20 etal BMC Public Health (2016) 16:170, Ot 10.1 186/512889-016-2835-1 BMC Public Health RESEARCH ARTICLE Open Access Hypertension unawareness among Chinese o- patients with first-ever stroke Qingin Cao"’, Pei Pei?", Jun Zhang Jillian Naylor’, Xinying Fan', Biyang Cai’, Qiliang Dai’, Wen Sun', Ruidong Ye', Ruifeng Shi, Keting Liu, Yongjun Jiang!, Wenhua Liu', Fang Yang’, Wusheng Zhu’, Yunyun Xiong!, Xinfeng Liu! and Gelin Xu!” Abstract Background: The low rates of hypertension treatment and control, partly due to its unawareness, are the main causes of the high stroke incidence in China. The purpose of this study was to evaluate hypertension unawareness amongst patients with first-ever stroke and to detect factors associated with its unawareness. Methods: We selected those diagnosed with hypertension from patients with first-ever stroke registered in the Nanjing Stroke Registy Program between 2004 and 2014. These hypertensives were divided as being aware or unaware of their hypertension by using a brief questionnaire conducted shorly after the stroke. Multivariate logistic regression analysis was performed to identify potential factors associated with hypertension unawareness Results: OF the 5309 patients with first-ever stroke, 3732 (703 5) were diagnosed with hypertension. Among which, 593 (15.9 %) were unaware of their hypertension at the time of stroke onset. Lower-level of education (primary School or iliteracy) and smoking were associated postively with hypertension unawareness; while advanced age, overweight, diabetes mellitus, heart diseases and family history of stroke were associated negatively with hypertension unawareness. Annual data analyzed indicated that the rate of hypertension awareness increased during the past 11 years ((=0613, P= 0045 for trends), Conclusions: A substantial proportion (15.9 %) of Chinese patients with hypertension had not been aware of this covert risk until an overt stroke occurred. Hypertension unawareness was associated with lower educational levels and smoking, which address the importance of health education especially in these individuals. Keywords: China, Hypertension unawareness, Patient education, Risk factors, Stroke Background Hypertension is the leading modifiable risk factor for cardiovascular disease, involved in approximately 54 % of stroke cases and 47 % of ischemic heart disease inci- ences worldwide [1]. With 10-mm Hg lowering in sys- tolic blood pressure (SBP), the relative risk for major cardiovascular events can be reduced by 20 to 25 %, with more remarkable effects on stroke than coronary out- comes (2|. Unfortunately, the control rate of hyperten- sion is as low as 5 % in China [3]. This prevalence of * caneepondence: gelinuonjuecicn "equal contbutor "Deparment of Newology, ing Hospital Medical Schoo of Naryng Lniversty 305 ast Zhongshan Road Nonjing 210002 Jiangsu Prone. China ‘Deparment of Newaogy, eg Hosp Souther Nadal Une, Nanjing 210202Iangau Posnee, China Flr of utr information eae the eof he anicle the Ceane Conor lksnie ard (Biomed central uncontrolled hypertension has been associated with the high stroke incidence and mortality in developing coun- tries (2, 4], Unawareness of elevated blood pressure may bbe a major contributing factor for the inappropriate con- trol of hypertension, absence of anti-hypertension treat- ments (including behavioral interventions) and improper monitoring of blood pressure even with treatments. Ex- ploring possible factors associated with unawareness of elevated blood pressure is of vital importance, therefore, for preventing cardiovascular diseases and other hyper- tension related conditions in the population. Most of the previous studies on hypertension aware- ness, treatment and control were conducted in com- munities or in general populations. Few studies have investigated the hypertension unawareness in stroke patients, especially patients with first-ever stroke. 1 206 Ca t Open Aces This it ne te ams oh Crate Ceres Aon Ritmaresrrncgaoeit) wich per rad enon te changes wae a The Cesta Pte Daman atone rarest apes othe ta mae vten he ee, ne there ae,(20 etal BMC Public Health (2016) 16:170 Considering the high prevalence of untreated and un- controlled hypertension in China (3, 5:6) it is possible that a substantial proportion of hypertensives have been unaware of their elevated blood pressure until a stroke occurred. It is reasonable to predict that stroke incidence may be reduced if hypertension awareness is, strengthened. To evaluate the magnitude of unaware- ness and elucidate possible correlates, we assessed, hypertension unawareness in a large Chinese patient group with first-ever stroke. Methods Study subjects Subjects in this study were patients with first-ever stroke encolled in the Nanjing Stroke Registry Program (NSRP) between January 2004 and December 2014. The NSRP, established in July 2002, is the first hospital-based stroke registry program in the Mainland. Its central base is in Jinling Hospital, Nanjing, a city located in the southeast area of China, Detailed procedures for patient enroll- ment in NSRP have been published [7]. Patients. were cligibe for this study if they had a first-ever stroke con- firmed by a CT or MRI sean within 14 days of onset, aged 18 years or above, and survived 2. weeks after the index stroke. Written informed consent was obtained from each patient and the study was approved by the Ethies Committee in Jinling Hospital Definitions Stroke was defined by the World Health Organization (WHO) as rapidly developed clinical signs of focal (or lobal) disturbance of cerebral function, lasting for more than 24 h or being interrupted by death within 24 hy with no apparent cause other than of vascular origin [8]. Hypertension was defined as an average SBP >140 mm_ Hig or an average diastolic blood pressure (DBP) 290 mm Hg on at least three measurements after the frst week of stroke onset, or receiving pharmacological treatment for hypertension [9] Blood pressure monitoring To determine the status of blood pressure at time of stroke onset, all patients were scheduled for blood pres- sure monitoring at least twice daily within 14 days of stroke onset. For those discharged from hospital earlier than the 15th day of stroke onset, blood pressure moni- toring continued in local clinics, nursing homes, or at homes by a trained family member with an electronic sphygmomanometer (preferably Omron HEM7051). The results were collected during a subsequent clinical visit. ‘Management of blood pressure in patients with acute stroke was in accordance with guidelines. For ex- ample, the blood pressure should not be lowered in Page 2of the acute stage of stroke unless it is higher than 220/ 120 mmHg (10). Evaluation of blood pressure awareness To evaluate the awareness of blood pressure status, each patient enrolled was assessed with a brief questionnaire shortly after stroke admission. Issues in the question- naire included experiences and frequency of blood pres- sure measurement before the index stroke, numeric SBP and DBP if measured, awareness of a hypertension diag- nosis raised by a physician, any antihypertensive medica- tion usage within 2 weeks before the index stroke, blood. pressure responsiveness to the treatments and history of cardiovascular disease other than stroke. The question: naire was preferably responded by the patient. In case of coma or advanced cognitive impairment, a relative or guardian who was familiar with the medical history of the patient was encouraged to participate in the ques- tionnaire survey. To exclude possible memory bias, the survey was conducted before blood pressure monitoring, Stratification of blood pressure status For all patients, results of blood pressure monitoring and history of antihypertensive medication were consid- ered for the diagnosis of hypertension at time of stroke onset, Patients diagnosed with hypertension were grouped as being aware or unaware of this condition based on their responses to the questionnaire. Those ‘who were aware of the hypertension were stratified as treated or untreated, and those being treated were fur- ther stratified as controlled or uncontrolled. Being aware of hypertension indicated that the patient or family members recalled! a hypertension diagnosis made by a physician. Being treated for hypertension indicated that the patient took at least one antihypertensive medication, for elevated blood pressure within 2 weeks immediately before the index stroke [3, 6, 11]. When the DBP <90 mm_ Hg and the SBP <140 mm Hg, hypertension was regarded as being controlled (12) Possible influencing factors Data of demographic profiles (age, sex, marriage status), major risk factors for cardiovascular disease other than hypertension (diabetes mellitus (OM), hyperlipidaemia, smoking, alcohol drinking, overweight), type of index stroke, history of heart diseases, socioeconomic status (resident environment, occupation, educational level, possession of health insurance) and family history of stroke were collected from NSRP and analyzed as poten- tial influencing factors associated with hypertension un- awareness. Smoking was defined as that patient had smoked more than 1 cigarette per day for at least 6 months. Alcohol drinking was defined as that patient consumed more than two drinks a day for at least(20 etal BMC Public Health (2016) 16:170 2 months. Overweight was defined as a body mass index (BMI) 225 kg/m’. Presences of DM, heart diseases and hyperlipidaemia were confirmed by medical records. Statistical analy Kolmogorov-Smirnoy test was performed to determine ‘whether the distribution of a continuous parameter was normal. Continuous variables were presented as median, (interquartile range (IQR), whilst categorical variables were presented as frequencies. For inter-group compari- sons, continuous variables were analyzed with Mann— Whitney L test, whilst categorical variables were analyzed with 1? test or Fisher's exact test. To identify possible fac- tors associated with hypertension unawareness, the signifi cant variables (P<0.1) identified in univariate analyses were entered in a multivariate logistic regression model for further analysis. Results were presented as odds ratio (OR) and 95 % confidence interval (C1) The linear regres- sion analysis was performed to test the temporal trends of hypertension awareness, treatment and control over years P<0005 for two-sided test was deemed as statistical sig- nificance. All analyses were conducted using SPSS soft- ‘ware version 17.0 (SPSS Ine, Chicago, IL). Results ‘The study screened 5309 patients with first-ever stroke registered in NSRP between 2004 and 2014. Based on the results of blood pressure monitoring and history of antihypertensive medication usage, 3732 (70.3 %) patients Page 3 of 6 ‘were confirmed with hypertension at time of stroke onset. These 3732 patients were selected as subjects for the analyses of hypertension unawareness and the factors associated. Of all 3732 hypertensive patients chosen, 3367 (002 %) were diagnosed with ischemic stroke, 222 (6.0 %) with intracerebral hemorrhage and 143 (38 %) with subarachnoid hemorrhage. At time of stroke onset, 3139 (84.1 %) patients were aware of their hypertension. through a previous diagnosis, whilst 593 (15.9 %) were ‘unaware; 1534 (41.1 %) received anti-hypertension treat- ‘ment, and 658 (17.6 %) had their blood pressure controlled. After dichotomizing patients as being aware or un- aware of hypertension at time of stroke onset, data of demographic profiles, major risk factors for stroke, so- cioeconomic status and family history of stroke from each group were compared using univariate analysis (Table 1). In contrast with patients who were aware of their hypertension, those who were unaware were youn- ger (median 60 vs 62 years, P=1.31 x10) and had a lower BMI (median 24.0 vs 245, P=347 x 10-%), They also had a lower prevalence of DM (13.7 % vs 27.8 %, P=434x10"), heart diseases (5.4 % vs 11.0 %, P= 14x 10) and family history of stroke (4.6 5 vs 11.1 %, P=1.55 x 10”), Furthermore, patients who were smokers (420 % vs 355 %, P=0.003), engaged in manual work (626 % v5 53.2 %, P=2.78 x 10-%), lack of health insurance (650 % vs 49.8 %, P= 0022), with lower-level of education Table 1 Baseline characteristics of stroke patients by hypertension awareness Aare (= 3139) Unaware (9= 595) Prae 2ige mecian 00) 22 54-70) 0 (50-69) Taxa Age 60 years, (8) 135 (585) 300 608) avait Male, 68) 2186 608) 2265) 0951 Maried, 08) 3135 (699) 502098) as 2M, median (08) 245 029.260) 240 225-254) sare M2 25,008) 1292 396) 198 634) 2005 Smoking, m8 115 855), 299 (20) (0003 [cohol dining, 0 (8) exon wea 0235 Diabetes melts. (4) a a7) 81037) ashi Hypetipidaemia, m5) 69 149) 760128) 0205 Hea alscases 1 8) 35 (110 264) tae History of MA, 9 6) 123.89) 1860) 0388 Lack of haath insurance, n (8) 164 198) 326.650) 022 url residency, m8) 877 279) 223 G84) s2x107 Loner evel of eduction n 8) 06 073) 22680) 335x107 Manual work 98) 13 (532 see 27ax10 Fay story of token (90) 300.010) 206) 155x107 To indicates wterqure anges, BM Indes body mass inde, TA nates Wanset chemi atack Lowerevel of education ates primay Scho!(20 etal BMC Public Health (2016) 16:170 (primary school or illiteracy, 38.0 % vs 27.3 %, P= 3:35 x 107), and lived in rural areas (38.4 % vs 27.9 % P= 5.23 x 10”) were less likely to be aware of their hypertension. To determine potential factors attributable to hyper- tension unawareness, those parameters manifested. sig- nificant difference (P <0.1) between groups were further analyzed with multivariate logistic regression (Table 2) ‘Smokers (OR: 1.38; 95 % Cl: 1-11 to 1.71) and those with lower-level of education (OR: 1.61; 95 % Cl: 1.27 to 2.03) ‘were less likely to be aware of their hypertension. Whilst patients with advanced age (OR: 0.69; 95 % CI: 0.56 to 0.83), overweight (OR: 0.77; 95 % Cl: 0.64 to 0.94), DM (OR: 0.44, 95 % Cl: 034 to 057), heart diseases (OR: 054, 95 % Cl: 0.37 to 0.80) or with family history of stroke (OR: 0.38, 95 % Cl: 0.25 to 0.57) were more likely to be aware of their hypertension To assess the temporal trends of hypertension aware- ness, treatment, and control, we evaluated these rates over the years (Fig. 1). Linear regression indicated the rate of awareness increased slightly but significantly in 11 years (from 84.0 % in 2004 to 87.4 % in 2014, r= 0.613, P=0.045 for trends). Although rates of hyperte sion treatment (from 30.8 % in 2004 to 51.9 % in 2014, 0.947, P=989% 10° for trends) and control (from 9.0 % in 2004 to 253 % in 2014, r=0.890, P= 2.39 x 10° for trends) at time of stroke onset increased, there was considerable margin for improvement due to the extensive hypertension unawareness. Discussion This study presents several important findings regarding, hypertension unawareness, associated factors as well as hypertension treatment and control in China. A substantial proportion (15.9 %) of Chinese patients with hypertension Table 2 Factors associated with hyp Hypertension unawareness ariables ores Palo ge 260 (069/056t0085) 00002 Male ossa7iwlin oss eMiz25 O77 WsAroos) —— 0008 smoking 138(L11 17) 004 Hear eases 054(037 tos) 0002 Diabetes reli osaasdtoosy 25x 10"% Lack of heh insurance 093 (075% 115) 089 Rural esidency 23 (ager 157) anus Lowersevl of education 61127 t© 203) 073 x10 Manual work a3 (as0%© 141) 0282 ily history oF stroke os802sto0s) ——_258x10% aramsters were analjed wth morte logit egresion nays OF Inaeates odds ate, Crincates confidence ital Bi ineates body mas index Page 4 of hhad not been aware of this covert risk until an overt stroke occurred. Lower-level of education and smok- ing were associated with hypertension unawareness, whilst advanced age, overweight, DM, heart diseases and family history of stroke were associated with im- proved hypertension awareness. AAs expected, this study associated lower-level of edu- cation (primary school or illiteracy) with hypertension unawareness in Chinese stroke patients. Patients with lower-level of education may lack sufficient drive and/or adequate skills to monitor their blood pressure over an extended period of time [13-15]. Their knowledge of hypertension as a risk factor for cardiovascular disease may be limited compared with that of those with ad- vanced education [16-18]. They are more prone to dis- regard health education programs as available [13] Poorly educated patients, therefore, may be less likely to have their blood pressure measured regularly [16]. Con- versely, the promoting effects of advanced education on. hypertension awareness have been observed in other studies [11, 19} In this study, hypertension unawareness was more prevalent in young than in elderly patients. Young people may be less vigilant to the hazardous effects of el- cevated blood pressure to their health. Many other stud- ies also reported that young people have a lower rate of hypertension awareness [11, 19-21] Compared with non-smoking, patients, smokers were less likely to be aware of their hypertension. ‘This finding ‘was in consistent with results from some community- based studies [20, 22], but contrary to those from others [11, 19]. This finding highlighted the importance of hypertension education in smoking individuals, which may be more feasible and effective in communities. Still other studies have reported that women had a higher level of hypertension awareness than men, however in this study we did not detect different hypertension awareness between sexes [11, 19, 20]. Selection bias may be responsible for these discrepancies, for example, stroke patients enrolled in this study showed a male pre- dominance (69.6 %), while the sex distribution of com- ‘munity populations were more even. No significant correlation between health insurance and hypertension ‘unawareness was detected in this study. The socioeco- nomic development was remarkable in recent years, but the situation that patients are responsible for their own health remained largely unchanged in Nanjing and also in China. Although more citizens especially those in urban were covered by the government-run health insurance in recent 10 years, there was no regular blood pressure-checking plan even for patients with hypertension. Patients, with or without health insur- ance, usually had their blood pressure being checked at their own will20 etal BC Public Health (2016) 16:170 Page 5 of ‘00. Aware oe Treated : = Tea no. = controbed 40. ‘2004 2006 2006 2007 2008 2008 2040 2011 2042 2018 2014 Year Fig. 1 Trends in awareness, reatment, nd contol of hypetersion in svoke pases 204-2014. There had ben sgnicant increases in hypertension avareness (0613, P= 0048 fr tends), teatment (0947, P= 999. 10" for tend) and contol (= 0890, P= 239% 10 far trend inthis stroke patient cohoet during the 11 yeas In this study, patients with comorbidities, such as DM, heart diseases and overweight were more likely to be aware of their hypertension. These concomitant chronic conditions usually require regula follow-ups, thus the oc- casions of patients meeting with their healthcare providers may inerease, so does the chance of a covert hypertension being diagnosed. Patients experiences in diagnosing and managing DM, heart diseases and overweight may help for improving blood pressure administration. Other chronic diseases may also alert the patients with the pos- sible catastrophic outcomes of uncontrolled hypertension, therefore reinforcing their drive for blood pressure mon toring and management. These synergetic effects of con- comitant chronic diseases on hypertension management ‘were also reported in other studies [19, 20, 22} Several major limitations of the study should be empha- sized when interpreting the results. Responsive elevation of blood pressure was not uncommon after acute stroke especially in hemorrhagic stroke [23]. The blood pressure ‘may rise as a result of increased intracranial pressure, pain, infection, psychological stress, urine retention, dam- age of brain regions that regulate the autonomic nerve tonic after stroke [24]. These responsive hypertensions ‘were usually transient and the blood pressure, in most «cases, would return to the baseline levels within the first ‘week [25, 26]. To prevent misdiagnosed hypertension due to these conditions, blood pressure was monitored at least ‘twice daily within 14 days of stroke onset. Because only 6 % of enrolled stroke patients were hemorthagic in this, study, we believe the total impact of inconsistency be- tween pre-and post-stroke blood pressure in hemorrhagic stroke was minimal. In addition, hypotension caused by the index stroke (eg, infarct in insula) may increase the likelihood of false negative in presuming a hypertension diagnosis immediately before the index stroke. But this condition is ess common [27] Cognitive impairments were common in the first few ‘weeks after stroke [28]. Impaired consciousness may also present in stroke patients [29]. Both conditions may affect the evaluation of hypertension awareness at time of stroke onset. To minimize these confounding effects, wwe asked a relative or guardian who was familiar with the medical history of the patient to confirm the hyper- tension awareness before the index stroke. The question- naire was conducted before blood pressure monitoring to exclude possible memory bias. Finally, all patients in this study were enrolled from fone center (Nanjing) in southeast China, where the so- civeconomic development is noticeably more advanced, educational level higher and general healthcare status ‘more advantageous than other parts of the country. ‘Thus, the awareness of hypertension may be higher in this patient group than that in other populations. Conclusions ‘A substantial proportion (15.9 %) of Chinese patients ‘with hypertension had not been aware of this covert risk until an overt stroke occurred. Hypertension unaware- ness was associated with lower educational levels and. smoking, which address the importance of health educa- tion especially in these individuals [Abbreviations SP ayo tod pressure NSFP: Nang Stoke Reger Program, {HO Wo Heh Organaaten; OB ashe laod pres: OMedabees ‘malts BM body mass Index, OR inerquatle ange OR os ate, Ceanfidence era Competing interests The author dec tht they have no competing teres ‘urhors’ contributions (Gkconccied and designed the sud. OC wrote the dia of the manuscript XE, RIURS KL VLWL FY, WZ and YX colcted he dt. BC, OD and WS Ladertook the sats arabes P, 2 and JN gave erica comments ona0 eto BMC Public Health (2016) 168170 ‘he dah and contbted othe manuscgtwitinn. GX ae XL supe ‘his sudy and approved ofthe verso to be submited. Al authors ea and spptoved the nal manusipe Acknowledgements This sty was supported parly by National Nal Scene Foundation of (China (SF 81200017 1 XE, NSFC-21171009 to W2) the ange Nature Science Foundation (2013713 to GX, BRQO1N07 to WI. The sad was conducted in the department of Neurgyling Hostal wich povided ‘cote suppor fr this work We thank al the prtiponts of th ay and "escarch muses, interviewer and ater sa who Pave ian pn ‘athesng oF aang the data of ths su. Author details "Dopunmant of Neuclogy ing Hospital Meal Schoo of Naryog Univers 308 East Zhongshan Reed Nanjing 21D002}angsu Province, China. "School of Hunan, Ngbo Danorsying Univers, Ningbo 31817Szhajang Prewne, China “Deparment of Neuron, Mebourne Ban Centre ya Maboune Hospital Unies af Melbourne, Melbourne Verona sala ‘Deparment of Rewoiogy, Jing Hsp Souther Macca Univer, Nanjing 210002Hangss Prove, Chir Pee ihe 2 Ace nny a6 References 1 Lawes Cy, Vander Hoam 5, gas A. 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