contributes to the prevalence of other cardiovascular risk factors, such as insulin re- sistance, lipid abnormalities, changes in renal func- tion, obesity, left ventricular hypertrophy, diastolic dysfunction, and abnormalities in vascular structure.8 Clinical trials have unequivocally shown that lowering BP reduces cardiovascular morbidity and mortality in patients with hypertension of all degrees of severity.8 Despite the significance of the problem with respect to overall health, control of high blood pressure (BP < 140/90 mmHg while on antihypertensive medication) is far from being optimal. Data from the USA (the Na- tional Health and Nutrition Survey) have shown that those achieving target BP account only for 36% of the hypertensive population.9 A control rate of 25% was reported from a primary health care in Saudi Arabia.10 Researchers from Bahrain have reported a control rate of 16.5%.11 Similar data on hypertension control from Oman is lacking. The aim of this study was to determine the preva- lence of hypertension, its control and management at Sultan Qaboos University (SQU) Health Centre in Muscat, Oman. The SQU Health Centre provides free health care services to all university employees and their dependants. M E T H O D S This study included all patients, 18 years and above, who were documented to have “essential hyperten- sion” in their medical records at the Health Centre. The cohort had to have a minimum period of one year follow up. The charts reviewed were of those patients attending the Health Centre over a five-year period between January 1st 1998 and December 31st 2002. The following information was collected: age, gen- der, nationality (Omani, non-Omani), the three most recent BP readings, medications, current smoking sta- tus (yes, no), body mass index (BMI), the frequency of attendance at the outpatient clinic (within 3 months, 3-6 months, > 6 months), associated chronic diseases and the presence of any complications secondary to Advances in Knowledge - Blood pressure (BP) control in this cohort was low. - Diabetics, in particular, had a much lower BP control. - Omanis were significantly less likely to achieve BP targets compared to non-Omanis. - The majority of the subjects were on mono anti-hypertensive therapy. - Beta-blockers were the most commonly used monotherapy followed by angiotensin-converting enzyme (ACE) inhibitors. - The most commonly prescribed dual anti-hypertensive regimens were ACE inhibitor plus beta-blocker and beta-blocker plus diuretic. Application to Patient Care - Physicians should be more aggressive in controlling hypertension. - Physicians should continually update their knowledge with the latest treatment guidelines. - Combination therapies should be prescribed more often, particularly in diabetics. - Close attention should be paid to Omanis in order to improve their BP control. C O N T R O L A N D M A N A G E M E N T O F H Y P E R T E N S I O N AT A U N I V E R S I T Y H E A LT H C E N T R E I N O M A N 181 hypertension. Descriptive statistics were used to describe the data. For categorical variables, frequencies and per- centages were reported. Differences between groups were analyzed using Pearson’s χ2 tests or Fisher’s exact tests (for cells less than 5). For continuous variables, means and standard deviations (±SD) were presented. Mean differences between groups were analysed us- ing unpaired Student’s t-tests. An a priori two-tailed level of significance was set at the 0.05 level. Statisti- cal analyses were performed using STATA version 9.2 software (StataCorp 2006, Stata Statistical Software; Release 9.2, College Station, TX, USA). Table 1: Demographic, clinical, healthcare resource use, and pharmaceutical characteristics of the study cohort stratified by blood pressure (BP) goal attainment as per the Joint National Committee ( JNC-7) recommendations Characteristic Blood Pressure Goal Attainment as per JNC-7 No (n = 110) Yes (n = 77) p-value Demographic Age, mean±SD, in years 54±11 55±11 0.546 Female gender, n (%) 57 (52%) 44 (57%) 0.472 Omani national, n (%) 80 (73%) 43 (56%) 0.017 BMI, mean±SD, in kg/m2 30±5.7 31±6.4 0.558 Smoking status, n (%) 8 (7.3%) 4 (5.2%) 0.764 Clinical Dyslipidaemia, n (%) 44 (40%) 34 (44%) 0.571 Diabetes mellitus, n (%) 34 (31%) 25 (32%) 0.821 Cardiac disease, n (%) 13 (12%) 5 (6.5%) 0.315 Diabetic nephropathy, n (%) 4 (3.6%) 1 (1.3%) 0.650 Diabetic retinopathy, n (%) 3 (2.7%) 0 (0%) 0.269 Stroke, n (%) 3 (2.7%) 0 (0%) 0.269 Healthcare Resource Use Attendance of OPD Visits, n (%) 0.955 Within 3 months, n (%) 91 (83%) 63 (82%) Between 3-6 month, n (%) 13 (12%) 10 (13%) After 6 months, n (%) 6 (5.5%) 4 (5.2%) Pharmaceutical Not on anti-hypertensive, n (%) 4 (3.6%) 2 (2.6 %) 0.894 Monotherapy Beta-Blocker, n (%) 35 (32%) 29 (38%) ACEI, n (%) 23 (21%) 24 (31%) ARB, n (%) 7 (6.4%) 1 (1.3%) CCB, n (%) 4 (3.6%) 1 (1.3%) Diuretic, n (%) 5 (4.6%) 2 (2.6%) Dual therapy ACEI + Beta-Blocker, n (%) 9 (8.2%) 5 (6.5%) ACEI + CCB 3 (2.7%) 1 (1.3%) ACEI + Diuretic 2 (1.8%) 1 (1.3%) ACEI + ARB 1 (1.0 %) 0 (0%) Beta-Blocker + Diuretic, n (%) 7 (6.4%) 5 (6.5%) Beta-Blocker + CCB, n (%) 3 (2.7%) 2 (2.6%) Beta-Blocker + ARB, n (%) 2 (1.8%) 2 (2.6%) Diuretic + ARB 2 (1.8%) 1 (1.3%) CCB + ARB, n (%) 2 (1.8%) 0 (0%) CCB + Diuretic, n (%) 1 (1.0%) 1 (1.3%) SD = Standard deviation; BMI = Body Mass Index; OPD = Outpatient Department; ACEI = Angiotensin Converting Enzyme Inhibitor; ARB = Angiotensin Receptor Blocker; CCB = Calcium Channel Blocker; BP control was defined as casual BP of <140 (systolic) and <90 mmHg (diastolic) as per the JNC-7; Percents are column percents; Differences between groups were analyzed using unpaired Student’s t-test, Pearson’s χ2 test, and Fisher’s Exact test whenever appropriate. A B D U L A Z I Z A L M A H R E Z I , I B R A H I M A L - Z A K WA N I , AY M A N A L - A A M R I , S A M I A A L - K H A L D I , N I S R I N A L - Z A D J A L I , M O H A M M E D A L - H ATA L I A N D A B D U L L A H A L -S H U K E I L I 182 R E S U L T S Among the 7,702 charts reviewed, the prevalence of hypertension was 2.4% (n = 187). The characteristics of the study cohort are shown in Table 1. The overall mean age of the cohort was 55±11 years, 54% (n = 101) were females, and majority of the subjects were Oma- nis (n = 123; 66%). The proportion of subjects who had their BP controlled was 41% (n = 77) with Oma- nis significantly less likely to have their BP controlled compared to non-Omanis (35% versus 53%; p = 0.017). Omanis were also slightly more obese compared to the non-Omanis (BMI was 31 versus 29 kg/m2; p = 0.091). The proportion of diabetic subjects who had their BP controlled (<130 mmHg systolic and <80 mmHg di- astolic) was only 10% (n = 6 out of 59 diabetics) [Table 1]. Males were more likely to be smokers than females (12% versus 2%; p = 0.013). Furthermore, females were also more obese than their male counterparts (BMI was 31 versus 29 kg/m2; p = 0.048). However, there was no statistical difference in hypertension goal at- tainment between the genders (39% male versus 44% female; p = 0.472). The majority of the subjects were on monotherapy (n = 131; 70%) followed by dual regi- mens (n = 50; 27%). The most frequent mono anti-hy- pertensive therapies were B-blockers (n = 64; 34%) and angiotensin-converting enzyme (ACE) inhibitors (n = 47; 25%). Among the dual combination therapies, the most common prescribed regimens were ACE inhibi- tor plus B-blocker (n = 14; 28%) and B-blocker plus di- uretic (n = 12; 24%). Those on dual therapies were less likely to attain their goal than those on monotherapies (36% versus 44%; p = 0.359; power 12%). However, the dual regimen group also consisted of more diabet- ics (38% versus 27%; p = 0.169; power 25%) as well as those with dyslipidaemia (54% versus 37%; p = 0.043). D I S C U S S I O N The three main findings in our study were the follow- ing: the majority of our subjects (59%) were not treat- ed so as to achieve their target BP, particularly diabet- ics; Omanis were less likely to have their BP controlled compared to non-Omanis, and the majority of our pa- tients were on monotherapy. Research conducted worldwide points clearly to the difficulty in achieving satisfactory BP control in a large proportion of treated patients. Worldwide, control rates vary from as low as 5.4% in Korea to as high as 58% in Barbados.3 Numerous factors may contribute to ineffective hypertension control.12 Non- adherence with medication is very common amongst hypertensive patients. It has been reported that up to 60% of patients discontinue their anti-hypertensive medications within the first 12 months.13 Reasons include complex medication regimens, adverse ef- fects, convenience factors such as dosing frequency, personal health beliefs, and attitudes regarding treat- ment of an often asymptomatic condition.14 Physician behaviour could also be a major obstacle to the suc- cessful achievement of target BP goals. The major con- cern relates to the reluctance of physicians to change treatment when BP control is inadequate.15 The physi- cian might not also be aware of the recent treatment guidelines. For example, a study from the USA reveals that 41% of physicians have not heard of or are not familiar with the reports of the Joint National Com- mittee (JNC), Detection, Evaluation, and Treatment of High Blood Pressure and their hypertension treatment guidelines.16 Patients who have both diabetes and hypertension are at a higher risk of cardiovascular events compared to non-diabetics.17 The United Kingdom Prospective Diabetes Study (UKPDS) suggests that tight control of BP prevents the development of microvascular and macrovascular complications in patients with Type 2 diabetes.18 The guidelines of the seventh report of the JNC recommend a target BP of 130/80 in patients who have concomitant diabetes. 19 Physicians, however, ap- pear to be doing a poor job of helping patients with diabetes achieve this goal. In a study by Abbott and colleagues, only 11% of the diabetic patients treated for hypertension were reported to have achieved the systolic BP goal of <130 mmHg.20 In our study, the BP control in diabetics was similar (10%); furthermore, only 27% (16 out of 59) of the diabetics were on dual anti-hypertensive therapies in our study. This is against the JNC19 recommendations, which clearly state that diabetics be treated with at least two anti-hypertensive medications to obtain optimal BP control. Possible reasons for the poor control of BP among Omanis are ethnicity, higher prevalence of male gen- der (55% versus 45%; p = 0.003) and obesity (31 versus 29 kg/m2; p = 0.091). Racial differences have been doc- umented as a cause for differences in the prevalence, course, and control of hypertension.21 For instance, Af- rican-Americans were reported to have an increased prevalence of hypertension, higher mean BP levels, and higher morbidity and mortality rates attributable C O N T R O L A N D M A N A G E M E N T O F H Y P E R T E N S I O N AT A U N I V E R S I T Y H E A LT H C E N T R E I N O M A N 183 to hypertension, compared to white Americans.21 Hy- pertensive blacks have a higher incidence of left ven- tricular dysfunction, stroke, and renal damage, but a lower incidence of ischaemic heart disease, than do hypertensive whites.22 Hypertensive blacks also have lower rates of BP control.21 Furthermore, the two races respond differently to anti-hypertensive medications. Blacks respond well to thiazide diuretics, but poorly to B-blockers and angiotensin-converting enzyme (ACE) inhibitors compared to whites.23 Pathophysiological differences between the two populations such as salt sensitivity, rennin levels and dopamine response to a salt load might be responsible for the differences in effectiveness.22 Recent clinical trials have shown that effective BP control can be achieved in most hypertensive patients, but to do so requires two or more antihypertensive drugs for most patients.24, 25, 26 Thirty to 60% of patients will be controlled with a single drug regimen, while two drugs in combination are likely to improve control rates in 80 to 85%; three or more drugs will provide control in 90 to 95% of patients.27 Most of our patients were on monotherapy. In fact, this might have contrib- uted to unsatisfactory BP control in our subjects. In addition, diuretics which are widely recommended as a first line therapy were only rarely used in our cohort (3.7%) [Table 1]. This low use could be due to the fact that the pharmaceutical industry promotes the use of newer and more expensive alternatives. This study has two major limitations. The study population is highly educated, and the treatment of hypertension may not be representative of those expe- rienced by the general population. The ideal setting at the university which ensures the availability of a wide variety of anti-hypertensive medications and easy ac- cess to the facilities of a tertiary care hospital differ widely from the setting and population in the general community. C O N C L U S I O N In conclusion, hypertension is not adequately con- trolled in our cohort particularly in diabetics. The racial background was a significant factor correlating with BP control. 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