Variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level

O' Donnell M 1 , Hankey GJ 2 , Rangarajan S 3 , Chin SL 3 , Rao-Melacini P 3 , Ferguson J 4 Show all authors , Xavier D 5 , Lisheng L 6 , Zhang H 7 , Pais P 8 , Lopez-Jaramillo P 9 , Damasceno A 10 , Langhorne P 11 , Rosengren A 12 , Dans AL 13 , Elsayed A 14 , Avezum A 15 , Mondo C 16 , Smyth A 4 , Judge C 17 , Diener HC 18 , Ryglewicz D 19 , Czlonkowska A 19 , Pogosova N 20 , Weimar C 21 , Iqbal R 22 , Diaz R 23 , Yusoff K 24 , Yusufali A 25 , Oguz A 26 , Wang X 27 , Penaherrera E 28 , Lanas F 29 , Ogah OS 30 , Ogunniyi A 31 , Iversen HK 32 , Malaga G 33 , Rumboldt Z 34 , Oveisgharan S 35 , AlHussain F 36 , Daliwonga M 37 , Nilanont Y 38 , Yusuf S 3

Affiliations 

  • 1 HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland martin.odonnell@nuigalway.ie
  • 2 Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
  • 3 Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
  • 4 National University of Ireland Galway, Galway, Ireland
  • 5 St John's Research Insitiute, Bangalore, Karnataka, India
  • 6 National Center for Cardiovascular Diseases China, Xicheng District, Beijing, China
  • 7 Beijing Hypertension League Institute, Beijing, China
  • 8 St John's National Academy of Health Sciences, Bangalore, Karnataka, India
  • 9 Instituto de Investigaciones MASIRA, Universidad de Santander, Bucaramanga, Colombia
  • 10 Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
  • 11 Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
  • 12 Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
  • 13 University of the Philippines Manila College of Medicine, Manila, Metro Manila, Philippines
  • 14 Alzaiem Alazhari University, Khartoum, Sudan
  • 15 International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
  • 16 Kiruddu National Referral Hospital, Kampala, Uganda
  • 17 Medicine, National University of Ireland Galway, Galway, Galway, Ireland
  • 18 Department of Neurology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
  • 19 Military Institute of Aviation Medicine, Warsaw, Poland
  • 20 National Medical Research Center of Cardiology, Moscow, Russia, Moskva, Russian Federation
  • 21 Neurology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
  • 22 Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 23 Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
  • 24 Universiti Teknologi MARA, Selayang, Selangor and UCSI University, Kuala Lumpur, Malaysia
  • 25 Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, UAE
  • 26 Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Istanbul, Turkey
  • 27 Laboratory of Human Genetics, Beijing Hypertension League Institute, Beijing, China
  • 28 Department of Cardiology, Luis Vernaza General Hospital, Guayaquil, Guayas, Ecuador
  • 29 Internal Medicine, Universidad de La Frontera, Temuco, Chile
  • 30 Division of Cardiology, University of Ibadan, Ibadan, Oyo, Nigeria
  • 31 Neurology Unit, Department of Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
  • 32 Department of Neurology, University of Copenhagen, Rigshospitalet, Denmark
  • 33 School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
  • 34 Department of Medicine, University of Split, Split, Splitsko-dalmatinska, Croatia
  • 35 Rush University Medical Center, Chicago, Illinois, USA
  • 36 King Saud University, Riyadh, Riyadh Province, Saudi Arabia
  • 37 Department of Medicine, University of Limpopo, Sovenga, Limpopo, South Africa
  • 38 Division of Neurology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Heart, 2020 Dec 14.
PMID: 33318082 DOI: 10.1136/heartjnl-2019-316515

Abstract

OBJECTIVE: Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke.

METHODS: We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension.

RESULTS: Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46).

CONCLUSIONS: Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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