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(Hypertension. 1998;32:998-1002.)
© 1998 American Heart Association, Inc.

Scientific Contributions

Blood Pressure in Spain

Distribution, Awareness, Control, and Benefits of a Reduction in Average Pressure

José R. Banegas; Fernando Rodríguez-Artalejo; Juan José de la Cruz Troca; Pilar Guallar-Castillón; Juan del Rey Calero

From the Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid (J.R.B., J.J. de la C.T., P.G.C., J. del R.C.); and the Department of Preventive Medicine and Public Health, Universidad del País Vasco, Vitoria (F.R.-A.), Spain.

Correspondence to Dr José R. Banegas, Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad Autónoma de Madrid, Avda Arzobispo Morcillo s/n, 28029 Madrid, Spain. E-mail joseramon.banegas{at}uam.es

	Abstract

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Abstract—Distribution of blood pressure (as per US Joint National Committee VI classification and staging criteria) plus awareness, treatment, and control of hypertension were studied in a representative Spanish population sample of 2021 persons (age range, 35 to 64 years). Pressure was determined in accordance with World Health Organization guidelines. A total of 45.1% of subjects were hypertensive (140/90 mm Hg or undergoing drug therapy); 12% had isolated systolic hypertension, and 8.7% had isolated diastolic hypertension. Pulse pressure was 48.7 mm Hg. Heart rate was 81.4 bpm in untreated hypertensives and 78.9 bpm in normotensives (P<0.05). A substantial proportion of the community burden of blood pressure was attributable to stage 1 (28.3% of subjects), the most frequent category of hypertension, and to the high-normal blood pressure group (17% of subjects). A percentage breakdown showed that among hypertensives, 44.5% were aware of their condition; of these, 71.9% were undergoing drug therapy, and of those being treated, only 15.5% were controlled (5% of hypertensives). Not only are these figures consistent with the fact that Spain has a higher cerebrovascular mortality than other countries such as the United States, but they represent a great potential for improvement, particularly among those groups registering relatively worse data (younger men, rural residents, and unskilled professionals). A decrease of only 1 to 4 mm Hg in average blood pressure could reduce the prevalence of hypertension in Spain by 12.4% to 15.4%.

Key Words: hypertension, arterial • blood pressure • prevalence • cross-sectional studies • awareness

	Introduction

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Although it is well known that arterial hypertension (AHT) is a modifiable risk factor for cardiovascular disease and that there are important differences among developed countries regarding AHT frequency and consequences, countrywide information on awareness, treatment, and control of AHT is still scant.^{1 2 3 4 5 6 7} Similarly, there is an absence of reporting on new AHT-related cardiovascular risk indicators, such as isolated systolic AHT (ISH), isolated diastolic AHT (IDH), heart rate, and pulse pressure.^{2 3 4}

Furthermore, classifications of blood pressure values at progressive levels are used mainly to help in the clinical management of individual patients.^{1 2 3 4} Yet these same classifications can also serve to highlight the community burden ascribable to the proportions of subjects and blood pressure–related diseases at such levels.^{1 5 6} In this regard, US Joint National Committee V and VI (JNC-V and -VI) classifications could prove especially useful because they take into account the fact that blood pressure–related cardiovascular risk is continuous throughout all levels and that risk is thus present at mid-pressure distribution levels, at which the pressures are considered "normal" (high-normal category) or moderately high (stage 1), and in which, because of the high proportion of subjects involved, a sizable percentage of the population's cardiovascular events tend to occur.^{2 3 5 6 7} Moreover, these criteria make it possible to envisage the potential benefits to be derived from blood pressure levels achievable through a lowering of average pressures nationwide.⁵

On the basis of a representative sample of the Spanish population, this article therefore presents the blood pressure distribution according to JNC-VI categories; degree of awareness, treatment, and control of AHT; values of the new cardiovascular risk indicators; and the potential change in AHT prevalence after a reduction in blood pressure.

	Methods

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Data were drawn from a cross-sectional study conducted in 1990, the sole study available to date containing information representative of Spain as a whole. The sample was made up of 2021 individuals (age range, 35 to 64 years) selected by means of random multistage sampling stratified by age, gender, and rural or urban residence.⁸ Individuals in the sample were contacted by mail, followed by a home visit for reinforcement. The overall response rate to the survey was 73.3%. All the study participants agreed to have their blood pressures measured and other determinations carried out.

Blood pressures readings were obtained in a clinical setting after an interview on risk factors. Blood pressure was determined using standardized methods and conditions in accordance with World Health Organization (WHO) recommendations.⁹ Random-zero mercury sphygmomanometers were used. Observers were trained in measuring techniques and use of measuring devices. Systolic blood pressure (SBP) corresponded to Korotkoff phase I and diastolic blood pressure (DBP) to phase V. All those with average SBP 140 mm Hg or DBP 90 mm Hg (average of 3 measurements) or those undergoing antihypertensive drug therapy at the time were classified as hypertensive. Prevalence of AHT, ISH (SBP 140 mm Hg and DBP <90 mm Hg), and IDH (DBP 90 mm Hg and SBP <140 mm Hg); proportion of individuals in JNC-VI categories; and pulse pressure (mean SBP-mean DBP) were calculated.^{3 4 7}

AHT awareness was assessed through in-person interview on the basis of the question, "Has your doctor ever told you that you have high blood pressure?" No subjects undergoing drug treatment answered "no" to this question. Treatment was defined as use of antihypertensive drugs at the time of the interview. Control was defined as SBP <140 mm Hg and DBP <90 mm Hg and was ascertained by direct measurement of blood pressure.

The survey and study methods were approved by an institutional review board. Informed consent was obtained from every participant in the study.

Estimates were adjusted in line with the sampling design, with a weight assigned to all sample members according to the size of the respective strata to which they belonged (age, gender, and residence).^{10 11} For intercountry comparisons, age-specific and age-adjusted rates were calculated using the direct method and the World and European populations as standard.¹² The ² test was used for comparing proportions and Student's t test for comparing mean values. The relationships between AHT prevalence, awareness, treatment, and control and other cardiovascular risk factors were analyzed using logistic regression. Data analysis was performed with the Epi Info and SPSS/PC+ computer software packages.^{11 13}

Finally, a simulation was run to ascertain the magnitude of the reduction in AHT prevalence achievable if current average blood pressure were to be lowered by 1 to 4 mm Hg, a decrease regarded as feasible and forming part of a potential population-based interventional strategy.^{2 3 4 5 7 14 15 16 17} To this end, the entire blood pressure distribution was shifted to the left.

	Results

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AHT prevalence was 45.1%. This figure increased with age (P<0.01) and was higher in men than women 35 to 44 years of age and in rural than in urban dwellers (P<0.05; Table 1). The prevalence of ISH was 12%, with the percentages likewise proving higher in younger men and increasing with age (P<0.05; Table 1). A total of 8.7% of subjects had IDH, without any significant age- or gender-related differences. Pulse pressure was 48.7 mm Hg (mean SBP of 132.3 mm Hg-mean DBP of 83.6 mm Hg).

View this table: [in this window] [in a new window]   Table 1. Prevalence of Hypertension in Spain by Gender, Age, and Type of Residence

Analysis yielded a figure of 28.3% of subjects with stage 1 AHT and far lower figures for the other stages (Table 2). Furthermore, 17% had high-normal blood pressures, 16.7% normal pressures, and only 23.4% optimal pressure (<120/80 mm Hg), owing in the latter instance to the subjects being normotensives or controlled hypertensives.

View this table: [in this window] [in a new window]   Table 2. Percentage Distribution of Blood Pressure Levels Based on US JNC-VI3 Categories Before and After 2 Interventions Targeted at Reducing Blood Pressure

A percentage breakdown showed that among hypertensives, only 44.5% were aware of their condition; of these, 71.9% were undergoing drug therapy (32% of all hypertensives), and of those being treated, only 15.5% were controlled (5% of hypertensives; Table 3). AHT awareness was more frequent in women (P<0.05). The proportion of treated and controlled subjects was likewise higher among women than in men, although it was only with respect to the youngest age group that the figure attained statistical significance. Despite being more frequently aware of their AHT than their younger counterparts (P<0.05), older women showed a lower frequency regarding control of their condition (P<0.01). Rurally based hypertensives registered lower awareness figures overall (P<0.05; Table 3).

View this table: [in this window] [in a new window]   Table 3. Awareness, Treatment, and Control of Hypertensives in Spain by Gender, Age, and Type of Residence

Manual workers showed a lower frequency of AHT awareness than nonmanual workers (P<0.05; Table 4). Smoker or ex-smoker status was associated with a lower prevalence of hypertension (P<0.01 and P=0.1, respectively). Obesity and hypercholesterolemia were both positively associated with AHT and awareness of same (P<0.05). Treated hypertensives who were obese reported a higher frequency of control than those of normal weight. Family history of cardiovascular disease showed no association with AHT prevalence, awareness, or control. Compared with normotensives, however, hypertensives registered a higher frequency of family history of stroke (20% versus 14%, P<0.05) and personal history of cerebrovascular diseases (1.6% versus 0.6%, P<0.05) and ischemic heart diseases (2% versus 1%, P<0.05). In addition, untreated hypertensives had a higher heart rate than normotensives (81.4 versus 78.9 bpm, P<0.05) for both sexes and across all age and residence-based groups.

View this table: [in this window] [in a new window]   Table 4. Odds Ratios for Prevalence, Awareness, Treatment, and Control of Arterial Hypertension in Spain by Other Cardiovascular Risk Factors

A reduction of 3 to 4 mm Hg in current mean SBP and 1 to 2 mm Hg in current mean DBP would achieve a 12.4% to 15.4% decline in the prevalence of AHT (Table 2).

	Discussion

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This study shows that in Spain there are approximately 6 million middle-aged hypertensives, 3.3 million of whom are unaware of their condition. Of every 10 who are aware, 3 do not receive antihypertensive drug treatment; of every 10 who receive said treatment, 8 are not controlled. Taken together, those who "don't know," "don't receive treatment," and are "poorly controlled" represent 95% of all hypertensives. Hence, regarding control, Spain is still a long way from the so-called rule of halves: a mere 15% of those being treated are controlled. There are regions in Spain, such as Catalonia, where control and progress in this direction are already much improved (increasing by 17% from 50% in recent years) but, in general, improvement in other parts of the country has been scant.^{18 19 20}

The relatively small number of individuals in this national study translates into slightly high standard errors of some of the estimates and consequently into moderately wide confidence intervals (Tables 1 and 3). In addition, the preponderance of women in the study sample has been taken into account in the analysis of data, by the weighting process described in "Methods."

JNC classification shows stage 1 to be the most frequent form of AHT in Spain, a finding that is in line with the position elsewhere, ie, 66% of all Spanish hypertensives 35 to 64 years of age are in stage 1, as are 80% of US male hypertensives 35 to 57 years of age, according to the US-based Multiple Risk Factor Intervention Trial (MRFIT).^{4 6} Furthermore, the MRFIT found that it was precisely the 2 groups reporting stage 1 AHT and high-normal blood pressure that accounted for the greatest excess blood pressure–related coronary mortality.⁶ In part, this is due to the fact that taken jointly, these 2 groups embrace a considerable proportion of subjects: indeed, they account for 45% of all subjects covered in our study, 42% of subjects in the MRFIT, and 46% of non-Hispanic whites 50 to 69 years of age in the National Health and Nutrition Examination Survey (NHANES) III.^{6 21} This underscores the importance of detecting, preventing, and managing these 2 blood pressure categories so as to reduce the ensuing burden on the population in the form of patient numbers and cardiovascular diseases.^{1 3 6 21} Overall, AHT management is a necessary yet incomplete response to the community burden of blood pressure–related complications. Almost 60% of all middle-aged Spaniards, 76% of the MRFIT subjects, and 65% to 70% of the NHANES III subjects fall within a "normal" range of values, in which a not inconsiderable proportion of coronary events occur.^{6 21 22} Our data also confirm the importance attached to ISH,^{2 3 4 21} which affects 15.7% of Spanish men and 18.1% of Spanish women aged 55 to 64 years; and although the figures may be somewhat lower, the magnitude of IDH is by no means negligible.^{4 23}

Moderate changes in population lifestyles can lead to slight reductions in blood pressure.^{2 3 4 5 7 14 15 16 17} A reduction of only 1% to 3% in the average blood pressure of the Spanish population, that is, 1 to 4 mm Hg, could bring about a decline in AHT prevalence from 43% to approximately 36% to 38%, which would in turn translate to a 12% to 15% decrease in the size of the AHT-related clinical problem and treatment corresponding to same (Table 2). In addition, the proportion of the population with pressures below 120/80 mm Hg—pressures viewed as optimal^{3 24} —would rise from a current level of 23% to approximately 28% to 29%. These benefits are easily discernible with the aid of the JNC classification and emphasize the importance of population-wide prevention as a complement to individual control of AHT (Table 2).^{1 2 3 4 7 25}

Applying roughly identical AHT criteria, age groups, and study period, Spain is seen to rank midway between the WHO MONICA centers and many developed countries in terms of age-adjusted AHT prevalence, treatment, and control (25%, 13%, and 6%, respectively), which is in line with the country's similarly intermediate cerebrovascular mortality.^{12 26 27 28} Prevalence and control of AHT are predictors of geographic variations in cerebrovascular mortality between countries.^{29 30} Spain's age-adjusted cerebrovascular mortality is almost double that of the United States (89.3 versus 48.3 per 100 000 population in 1991),¹² a finding consistent not only with AHT prevalence among white subjects aged 40 to 59 years (45% for Spain versus 26% for the United States) but also with awareness and control of treated hypertensives (48% and 13% for Spaniards aged 50 to 64 years versus 76% and 48%, respectively, for US whites aged 50 to 69 years).²¹ Furthermore, comparison with the Atherosclerosis Risk in Communities (ARIC) Study reveals a similar situation for the 45- to 64-year age group, with AHT prevalence being 54% and 35%, awareness 46% and 84%, and control among treated patients 14% and 68%, for Spain and the United States, respectively.³¹ However, relative differences in the degree of treatment are smaller, which leads one to conclude that poorer control in Spain must be linked to poorer prescription and/or compliance.^{32 33} Indeed, therapy compliance in Spain stands below 60%.³³

In Spain, as elsewhere, male hypertensives are less aware of their condition than female hypertensives.^{1 2 3 4} Unlike other countries, however, Spain is characterized by higher prevalence and lower AHT awareness in rural areas.^{4 26} Enhanced AHT awareness among the obese (a finding also reported by the ARIC Study)³¹ and among those with high cholesterol may be due to more concerted AHT screening efforts in these groups than in manual workers. The greater control of treated hypertensives who were obese was not found in other studies.^{31 33} The "paradox" of lower AHT frequency among smokers, also observed in other cross-sectional studies,³⁴ could be due to the fact that such persons tend to be thinner.

Of the new risk indicators examined by this study, observed pulse pressure is well below the reading of 65 mm Hg, regarded as posing the highest risk.³⁵ The higher heart rate seen for untreated hypertensives versus normotensives, across all study groups, although conceivably reflecting a readjustment of sympathetic activity at a higher level, could constitute an additional risk factor.^{4 36}

In conclusion, approximately 1 of every 2 Spaniards aged 35 to 64 years is hypertensive, and 1 of every 10 suffers from ISH or IDH. To a great extent, the country's blood pressure–related community burden is accounted for by subjects with stage 1 AHT and high-normal blood pressures, thus requiring special surveillance of these 2 groups. AHT awareness, treatment, and control levels, the latter in particular, are still extraordinarily low, especially among younger men, rural residents, and unskilled professionals, suggesting a need for greater efforts in these groups. An improvement in the situation would contribute to reducing Spain's considerably high cardiovascular risk.^{12 28 37}

	Acknowledgments

 
This study was supported in part by a research grant from Novartis. We thank Michael Benedict for translating this report into English.

Received June 11, 1998; first decision July 1, 1998; accepted August 19, 1998.

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