Invest Clin 60(4): 319 - 335, 2019 https://doi.org/10.22209/IC.v60n4a06

May measurement month 2017 campaign screening results from Venezuela: an analysis of blood pressure, abdominal circumference and body mass index.

Rafael Hernández-Hernández1, José Andrés Octavio-Seijas2, Jesús López-Rivera3, Igor Morr2, Antonieta P. Costantini-Olmos4; Mónica L. Gúzman-Franolic4; Egle Silva5;

Amanda Duín1; José Marval6; Nedina Coromoto Méndez-Amaya6, José Félix Ruíz-Lugo6; Dámaso Vásquez6; Carlos Ignacio Ponte-Negrete7; Thomas Beaney8, Elsa Kobeissi8,9, Neil R Poulter8 and the investigators of Venezuela MMM-17 blood pressure campaign (listed at the end).

1 Hypertension and Cardiovascular Risk Factors Clinic, School of Medicine, Universidad Centro Occidental Lisandro Alvarado, Barquisimeto, Venezuela. 2Department of Experimental Cardiology. Tropical Medicine Institute, Universidad Central de Venezuela, Caracas, Venezuela.

3Hypertension Unit, General Hospital, San Cristóbal, Venezuela.

4FARMATODO pharmacy group, Caracas, Venezuela.

5Instituto de Investigaciones de Enfermedades Cardiovasculares de LUZ. Universidad del Zulia, Maracaibo, Venezuela.

6Venezuelan Society of Cardiology and Venezuelan Society of Hypertension. 7Caribbean Cardiologic Unit. Venezuelan Foundation of Preventive Cardiology. 8Imperial Clinical Trials Unit, Imperial College London, Stadium House, London, UK.

9Conflict Medicine Program, Global Health Institute, American University of Beirut, Beirut, Lebanon.

Key words: hypertension; body mass index; abdominal circumference.

Abstract. The present study had the purpose of evaluating the proportion of subjects with hypertension, treatment, control rates, and the relationship be- tween blood pressure (BP) with body mass index and abdominal circumference in a cross-sectional study, as part of a worldwide study designed by Internation- al Society of Hypertension, performed during May 2017. After the protocol´s approval by the local Ethical Committee, 64 sites were included from eight Venezuelan regions. A short questionnaire was completed for each participant, including knowledge of taking antihypertensive treatment, diabetes, previous

Corresponding author: Rafael Hernández-Hernández. Hypertension and Cardiovascular Risk Factors Clinic, School of Medicine, Universidad Centro Occidental Lisandro Alvarado, Barquisimeto, Venezuela. E-mail: rafael. hernandez.h@gmail.com

myocardial infarction or stroke, alcohol intake, and smoking. BP was measured in the sitting position three times after resting for 5 minutes, one minute apart, using mainly oscillometric devices. Height, weight and abdominal cir- cumference were measured. Data analyses were performed by the MMM central team. 21644 individuals were screened. After multiple imputations, 10584 indi- viduals [48.9% (50.7% male; 47.7% female)] had hypertension. Of subjects not receiving antihypertensive medication, 1538 (12.2%) were hypertensives. Of hypertensive individuals receiving antihypertensive medication, 2974 (32.9%) had uncontrolled BP. 15.6% of our sample had obesity according to their body mass index; 43.8% of women and 20.7% of men had abdominal obesity. BP was positively correlated with BMI and abdominal circumference. In this largest BP screening carried out in Venezuela, 48.9% of the individuals had elevated BP and 12.2% did not know that they had hypertension, and in one third of those with hypertension on treatment, BP was not controlled. 15.6% had obesity by BMI, and 35.1% abdominal obesity. Screening such as the MMM17 can evaluate the association between hypertension and obesity and therefore may help to inform control programs.

Campaña de Medición del mes de mayo-2017: un análisis de los resultados de la presión arterial, circunferencia abdominal e índice de masa corporal en Venezuela.

Invest Clin 2019; 60 (4): 319-335

Palabras clave: hipertensión; índice de masa corporal; circunferencia abdominal.

Resumen. Se realizó el presente estudio con el objetivo de evaluar la pro- porción de sujetos con hipertensión, tratamiento, tasas de control y la relación entre la presión arterial (PA) con el índice de masa corporal y la circunferencia abdominal en un estudio transversal, como parte de un estudio mundial dise- ñado por la Sociedad Internacional de Hipertensión, realizada durante mayo de 2017. Luego de la aprobación del protocolo por el Comité de Ética local, se incluyeron 64 sitios de ocho regiones venezolanas. Se completó un breve cuestionario para cada participante, que incluye el conocimiento de tomar tra- tamiento antihipertensivo, diabetes, infarto de miocardio o accidente cerebro- vascular previo, consumo de alcohol y tabaquismo. La PA se midió en posición sentada tres veces después de descansar durante 5 minutos, con un minuto de diferencia, utilizando principalmente dispositivos oscilométricos. Se midieron la talla, el peso y la circunferencia abdominal. Los análisis de datos fueron rea- lizados por el equipo central de MMM. Se evaluaron 21644 personas. Después de múltiples imputaciones, 10584 individuos [48,9% (50,7% hombres; 47,7% mujeres)] tenían hipertensión. De los sujetos que no recibieron medicación an- tihipertensiva, 1538 (12,2%) eran hipertensos. De las personas hipertensas que recibieron medicamentos antihipertensivos, 2974 (32,9%) tenían BP no con- trolada. El 15,6% de nuestra muestra tenía obesidad según su índice de masa corporal; el 43,8% de las mujeres y el 20,7% de los hombres tenían obesidad abdominal. La PA se correlacionó positivamente con el IMC y la circunferencia

abdominal. En esta encuesta de detección de la PA más grande realizada en Venezuela, el 48,9% de los individuos tenían presión arterial elevada y el 12,2% desconocían tener hipertensión, y en un tercio de aquellos con hipertensión en tratamiento, la PA no estaba controlada. El 15,6% tenía obesidad por IMC y el 35,1% obesidad abdominal. Los exámenes de detección como el MMM17 pue- den estimar la prevalencia de hipertensión y obesidad y pueden ayudar a evaluar los programas de control.

Recibido: 28-05-2019 Aceptado: 16-10-2019

INTRODUCTION

Hypertension is considered the single most preventable cause of premature death

(1) and is the biggest contributor to the global burden of disease (2), and to mor- tality, leading to 10.4 million deaths every year worldwide. In Latin America almost 1 million cardiovascular deaths occur annu- ally, with coronary heart disease, stroke, and hypertension as the primary cause of death (3). Cardiovascular mortality in Latin America increases every year due to aging of the population, and importantly, for the epidemiological transition, with changes in the way of living, including increased con- sumption of processed foods with high salt, fat, and sugar content, accompanying low levels of physical activity, and smoking (4). Cardiovascular diseases are the first cause of deaths in Venezuela, mainly coronary ar- tery disease, stroke, heart failure, and hyper- tension reported as primary cause of death (3,5). On the other hand, cardiovascular diseases have hypertension in common as a primary risk factor, also, for renal disease; they are frequently accompanied by other risk factors, such has obesity, diabetes mel- litus, lipid abnormalities, smoking, and low physical activity.

In fact, hypertension is the risk fac- tor most strongly associated with the first myocardial infarction in Latin American countries (6). Furthermore, the end-organ damage (e.g, renal failure, stroke or pe-

ripheral vascular disease) associated with hypertension emphasizes the importance of prevention, detection and control efforts worldwide (7,8). Epidemiological informa- tion in Latin America is mainly focused on the prevalence of hypertension and few such studies, in different areas of Latin America, are available. Among these studies, the Car- diovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study (9,10), a representative, multicentre observational study including 11550 individuals of both sexes, aged 25–64, from seven large cities: Barquisimeto (Venezuela), Bogota (Colom- bia), Buenos Aires (Argentina), Lima (Peru), Mexico (Mexico), Quito (Ecuador) and San- tiago de Chile (Chile), showed a hyperten- sion prevalence range between 11.7 and 29.8%. In 2008, when CARMELA was car- ried out, Barquisimeto (Venezuela) had the second largest prevalence of hypertension in Latin America, and the highest preva- lence of any lipid abnormalities (81%), dia- betes (6%), obesity measured by body mass index (25.1%), abdominal obesity (29.2%); metabolic syndrome (25.8%) and smoking (25.0%).

Since 2000, but more so in the last few years, Venezuela has had important changes in the political, economic and social systems, and it is important to know the impact of such changes in the prevalence of hyperten- sion, and other cardiovascular factors, such as obesity, diabetes and the degree of blood pressure control in hypertensive patients.

The aim of this study was to evaluate the proportion of subjects with hyperten- sion, treatment and control rates, and the relationship between blood pressure (BP) and body mass index and abdominal circum- ference in a cross-sectional study, as a part of the study design by the International Society of Hypertension; carried out during month of May 2017.

METHODS

Study Design

The MMM cross-sectional survey was designed by the International Society of Hy- pertension to be carried out in about 100 countries (11). Target participants were vol- unteer adults (≥18 years) who ideally had not had their blood pressures measured in the previous year; however this was not an exclusion to participation.

In Venezuela the final protocol was approved by the Ethical Committee of the School of Medicine of the Centro-Occidental Lisandro Alvarado University and was per- formed in universities, health centres and mainly in a chain of pharmacies (Farmatodo) located in several important towns of Ven- ezuela. There was a national leader and a local coordinator in each region. Voluntary staff were pharmacists, nurses, medical and nursing students and physicians. Local cam- paigns to incentivise participation from the public were carried out using social media communications.

A short questionnaire, which included knowledge of taking antihypertensive treat- ment; suffering from diabetes, previous myocardial infarction or stroke; frequency of alcohol intake, and current smoking was completed for each participant; follow- ing this, physical measurements were car- ried out; including blood pressure, height, weight and abdominal circumference. Data were entered on paper forms and later trans- ferred to spread sheets for analysis.

Blood pressure was measured in the sit- ting position three times after resting for at

least 5 minutes, one minute apart. Record- ing was carried out mainly, but not limited to, the left arm, using validated oscillomet- ric devices of different brands, mainly from Omron Healthcare. Manual sphygmoma- nometers were used in about 1% of read- ings. Blood pressure was calculated from the mean of the second and third readings, and hypertension was defined as a systolic blood pressure of at least 140 mm Hg and/or a diastolic blood pressure of at least 90 mm Hg. Participants receiving antihypertensive treatment were also assumed to have hyper- tension. Among those on antihypertensive treatment, controlled blood pressure was de- fined as a blood pressure of less than 140/90 mmHg.

Abdominal circumference was mea- sured at the level of the umbilicus, with the subjects standing and breathing normally; normal values were defined <102 cm in males and <88 in females (12); also, height and weight was measure, and body mass in- dex was calculated. The WHO Classification of body mass index was used (13).

Data handling and statistical analysis Data cleaning was done locally and cen- trally by the MMM project team. Data from 21644 individual from Venezuela were divid-

ed into eight regions.

Blood pressures were recorded, and crude analyses were done using the mean of the second and third blood pressure read- ings, available in 97.9% of subjects. Using only those individuals with all three readings we compared mean blood pressures and the proportion of participants with hypertension using different combinations of the three readings. For further analyses, multiple im- putation was used to impute the mean of the second and third reading where this was missing, based on the available reading, along with age, sex (with an interaction be- tween age and sex) and use of antihyperten- sive medication. Both systolic and diastolic components were included within the impu- tation models.

Mean blood pressures were standardised for age and sex according to the WHO world age-standard population along with an as- sumed sex ratio of 1:1 (13).

Linear regression models were run sep- arately for systolic and diastolic blood pres- sures. In all models, the association of blood pressure was adjusted for age and sex (with an interaction term) and antihypertensive medication. Complete details of statistical analyses have been published in WWW17 worldwide results (11).

RESULTS

The number of participants included from Venezuela was 21644 subjects with a mean age of 53.2 years (SD: 15.64), more women were included (62.8%), the self-re- ported ethnicity was predominantly mixed (62.4%) follow by white (30.4%) ethnicity. The whole group of general characteristics of the sample is in Table I. Table II presents the distribution for age group and sex and distribution of sample for the eight Venezu- ela regions.

BP was measured three times in 97.9% of subjects, the average blood pressure in first, second and third reading was on aver- age: 126.8/76.1 mmHg; 124.5/74.9 mmHg and 123.8/75.8 mmHg respectively; for anal- ysis the average of 2nd and 3rd reading was used for different calculations.

Blood pressure and age

Based on a linear regression model, the association between age and sex with sys- tolic and diastolic BP in subjects who were not receiving antihypertensive treatment (12303 subjects) showed a linear increase, with the mean systolic blood pressure in women exceeding the mean systolic blood pressure in men at 80-85 years of age. For diastolic blood pressure, the relationship showed an inverted U shape, with highest levels at age 55-60 years, and with blood pressure in women lower than in men until aged 80-85 (Fig. 1).

The percentages of subjects with el- evated blood pressure (≥140/≥90 mmHg) by sex and age group are shown in Fig. 2. Overall, 48.9% (50.7% of male and 47.7% of female) have elevated blood pressure; and the proportion of hypertension increases with age.

Blood pressure by Venezuelan regions

Mean systolic and diastolic blood pres- sure by region are shown in Table III. The proportion of subjects with elevated blood pressure (≥140/≥90 mmHg) by region and age group in Table IV; there is variation in both blood pressure and hypertension in different regions, with hypertension being higher in the capital region (54%), and the lower in the eastern region with 41.0% for both sexes.

Physical measurements and risk fac- tors and their relationship with blood pres- sure

Body mass index was calculated for all participants and according to age groups; 4.8% of subjects are defined as underweight; 46.5% as normal; 32.0% overweight and 15.6% obese in the female population; and 3.1%; 42.4%; 36.9% and 16.8% respectively among men (Table V).

Abdominal circumference defined as high (≥ 88 cm in female and ≥102 cm in male) was present in 43.8% of women and 20.7% of men; and hypertension was more frequent in participants with higher waist circumference in males and females (Table VI). In comparison to a desirable abdominal circumference, systolic and diastolic blood pressure are higher by 4.2/3.1 mmHg in fe- male and 5.6/4.3 mmHg in male with high abdominal circumference, which was statis- tically significant in both cases (p>0.001). After adjustment for age and sex, significant- ly higher systolic and diastolic blood pres- sures were apparent in subjects who were receiving antihypertensive drug treatment. Only systolic blood pressure was higher for subjects with self-reported diabetes, previ-

TABLE I

PARTICIPANTS MAIN CHARACTERISTICS IN VENEZUELA

ous myocardial infarction or stroke. Alcohol intake and current smoking showed little ef- fect on BP; meanwhile pregnancy was associ- ated with lower systolic and diastolic blood pressure (Fig. 3).

Hypertension control

A group of 1526 subjects (14.4%) not re- ceiving antihypertensive therapy were found to have elevated blood pressure (≥140/≥90 mmHg). 9046 subjects (58.2%) were on anti-

hypertensive drug therapy; 30.0% of females and 38.5% of males were not controlled (BP

≥ 140 / ≥ 90 mmHg). Table VII shows blood pressure control by age group and sex.

DISCUSSION

This study was part of the worldwide MMM17 campaign initiated by the Interna- tional Society of Hypertension, and was a synchronised, standardised and multination-

TABLE II

NUMBER OF SUBJECTS BY SEX AND AGE IN 8 VENEZUELAN REGIONS.

*Regions: Andes: Táchira and Mérida States; Capital: Federal District, Guarenas, Los Téques. Central Western: Lara and Yaracuy States; Island: Porlamar City. Eastern: Anzoátegui, Sucre and Monagas States; Sothern: Barinas State; Western: Zulia and Falcón States.

** 548 subjects were not classified by regions.

al BP screening campaign and cardiovascu- lar factors and events (11). In our case, most subjects were screened at the pharmacy lev- el, < 2% from health centres or universities; unlike the global MMM17 study (11) 97.9% of subjects had three BP readings recorded, mainly in the left arm, using validated oscil- lometric devices. Abdominal circumference was also recorded, which was not collected globally.

However, in view of the convenience sampling it is inappropriate to compare the prevalence of hypertension observed previ- ously in Venezuela, in representative stud- ies, but the association of blood pressure in 21644 subjects gives an idea of comparative

prevalence with other countries participat- ing in the worldwide campaign; as well as between different Venezuelan regions. Also, the relations of blood pressure in subjects with obesity (either body mass index clas- sification or central obesity by abdominal circumference), reported diabetes, previous cardiovascular diseases, alcohol intake, and smoking are valid.

Subjects found with high blood pressure (≥140/≥90 mmHg) whether they remained on treatment, were recommended to visit their physician for proper clinical evaluation or treatment adjustment if necessary. For all participants, general recommendations on cardiovascular health were given.

Fig. 1. Change in blood pressure with age and gender.

Fig. 2. Defined according to ESC/ESC and LASH guidelines (7,8).

This study included a sample of 21644 subjects, being the largest study carried out in Venezuela until now. The second largest study was carried out in 15000 subjects >18 year of age, back in the 1990s in one single city (Barquisimeto – central-western region)

(14) which showed a prevalence of hyperten- sion in 23.6% (27.75% male and 21.39% fe- male); another large study was carried out in Maracaibo (Western region) in 7424 sub- jects with a prevalence of hypertension in

39.2% (45.2% in male and 28.9% in female) (15). The Cardiovascular Multiple Risk Fac- tor Evaluation Study (CARMELA study), included a sample of 1848 subjects from Barquisimeto (Venezuela) as part a Latin American study major cities. The CARMELA study includes an evaluation of physical mea- surement of BP, weight, height, abdominal circumference, lipid levels, glucose level and carotid intima media thickness and plaques, in subjects 25 to 64 years old (9,10). In CAR-

TABLE III

MEAN CRUDE SYSTOLIC AND DIASTOLIC BP BY REGION IN VENEZUELA, AND AGE AND SEX STANDARDISED ON SUBJECTS NOT ON ANTIHYPERTENSIVE TREATMENT AND ON ANTIHYPERTENSIVE TREATMENT.

*p<0.0001 versus subjects not on treatment. SE: standard error.

MELA, the prevalence of hypertension, in Venezuela was 24.7% (27.5% male and 22.9% female), the second highest prevalence after Buenos Aires with 29% in subjects 25 to 64 years old. Other studies in Venezuela with broad age groups and not representative samples, found a prevalence of 34% (16).

In the present study, the percentage of people in Venezuela with hypertension was 48.9% (50.7% male; 47.7% female), with varia- tions for different Venezuelan regions indicat- ing an apparent increment in prevalence com- pared to previous studies in Venezuela; which may be genuine or due to bias in terms of more participation of hypertensive patients receiving medication, than would be expected, compar- ing to the overall MMM17 report, where per- centage was 34.9% worldwide (80 countries) and 41.0% in the Americas region (11). The proportion of patients with hypertension of those not receiving treatment was 12.4% in

Venezuela, comparing to 17,3% globally and 14.4% in the Americas; the percentage of subjects receiving treatment but with uncon- trolled blood pressure was 33.1% in our study comparing to 46.3% globally and 38.6% for the Americas (11). This indicates a smaller propor- tion of individuals not receiving treatment and smaller proportion with uncontrolled hyper- tensive group receiving treatment, in relation to both worldwide and Americas data. Also, females older than 65 years and males 24 to 54years were more likely to be uncontrolled. Those results are consistent with CARMELA study which reported 28.2% of those treated with antihypertensive medication but not con- trolled (17). On the other hand, percentage of hypertension in Venezuelan regions goes from 54.0% in the capital region to 41.0% to the eastern region; which is consisted with car- diovascular mortality rates reported in that re- gions in Venezuela (5,18).

TABLE IV

PERCENTAGE OF SUBJECTS WITH HYPERTENSION BY GROUP-AGE AND SEX IN VENEZUELAN REGIONS ACCORDING TO ESH/ESC AND LASH GUIDELINES (7,8).

* Regions: Andes: Táchira ad Mérida States; Capital: Federal District, Guarenas, Los Téques; Central: Aragua and Carabobo States; Central-Western: Lara and Yaracuy States; Island: Porlamar City; Eastern: Anzoátegui, Sucre and Monagas States; Southern: Barinas State; Western: Zulia and Falcón States.

**548 subjects not classified by regions.

In 2017 the American Heart Associa- tion (AHA)/American College of Cardiology (ACC) changed the criteria to define hyper- tension with a cut-off values of ≥130/80 mmHg (19), instead the approved for all guidelines until that year (≥140/90 mmHg), founded in a particular way of measure BP in the office and mainly on one study results (SPRINT) (20). Our study did not analyse

upon the AHA/ACC guideline, because it was designed previously of that guideline, but above all, we follow ESC/ESH, LASH, and Venezuelan guidelines which maintained the criteria ≥140/90 mmHg (1,7,8, 21), also the way as BP was measured was those follow by most of the clinical or epidemiological studies in Venezuela and worldwide, allowing comparison among previous studies.

TABLE VI

ABDOMINAL CIRCUMFERENCE IN FEMALE AND MALE (ABSOLUTE NUMBERS AND PERCENTAGE), WITH AND WITHOUT HYPERTENSION.

*Desirable: <88 cm in female; <102 cm in male.

**High: ≥88cm in female; ≥102 cm in male.

Fig. 3. Difference in blood pressure according to individual characteristic from linear adjusted regression model.

TABLE VII

BLOOD PRESSURE CONTROLLED (<140/<90 MMHG*) ACCORDING TO SEX AND AGE GROUP IN SUBJECT ON ANTIHYPERTENSIVE DRUG TREATMENT.

*According to ESH/ESC and LASH Guidelines (7,8).

Note: from the whole group 141 females and 58 males did not record age; 20 individuals did not record sex.

However, a recent publication of one Venezuelan study (EVESCAM) carried out between 2014 and 2017, in 4454 subjects

(22) was re-analysed following criteria of JNC-7 (cut-off ≥140/90 mmgHg) and AHA/ ACC guidelines (23); and they found a crude prevalence of hypertension of 47.4% for JNC- 7 criteria and 60.4% for AHA/ACC criteria; and the prevalence standardized for age and sex, in 37.9% (men) and 36.3% (women) for JNC-7 and 55.4% (men) and 49.0% (women) for AHA/ACC criteria. Our results shown higher percentage of hypertension stan- dardized by age and sex, using the same cut off (≥140/90 mmHg) which may be due to higher age in our study (50.2 y vs. 53.2 y). Prevalence calculated over AHA/ACC guide- lines may overestimate the situation. How- ever, usage of AHA/ACC criteria is open to discussion worldwide.

In the present study, body mass index was in average 25.5 (SD 4.68) kg/m2; un- derweight subjects represent 3.9% (female:

4.8%; male: 3.1%); normal weight: 44.4%; overweight: 34.4% and obesity in 16.2% (fe- male: 15.6%; male: 16.8). Blood pressure increase in obese subjects with reference to underweight individuals was 11.4/7.5 mmHg higher (SBP/DBP p<0.0001); (Table VI). Central obesity measured throughout abdominal circumference was on average for females 86.9 (SD 12.63) cm and males

93.2 (SD 13.34) cm; 43.8% of women had an abdominal circumference over 88 cm; and 20.7% of men, over 102 cm, indicating ab- dominal obesity. Blood pressure was 4.2/3.1 mmHg (SBP/DBP) higher in females and 5.6/4.3 mmHg higher among underweight subjects.

The CARMELA study reported the aver- age BMI for Venezuela was 27 Kg/m2 (male:

26.9 Kg/m2, female 27 Kg/m2); underweight

2% (female: 2.1%; male: 1.7%); normal

weight 36.8%, overweight 36.2%; obesity

25.1% (female: 26.1%; male: 23.6%); central obesity in 29.2% (24). Another study carried

out in the west region of Venezuela (Mara- caibo), in 2012, reported an average BMI of

1. Kg/m2, with a prevalence of obesity of 33.3% (female: 32.4%; male: 34.2%) (25).

   Presuming these are comparable, those studies indicate an apparent progressive loss of average body mass index in the Venezu- elan population since 2008. Loss of weight for the population could cause lowering of blood pressure or produce an apparent bet- ter control of blood pressure (26). Carabal- lo-Arias in 2015 reported important changes in the economic and job situation and in health in Venezuela since 2006 which might explain weight loss in the Venezuelan popu- lation (27). Also, another publication made observations about the economic crisis and migration of scientific and health personal from Venezuela (28), which importantly af- fects the health care system for the atten- tion of patients with hypertension and car- diovascular diseases.

   Subjects in our study reported to hav- ing diabetes was 10.7% in contrast with oth- er studies showing 7.7% (range 6% to 14.9%) in several Venezuelan regions (29), and 6.4% (Central-Western region), including fasting glucose determination (30). The percent- age of diabetes seems to be consistent with those studies, however population based rep- resentative samples are required to confirm the prevalence.

   Adjusting for age, sex and antihyperten- sive treatment; both systolic and diastolic BP was significantly higher for individuals receiving antihypertensive treatment; sys- tolic BP was significantly higher in individu- als with a previous history of diabetes, stroke and myocardial infarction. Alcohol intake and smoking did not significantly change BP. The proportion of participants reporting either alcohol intake or smoking were low, and lower than previous reports (10,14,15); this situation may be as consequence of the current economic situation in Venezuela. Pregnant women tended to have lower sys- tolic and diastolic BP, as expected.

   This study has the advantage of being the largest study of this type carried out in Venezuela to detect hypertension associated with obesity and other risk factors; it can give an idea of the cardiovascular risk factors in the country; and can also help to identify unknown subjects with the disease; however this is not a representative sample and their values cannot be used as prevalence; which require appropriate epidemiological design studies. However, using the same methodol- ogy in different years and regions could help to identify tendencies and comparisons.

   In conclusion, this largest cross-sec- tional survey in Venezuela allows us to state:

   • Systolic and diastolic blood pressure increases with age; it is higher in young men and elderly women; and tend to be higher in obese, either classified by body mass index or abdominal circumference.

   • The percentage of current hyperten- sion for Venezuela, in a comparative way, was higher than worldwide and the America Con- tinent (48.9% vs 34.9% and 41.0% respec- tively).

   • Treated hypertensive subjects tend to have higher systolic and diastolic than not treated and not hypertensive subjects.

   • Obesity, previous myocardial infarc- tion or stroke, and diabetes affect mainly the systolic blood pressure.

   • One third of hypertensives who re- ported to be taking treatment were not con- trolled - mainly elderly women and young men, but these values were lower than among the world-wide and American conti- nent data.

   • The economic crisis in Venezuela may have influenced the rate of obesity, diabetes, alcohol intake, smoking and also on blood pressure control.

Investigators of Venezuela MMM-17 blood pressure campaign

Rebeca Arrage; Gloria Alvarado; Maria Gracia Alvarado; Adonis Diomar Álvarez; Daana Arnaud; Gracia Asbati; Peggy Asuaje;

María De Los Ángeles Avendaño; Karlianys Barrios; Sebastián Bracho; María Laura Bos- chetti Saer; Luis Blanco; Marilú Bermúdez; Juan Carlos Camacho Duin; Noe Alexander Campos; Korint Carrillo; Mary Carmen Cas- tellón; Mary Francis Carrión; Carla Maria Cotonne Di Mauro; Maryolga Cova; Kira Na- thaly Cuenca Camejo; Andreina Fernández; Loyda Fonseca; María Antonieta Gámez; Rig- mari García; Fernando González; Daysi De Gouveia; Angeli Hernández; Petra Luisa Her- nandez; Bertulio Izarra; Maria De Lourdes Natera; Ines Padrón; Julio Palacios; Lisbeth Pereira; Yalí Pereira; Gabriela Pérez; Nilda Pietrobono; Sandra Porreca; Maryoritza Pu- ente; Renne Ramirez; Ilsa Ramos; Yuli Rawik; Carmen Ríos; Maria Rimer; Fanny Rojas; Lu- isa Rondón; Maria Carolina Messina; Meybi Montilla; Gilda Noguera; Sergio Sanchez; Alfonzo Sulbarán, Danila Sbrizzi; Saman- tha Valentina, Astrid Varela; Zoyla Elizabeth Vega; Luis Zambrano; Rubén Zambrano.

ACKNOWLEDGMENT

The authors would like to acknowledge, for the extraordinary help to FARMATODO, as an institution, who fully collaborated with us, using their pharmacies, equipment and employees’ time to make possible this study and OMRON Healthcare for providing some automated devices.

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