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Khartoum Medical Journal (2011) Vol. 04, No. 02, pp. 584 - 589
584
Original Articles
Pattern of hypertensive target organ damage in
Khartoum and Elshaab hospitals
Ihab B Abdalrahman1*, Jafar Saeed Musa Mohammed2, Musa Mohammed Khair1
Faculty of Medicine, University of Khartoum.
1
Faculty of Medicine, University of Gezira.
2
Abstract
Background: The development of any form of hypertensive Target Organ Damage (TOD) indicates that
other major target organs have also been damaged and that there is increased risk for the overall morbidity and
mortality. In this study, we looked at the pattern of TOD in Khartoum and El Shaab Teaching hospital.
Methods: This is a cross sectional prospective study conducted in Khartoum and Elshaab teaching hospitals
from February/2011 to May/2011. Study populations were 150 patients with hypertension and target organ
damage. Data were collected by direct interview and chart abstraction using a structured questionnaire and was
analyzed by computer software (SPSS). Results: The study populations were hundred and fifty patients with hypertension and target organ
damage. Females (55.3%) were slightly higher than males. The frequency of diagnosing HTN for the first
time presenting with TOD was 26.7%. The presence of TOD was 26.7%, 53%, 57.3%, 36.7% and 68.7%
for cerebrovascular disease, ischemic heart disease, left ventricular hypertrophy, chronic kidney disease and
retinopathy respectively. Half of the patients (52.7%) did not have regular follow-up. Compliance with life
style modification was observed in less than 25%. Achieving target blood pressure was noted in only one third
of the patients (36.7%). Sixty six percent of the study population did not know their target blood pressure.
Conclusion: TOD was observed in those with long duration of hypertension, poor follow up, and uncontrolled
blood pressure. Delayed diagnosis, lack of life style modification and poor awareness may have contributed to
the development of TOD.
‫الملخص‬
‫الضرر أو اإلصابة في األجهزة المستهدفة بمرض ارتفاع ضغط الدم يشير إلى أن األجهزة‬ ‫ إن ظهور أي شكل من أشكال‬:‫الخلفية‬
.‫الضرر أو التلف في األجهزة المستهدفة بمرض ارتفاع ضغط الدم‬ ‫نمط ونوع‬ ‫ هذه الدراسة تهدف إلي تقييم‬.‫األخرى ربما أصيبت بضرر‬
‫تمت دراسة‬ . 2011 -5- 30 ‫ إلى‬2011 -1-2 ‫مستشفى الخرطوم والشعب التعليمي من‬ ‫أجريت في‬ ‫مقطعية‬ ‫ هذه دراسة‬:‫األساليب‬
‫المباشرة‬ ‫المقابلة‬ ‫البيانات عن ريق‬ ‫ تم جمع‬.‫ مريضاً يعانون من ارتفاع ضغط الدم مع وجود عضو مصاب بنوع من الضرر‬150
.‫بواسطة الكمبيوتر‬ ‫استبيان ثم تحليلها‬ ‫واالستخالص من الملفات باستخدام‬
‫أكثر من ثلثي‬ ‫كان‬ .)44.7%( ‫) ونسبة الذكور‬55.3%( ‫نسبة اإلناث‬ ،ً‫مريضا‬ ‫ عدد أفراد الدراسة مائة وخمسون‬:‫النتيجة‬
.٪ 26.7 ‫مع حدوث إصابة بعضو مستهدف‬ ‫وكانت نسبة تشخيص ارتفاع ضغط الدم للمرة األولى‬ .ً‫ عاما‬60 ‫المرضى أكبر من‬
،٪26.7‫ بنسبة‬ ‫واعتالل الشبكية‬ ‫ تضخم عضلة القلب ومرض مزمن في الكلى‬،‫القلب‬ ‫مرض قصور‬-‫وجود إصابة بالمخ‬ ‫وكان‬
.‫على التوالي‬ ٪ 68.7‫و‬ ٪36.7 ،٪ 57.3 ،٪ 53
‫أن‬ ‫ولوحظ‬ .٪5 ‫في أقل من‬ ‫نمط الحياة‬ ‫لتعديل‬ ‫أن االمتثال‬ ‫ولوحظ‬ .‫لم يكن لديهم متابعة طبية منتظمة‬ )٪ 52.7( ‫نصف المرضى‬ ‫ من المرضي لم يكن لديهم معرفة‬66% ‫و أن هنالك‬ .‫) من المرضي‬٪ 36.7( ‫نسبة انضباط ضغط الدم قد تم إنجازه في‬
.‫بالمستوي األمثل لضغط الدم‬
،‫المتابعة‬ ‫ وضعف‬،‫ إن حدوث إصابة في األعضاء التي يستهدفها مرض ارتفاع ضغط الدم له عالقة بطول مدة المرض‬:‫الخالصة‬
.‫الحياة وضعف الوعي بمضاعفات المرض‬ ‫وعدم االمتثال لتعديل نمط‬ ،‫المتأخر‬ ‫والتشخيص‬
*Corresponding author: Faculty of Medicine, University of Khartoum, Khartoum, Sudan
[email protected]. 0912347666
585
Ihab B Abdalrahman, Jafar Saeed Musa Mohammed, Musa Mohammed Khair
Introduction
oLeft Ventricular Hypertrophy (LVH),
Hypertension (HTN) is a public health problem. It
affects approximately 1 billion people worldwide. As
the population ages, the prevalence of hypertension
will increase even further unless, broad and effective
preventive measures are implemented (1). HTN is a
major risk factor for coronary artery disease (CAD),
cerebrovascular disease (CVD), retinopathy, and
nephropathy. Most patients with HTN are unaware
of their high blood pressure (BP) for a long time so
that a large number of hypertensive patients have
target organ damage (TOD) when first admitted
to hospital(2). The higher the BP, the greater is the
chance of heart attack, heart failure, stroke, and
kidney disease(3). The main goal of treating HTN is
to reduce HTN-related complications. The prevention
and detection of preclinical HTN related TOD is
becoming increasingly important in the stratification
of cardiovascular risks. The pattern of hypertension
related target organ damage among patients attending
Khartoum and Elshaab teaching hospitals is evaluated.
oIschemic Heart Disease (IHD)
Methods
Study design:
This is a cross sectional study conducted in two
major referral hospitals in Sudan, Khartoum and
Elshaab teaching hospitals from February/2011 to
May/2011. Study populations were 150 Sudanese
patients attending inpatient and outpatient referral
clinics. Patients with hypertension and target organ
damage during the study period were enrolled after
they consented to enter the study. Demographic and
clinical data were collected by direct interview using
a structured questionnaire.
Inclusion criteria were the presence of hypertension
and target organ damage. Only those who consented
were included.
Definitions
Hypertension: Patients were considered to be
hypertensive if already diagnosed, or had a confirmed
BP of 140/90 mm Hg or more in more than one
occasion.
• Hypertensive Target Organ Damage (TOD):
defined as the detection of any of the following:
oLeft Ventricular Failure (LVF)
oChronic Kidney disease CKD
oHypertensive Retinopathy (HR)
oCerebrovascular Disease (CVD)
• Left ventricular hypertrophy: Left ventricular
hypertrophy was diagnosed using echocardiography
or ECG
• Ischemic heart disease: patients who have clinical
picture highly suggestive of angina pectoris,
or acute coronary syndrome, augmented by the
presence of features on ECG, echocardiography, or
angiography.
• Left ventricular failure: Presence of symptoms and
signs highly suggestive of heart failure, with the
presence of diastolic or systolic heart failure on
echocardiography.
• Chronic kidney disease: assessed by urinalysis
showing albuminuria and/or high serum creatinine
(more than 1.6 mg/dl).
• Retinopathy assessment: examination of the retina
using an ophthalmoscope, or with documented
ophthalmologist diagnosis of hypertensive
retinopathy.
• Cerebrovascular disease: defined as current or past
clinical or radiologic picture suggestive of brain
injury related to vascular insult.
Statistical analysis
The data was analyzed and the results were expressed
into figures, tables, graphs using statistical package
for social science (SPSS).
Results
The study populations were hundred and fifty patients
with hypertension and target organ damage. Females
(55.3%) were slightly higher than males. Thirty eight
percent were illiterate. Sixty three percent of the
female had Body mass Index (BMI) more than 25kg/
m2 compared to 44% of the males. More than two
thirds of the patients were more than 60 years old.
The frequency of diagnosing HTN for the first time
586
Pattern of hypertensive target organ damage in Khartoum and Elshaab hospitals
presenting with TOD was 26.7% while asymptomatic
patients represent 22%. Forty four percent of the
patients were hypertensive for more than 10 years.
uncontrolled HTN thought their blood pressure was
good.
Half of the patients (52.7%) did not have regular
follow-up. The frequency of taking combination
therapy, single drug and no treatment were 38%,
54.8% and 7.2% respectively. Compliance with life
style modification like weight loss, low salt and
regular exercise was observed in only 4%, 25% and
1.3% respectively. Achieving target blood pressure
was noted in only one third of the patients (36.7%).
In this cross sectional study females were slightly
more than males. More than half of the female patients
had hypertension for more than 10 years compared
to one third of the males. More males presented with
complications. The reasons for the gender variations
in early detection and longer duration of hypertension
in females were not clear. Though illiterate females
represented 38% of the total population and 64.8% of
the illiterate patients, we speculate that females were
more likely to utilize health services than the men
during childbearing age. We wonder if the working
pattern of the males (as determined by the society
make up) had a role or not.
The presence of TOD was ranging from 26.7% for
CVD to 68.7 for retinopathy (table-1). HTN was
recognized for the first time in almost one third of
patients with TOD. Duration of HTN for more than
10 years occurred in patients who had from 46.3% to
67.2% of TOD (table 1).
Discussion
Table 1 Characteristics of 150 patients with target organ damage
TOD
Prevalence
Percentage of
patients older
than 60 years
Percentage
of patients in
whom HTN was
recognized for the
first time
Percentage of
patients who
had HTN > 10
year
Percentage
of patients
who had
no Regular
follow up
CVD1 (TIA2 & 26.7%
Stroke)
85%
32%
47%
57%
IHD3
53%
68.7%
23.7%
46.3%
63.3%
LVH4
57.3%
74.4%
26.7
50.0%
53.5%
CKD5
36.7%
67.2%
34.5%
67.2%
56.4%
Retinopathy
68.7%
69.9%
29%
46.6%
56.4%
1. CVD Cerebrovascular Disease 2. TIA transient ischemic attack
3. IHD Ischemic Heart Disease
4. LVH left Ventricular Hypertrophy
5. CKD Chronic Kidney disease
Lack of general awareness regarding cardiac, eye,
brain and kidney complication was seen in 75.3%,
87.3%, 80% and 80% respectively.
Sixty six percent of the study population did not know
their target blood pressure and 34% of those who had
Two thirds of the participants were older than 60 years.
There was 26.7% of the study sample presenting with
complications on their first medical encounter. This is
less than the figure reported from Ghana, where 52%
of newly detected hypertensive patients had TOD(4).
The overall rate of well-controlled hypertension was
36.7%. This is comparable to a report from the USA,
which showed that only 32.7% had systolic blood
pressure controlled to less than 140 mm Hg(5). Similar
findings were observed in the NHANES III cohort(6),
587
Ihab B Abdalrahman, Jafar Saeed Musa Mohammed, Musa Mohammed Khair
where 38.7% of the participants were taking combined
treatment and more than half of them were on single
medication. In ALLHAT (The Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack
Trial), 60 percent of those whose BP was controlled
to <140/90 mmHg received two or more agents, and
only 30 percent were controlled on one drug(7).
Fifty two percent of the participants did not have any
regular follow up. This percentage was well reflected
in those with specific TOD. Controlled clinical trials
have demonstrated that BP can be controlled in 60%
to 70% of patients when close follow up and optimal
drug titration were used(8).
Only 25% of patients claimed to reduce salt intake in
their meals, and less than 4% had lifestyle modifications
such as reducing body weight and regular exercise.
More than half of the patients had BMI greater than
25kg/m2. This raises the question of whether our
patients were well educated and empowered to achieve
these goals of life style modifications or not.
The frequency of Target Organ Damage (TOD) was
68.7%, 57.3%, 53%, 36.7% and 26.7 for retinopathy,
Left Ventricular Hypertrophy (LVH), Ischemic Heart
Disease (IHD), Chronic Kidney Disease (CKD) and
Cerebrovascular Disease (CVD) respectively. This
can be contrasted to prevalence of TOD in Cape Town
showing the occurrence of IHD in 49%, LVH in 35%
and CKD in 26 %. Both of the studies reported high
frequency of TOD. The present study was performed
in a referral center while the South African study was
in a primary care setting(9).
Stroke and Transient Ischemic Attack (TIA) were
detected in 26.7% in our study; this is compared to
17% in a study done in Kassala eastern Sudan (10). We
should point out that the latter study was in a rural
society, while our study was in an urban community.
There was not much difference between the prevalence
of cerebrovascular disease in males (52%) and females
(48%). In a study in the Middle East region, the mean
10-year risk of stroke in hypertensive patients was
estimated at 22.7% and was significantly higher in
males(11).
LVH affected more than two thirds of our study
population, and half of them had left heart failure.
Data on the prognostic implications of left ventricular
hypertrophy (LVH) in the Framingham Study
indicated that LVH has emerged as a powerful
indicator of rapidly evolving lethal atherosclerotic
disease, whether determined by ECG or ECHO(12).
Hypertensive retinopathy was found in two thirds
of the participants. This higher rate of prevalence
may be due to a racial factor. A higher prevalence of
retinopathy has been reported more frequently among
black than white patients. The difference is explained
in large part by the higher levels of blood pressure
among blacks(13, 14).
In this study, one third of patients had renal impairment.
Most of them were older than 60 years. Data from
the Third National Health and Nutrition Examination
Survey (NHANES III) estimated that seventy
percent of those with elevated serum creatinine had
hypertension(15). Our study showed that about half of
those with CKD did not have regular follow-up. In a
study from Spain, out of 6,113 charts of hypertensive
patients, 25.7% had a diminished GFR. Of these, only
19.1% had a good level of control of systolic BP,
49.9% had a good level of control of diastolic BP (16).
The National Kidney Foundation recommend a target
BP for all CKD patients of <130/80 mmHg and this
might require more than one antihypertensive drug to
be achieved(17, 18).
Only 20% of patients were aware of hypertension
complications. Lack of awareness of cardiac, eye,
neurological and renal complications occurred in
75.3%, 87.3%, 80% and 80% of patients respectively.
A study from Canada reported that the majority of
patients were unaware of the association between
hypertension and heart disease (80%), heart attack
(66%), kidney disease (98%)(19).
About half of our patients did not know the target
goal of their blood pressure. Thirty four percent of
those who had uncontrolled blood pressure thought
that their BP was good while 20% suspected their BP
to be high or bad. In a study from the USA 20.2% of
patients with uncontrolled hypertension labeled their
blood pressure as “high” and 38.4% as “borderline
high(19). In the present study, two thirds of patients
Pattern of hypertensive target organ damage in Khartoum and Elshaab hospitals
did not know the target or goal blood pressure. This
is comparable to what was reported in the US where
71.7% and 61% were not able to report target Systolic
or diastolic BP respectively(20).
Conclusion
More male patients presented with complication
and they developed these earlier. Most patients with
uncontrolled hypertension had poor follow up and
compliance with medication. Life style modifications
were almost ignored. The frequency of TOD was
reported in the following sequence retinopathy, LVH,
IHD, CKD and CVD. Lack of awareness regarding
blood pressure control, hypertension complications,
was evident in the majority of the participants.
References
1. Vasan RS, Beiser A, Seshadri S, et al. Residual
lifetime risk for developing hypertension in
middle-aged women and men: The Framingham
Heart Study. JAMA. 2002;287:1003-10.
2. Guidelines
Subcommittee of the World
Health Organization - International Society of
Hypertension Guidelines for the Management of
Hypertension, J Hypertens, 1999; 17: 151-83.
3. Lewington S, Clarke R, Qizilbash N, et al. Agespecific relevance of usual blood pressure to
vascular mortality: A meta-analysis of individual
data for one million adults in 61 prospective
studies. Lancet. 2002;360:1903-13.
4. Addo J, Sm21eeth L, Leon DA. Hypertensive
Target Organ Damage in Ghanaian Civil Servants.
PLoS One. 2009;4:6672.
5. Izzo JL Jr, Levy D, Black HR. Clinical Advisory
Statement. Importance of systolic blood pressure
in older Americans. Hypertension. 2000;35:10214.
6. Franklin SS, Jacobs MJ, Wong ND, et al.
Predominance of isolated systolic hypertension
among middle-aged and elderly US hypertensives.
Hypertension. 2001;37:869-874.
588
7. Cushman WC, Ford CE, Cutler JA, et al. Success
and predictors of blood pressure control in diverse
North American settings: The Antihypertensive
and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT). J ClinHypertens
(Greenwich) 2002;4:393-404.
8. Carter BL, Frohlich ED, Elliott WJ, et al.
Selected factors that influence responses
to antihypertensives: Choosing therapy for
the uncomplicated patient. Arch Fam Med.
1994;3:528-536.
9. Nasheeta Peer,
Krisela Steyn,
Cheryl
R. Dennison, et al, Determinants of Target
Organ Damage in Black Hypertensive Patients
Attending Primary Health Care Services in Cape
Town: The Hi-Hi Study, American Journal of
Hypertension 2008; 21: 896–902.
10. 10.Hussain AA, Elzubier AG, Ahmed ME, Target
organ involvement in hypertensive patients in
Eastern Sudan. J Hum Hypertens 1999;13:9-12.
11. Badr KF, Boudia KM, Alami M, et al, Assessing
and Reducing the Risk of Stroke in Hypertension
Survey Group. Physician. Assessment of stroke
risk in hypertensive patients in the Middle East
and Africa: results of the action survey. Ethn Dis.
2007;17:274-9.
12. Kannel WB, Cobb J. Left ventricular hypertrophy
and mortality--results from the Framingham
Study. Cardiology. 1992;81:291-8.
13. Sharp PS, Chaturvedi N, Wormald R, McKeigue
PM, Marmot MG, Young SM. Hypertensive
retinopathy in Afro-Caribbeans and Europeans:
prevalence and risk factor relationships.
Hypertension 1995;25:1322-1325.
14. Wong TY, Klein R, Duncan BB, et al. Racial
differences in the prevalence of hypertensive
retinopathy. Hypertension 2003;41:1086-1091.
15. Coresh J, Wei GL, McQuillan G, et al. Prevalence
of high blood pressure and elevated serum
589
Ihab B Abdalrahman, Jafar Saeed Musa Mohammed, Musa Mohammed Khair
creatinine level in the United States: Findings
from the third National Health and Nutrition
Examination Survey (1988-1994). Arch Intern
Med. 2001;161:1207-1216.
16. Vara-González L, Martín Rioboó E, Ureña
Fernández T, Dalfó Baqué A, Flor Becerra
I, López Fernández V. Prevalence of chronic
kidney disease in hypertensive patients under
treatment at primary care health centres in Spain
and the monitoring of their blood pressure. Aten
Primaria. 2008;40:241-5.
17. Sica DA. Rationale for fixed-dose combinations in
the treatment of hypertension: The cyclerepeats.
Drugs 2002;62:443-62.
18. Law MR, Wald NJ, Morris JK, Jordan RE.
Value of low dose combination treatment with
blood pressure lowering drugs: Analysis of 354
randomised trials. BMJ 2003;326:1427-34.
19. Petrella RJ, Campbell NR. Awareness and
misconception of hypertension in Canada: results
of a national survey. Can J Cardiol. 2005;21:58993.
20. Alexander M, Gordon NP, Davis CC, ChenRS.
Patient knowledge and awareness of hypertension
is suboptimal: results from a large health
maintenance organization. J ClinHypertens
(Greenwich). 2003;5:254-60.