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Arterial hypertension in Poland in 2002

T Zdrojewski1, P Szpakowski1, P Bandosz1, A Pajak2, A Wiecek3, B Krupa-Wojciechowska3 and B Wyrzykowski3
sk; 2Department of Epidemiology Department of Hypertension and Diabetology, Medical University of Gdan w; and Population Studies, Institute of Public Health, Collegium Medicum, Jagiellonian University, Krako 3 Department of Nephrology, Endocrinology and Metabolic Diseases, Silesian University School of Medicine, Katowice, Poland
1

Arterial hypertension represents a serious medical, social and economic problem in Poland. Owing to a small number of studies concerning HT epidemiology in Poland and large differences in methodology, it is difficult to make an objective verification of the changes regarding principal parameters in our country within the last decade. Important programme for the assessment of the situation in our country is NATPOL PLUS, carried out in the year 2002 on a representative sample of 3051 adult Polish residents aged between 18 and 93 years, using the current diagnostic criteria for arterial hypertension (blood pressure readings obtained at three separate visits in cases of newly detected HT, different cuff sizes for different arm circumference, age range 1893 years, rejection of first measurement during initial screening visit). Prevalence of HT in Poland is 29%,

awareness67%, and effectiveness of treatment12%. This means that while HT affects about 8.4 million adult Poles, only 1 million of them get effective treatment. Moreover, as much as 8.7 million Poles have high normal blood pressure and they should apply active prevention. The awareness, detection and control of hypertension is much worse in men than in women. A series of NATPOL studies indicated over the period 19942002 a significant and rapid decrease in the awareness of ones own blood pressure among the adult Polish population, especially in small towns and villages, among less educated people, and in males. Journal of Human Hypertension (2004) 18, 557562. doi:10.1038/sj.jhh.1001739 Published online 6 May 2004

Keywords: representative survey; blood pressure; arterial hypertension; awareness; prevalence; control

Introduction
Hypertension (HT), due to its prevalence, complications and treatment costs represents one of the most important health and social problems in Poland.1 It was estimated that the impact of hypertension on mortality in middle age in Poland is greater than in the United States and about 50% of deaths due to cardiovascular disease can be attributed to hypertension.2 During the last years it was proved that HT may be effectively treated and this brings measurable benefits. In the US, The National High Blood Pressure Education Program was developed and implemented in early 1970s. Subsequently, improved levels of awareness, treatment and control of hypertension were demonstrated, coincident with continued declines in coronary heart disease mortality and striking declines in stroke mortality.3,4 In other countries where such long-term nationwide integrated programmes directed against hypertension have not been developed, time trends in the prevalence of cardiovascular and cerebrovascular
Correspondance: Dr T Zdrojewski, Department of Hypertension and Diabetology, Medical University of Gdansk, ul. Debinki 7, 80-211 Gdansk, Poland. E-mail: tzdroj@amg.gda.pl Published online 6 May 2004

diseases reveal an even greater importance of hypertension as cardiovascular disease risk factor.2,5 According to the World Hypertension League Statement, published in 1997, in those countries where cardiovascular and cerebrovascular diseases are on the increase (eg in the eastern part of Europe) there is particularly an urgent need for more vigorous public health action against hypertension.5 In Poland, the National Heart Program directed against high blood pressure and cardiovascular diseases has been developed and implemented since early 1990s. These activities, however, have been overlapped by a rapid transformation into a market economy, following the collapse of the former economic and political system. This process, being in itself a unique psychological and social experience for our populations, presents a source of considerable stress related to the need to adjust to new economic conditions. Changes in inflation rate (up to 618% in 1990) and real wages (70% in 1993) illustrate well the potential influence of these hardto-be-measured psychosocial contributors. In order to be able to plan properly as to how to combat hypertension on the scale of the whole population, it is essential to know the fundamental parameters, such as prevalence, detectability and

Arterial hypertension in Poland in 2002 T Zdrojewski et al 558

treatment effectiveness in the whole population and its clusters, for example, according to sex, age, place of living, level of education, income, etc. There is no doubt that in countries like Poland, with limited health care funding, access to such information and periodical update of most important data is particularly important, due to the need to rationalize expenses. Unfortunately, such knowledge was rather insufficient in our country until recently. The objective of this paper is to present the current epidemiological situation regarding arterial hypertension in Poland, preceded by a critical review of the methodology used in the research projects carried out so far. The data presented herein are based, first of all, on the findings of three nationwide projects carried out on representative samples of adult Poles over the period 19942002. The first projectNATPOL I (abbreviation of the nie Polish title Nadcis nie Tetnicze w Polsce (Arterial Hypertension in Poland))carried out in 1994 on a sample of 2080 respondents, was limited to a questionnaire interview.6 The NATPOL II project (sample size n 1664) of 1997 included three blood pressure readings at one occasion in all respondents.7,8 In the first half of 2002, the third national projectNATPOL PLUS (Arterial Hypertension in Poland Plus Lipid Disorders and Diabetes)was carried out on a sample of n 3051 respondents. Apart from the questionnaire interview and blood pressure readings (repeated on three separated occasion, if necessary), this most recent project included also evaluation of lipid disorders and diabetes. In order to evaluate the global cardiovascular risk in Poland, the project measured the prevalence of all major risk factors for myocardial infarction and stroke (HT, diabetes, lipid disorders, obesity, smoking and family history). The same set of question was used in NATPOL I, NATPOL II AND NATPOL PLUS projects.

measurements carried out on a properly selected, much smaller sample. The representative method, due to its accuracy and cost-effectiveness, is extremely suitable for achieving research objectives like thosein the NATPOL PLUS project, carried out on a representative sample of 3052 respondents. For the adult Polish population of over 29 million, the estimated statistical error (Po0.05) ranged between 1.2 and 2.0%, depending on the prevalence of the examined parameter in the population (10 and 50%, respectively).
HT detection principles

Methodological issues
The most important factors that determine appropriate evaluation of the prevalence of HT in the general population are: 1. correct sample selection, 2. appropriate diagnosis of hypertension by taking blood pressure at least three times, on separate visits occasions, 3. wide age range of the sample, 4. using cuff size suitable for arm circumference of the patient.
Sample selection

In the recommendations of JNC V in 1993 and JNC VI in 1997, it was suggested that HT should be diagnosed in patients with elevated blood pressure (systolic blood pressure X140 mmHg and/or diastolic blood pressure X90 mmHg) present at least on two separate visits, following the initial screening visit.10. According to 1999 WHO/ISH guidelines,11 diagnosis of HT in patients previously not treated should be based on readings taken during at least several separate visits. Both the JNC VI experts and WHO/ISH are thus in agreement that HT should be diagnosed on the basis of readings taken on at least three separate occasions. However, implementation of this recommendation is quite often difficult, especially in large epidemiological studies. An indication, how important this might be in practice, can be provided by the findings of a study carried out in the years 20002001 under the Polish FourCities Project HypertensionYou Should Know About It among the residents of the town of Kartuzy aged 3092 years.12 In almost half of those examined persons who had had elevated blood pressure during the first visit, no consistent occurrence of increased blood pressure was detected during subsequent regular visits, therefore they could not be diagnosed with HT. Consequently, if HT is diagnosed based on a single visit, this may result in substantial overestimation of the rate of HT occurrence.
Age range

The best way to assess prevalence of a given feature among the general population is to use the method of a representative survey.9 It draws conclusions on the parameters of the general population based on
Journal of Human Hypertension

Using as wide respondent age range as possible should be considered an important element in the assessment of the prevalence of HT in the general population. There are a number of reasons why it is important to monitor hypertension in an elderly population. Blood pressure clearly increases with age, therefore HT is most widespread among the senior population.13 Our knowledge on positive effects of HT therapy in elderly patients significantly increased over the last decade. Equally important is the fact that the population in Poland systematically grows old, just as it happens in the developed countries. In 2001 subjects over 64 years of age account for about 12.3% of Polands

Arterial hypertension in Poland in 2002 T Zdrojewski et al 559

population. It is prognosed (Central Statistical Office in Poland) that within the next 20 years this proportion may double.14 It is easy to forecast, therefore, that in the near future HT in senior population will become an increasingly serious economic and social problem.15,16
Cuff size

An important, even though often underestimated, factor that has an impact on the accuracy of blood pressure readings is the size of the cuff.17 Correct blood pressure measurement requires that cuff size should fit to arm circumference; standard cuff size may be used for arm circumference between 24 and 32 cm (both WHO and JNC VI guidelines). Unfortunately, except for scientific research projects and drug research programs, in their everyday practice doctors and nurses very seldom adapt cuff size to patients arm circumference, which may result in significant errors by causing a difference of 10 mmHg and more. The arm circumference distribution in the adult Polish population was obtained in the NATPOL II project.18 Arm circumference was below 24 cm for 6% of respondents, and over 32 cm for 11%. Therefore, a nonstandard cuff should be used, on average, for one in every six adult Poles. Besides, arm circumference was over 32 cm for as much as 18% of those with HT and for 22% of overweight or obese patients and in those cases blood pressure should be measured using a wider cuff. As discussed, in epidemiological surveys the methodological issues may be of crucial value for the parameters assessed. Thus, simple comparison of the results obtained in separate studies and different countries without a detailed analysis of methods that were used (age range, cuff size, algorithm for HT diagnosis) may be seriously misleading.

lities. The units drawn at the second stage were villages in rural areas and streets in urban areas. The units drawn into the sample at the third stage were individual respondents aged 18 or over. Thanks to this sample draw design, a representative, automatically weighted sample was obtained, with individuals drawn into the sample spread over 300 locations all over the country. Therefore, the sample was appropriately dispersed geographically. Blood pressure readings were taken using Omron M5-I devices. The results of the NATPOL PLUS project showed that in the year 2002 the prevalence of HT (blood pressure X140/90 mmHg or treatment) among adult Poles aged 18 years and more was 29% (female 29% and male 29%) what corresponds to 8.4 mln of adults in our country (Figure 1). In all 30% of respondents had high normal blood pressure (8.7 mln of adult population), 21%normal blood pressure, while 20% had optimal blood pressure. One-third of those who have HT was unaware of their condition. Among all hypertensives, good control of blood pressure (o140/90 mmHg) was observed in 12% of subjects. Control of hypertension was slightly better in female patients (14%) than in males (10%) (Figure 2). The analysis of the use of pharmacological therapy showed that 62% of HT patients took medication systematically, 19%from time to time, while the rest (19%: women 13%, men 27%!) of them had not started the prescribed therapy at all. Frequency of taking drugs in specific categories was as follows: ACE inhibitors59%, beta-adrenolytic drugs40%, calcium antagonists34%, diuretics 24%, drugs containing reserpine2%, other3%. These findings show that, compared to the data from early 1990 s, published by the authors of Pol-MONICA studies, apart from diuretics and
21% 30%
optimal normal high normal

Prevalence, detection and control of arterial hypertension in Poland in the year 2002
Main findings of the NATPOL PLUS project

hypertension

20%

29%

Figure 1 Prevalence of optimal, normal and high normal blood pressure, and prevalence of arterial hypertension in Poland in 2002. NATPOL PLUS project; age range: 1893 years.

Divergent results of previous studies1921 and lack of methodological homogeneity inspired authors from Department of Hypertension and Diabetology at the Medical University in Gdansk to design and carry out in 2002 the NATPOL PLUS project. In the projects design, diagnosis of newly detected HT cases was based on measurements taken at the respondents home on three separate visits. Selection of respondents in the NATPOL PLUS project was a three-stage procedure aimed to select a nationally representative sample of adult Poles (age range 1893 years, sample size n 3051). The units used for the first stage draw were municipa-

not detected 33%

detected, not treated 10%

treated, BP<140/90 12%

treated, BP>140 or 90 45%

Figure 2 Control of arterial hypertension in Poland in 2002. Results of the NATPOL PLUS project.
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Arterial hypertension in Poland in 2002 T Zdrojewski et al 560

beta-blockers, there has been a significant increase in the use of calcium antagonists and ACE inhibitors.

Changes in awareness of blood pressure between 1994 and 2002

An important objective of the series of the NATPOL projects was also analysis of changes in awareness of blood pressure among adults in Poland. In all studies (in 1994, 1997 and 2002) respondents were asked, among other questions,6 Do you know your own blood pressure?. The answer is a direct result of the frequency of blood pressure measurements, which are the essential prerequisite for a diagnosis and for treatment monitoring. The results obtained in 1997 showed a clear drop in the awareness of ones own blood pressure in Poland, compared to the situation 3 years before.8 In 2002 further significant deterioration of the awareness level was detected. Over the series of studies, the awareness of ones own blood pressure decreased from 71% in 1994, to 65.5% in 1997, and to 59% in the year 2002 (Po0.001)22 (Table 1). When translated into the general population of adult Poles (29.3 million), this means a reduction by approximately 3.5 million people. Decline of awareness of BP was most significant in small cities and villages as well as among less educated people representing lower social status. These facts indicate an urgent need to introduce effective prevention measures, especially in these most affected communities. Another fact that must be emphasized is insufficient frequency of blood pressure measurement during visits to a doctor. In the NATPOL II study, when asked whether they had their blood pressure taken during a visit to a doctor, 49% of respondents confirmed that their GP, family doctor or cardiologist measured their blood pressure every time or almost every time during visits, while for doctors practising in other fields of medicine the corresponding figure was 33%. A significant factor influencing the effectiveness of prevention and therapy is the knowledge among the general public concerning about the reasons and effects of HT as well as the methods to prevent the condition. That is why one of the objectives of the NATPOL projects was to provide an assessment of
Table 1 Changes in awareness of blood pressure among adults in Poland between 1994 and 2002
1994 Women Men Education: primary or post-primary Education: secondary or higher Large cities (4200 000) Small towns and villages 77 65 68 75 72 73 1997 71 60 59 74 73 64 2002 64 54 51 68 67 57

the general knowledge about HT among adult Poles. For example, respondents were asked what might be the results of untreated HT, what methods of HT and cardiovascular prevention they are aware of, and where they learnt about those? In the NATPOL PLUS project: among the effects of untreated HT those most often identified were myocardial infarct (62%), stroke (56%) and arteriosclerosis (21%). Kidney diseases were mentioned by 5% of respondents. Respondents were also asked about criteria of arterial hypertension. More than one third (36%) reported that did not know. However, among others 90% mentioned normal range as 90 mmHg or less for diastolic and 84% 140 mmHg or less for systolic blood pressure. These data show that criteria 140/ 90 mmHg have become in general public much more popular than older, that is, 160/95 mmHg.

Conditions for effective HT prevention in Poland

In view of limited funds available for preventive intervention, there is a clear need to identify those groups, which should be specifically addressed with such intervention. Undoubtedly, the epidemiological situation among the male population is clearly worse than among females. In all NATPOL studies, women knew their own blood pressure much better than men, and much higher proportion of women started and continued therapy. Also, the analysis of the results of the prevention program carried out in 70 towns in Poland in 1996 under the slogan Measure your blood pressure once a year, showed that behavior was gender-dependent.23 Among 308 361 people who came to have their blood pressure taken, women did so more often (proportion F:M 1.24 in the programme; while the corresponding proportion for the general population in Poland is F:M 1.08). It should be stressed that the NATPOL projects were carried out in the period of political and economic transformation in Poland. It seems highly likely that deep social and economic changes must have had an impact on such diseases in the population as arterial hypertension. This was one of the reasons why we undertook our studies and repeated the projects within a relatively short time frame. Importance of these factors, even in the situation of a country as stable as England is clearly perceived by a celebrated expert in the area of arterial hypertension, Professor JD Swales, who in his recently published article Hypertension in the political arena wrote that: ythe problems extend far beyond the implementation of expert guidelines. the social and political environment in which cardiovascular disease is managed is of crucial relevance to how successful we are in controlling ity.24 While recognizing todays difficult financial situation, one nevertheless has to see several factors,

Results of the NATPOL I (1994), NATPOL II (1997) and NATPOL PLUS (2002) projects. Journal of Human Hypertension

Arterial hypertension in Poland in 2002 T Zdrojewski et al 561

which create a chance to take effective action in the area of HT and cardiovascular prevention. Legal regulations, which are in line with the European Union requirements, create new possibilities to develop cardiovascular prevention. An example how actions of such type are integrated across Europe may be common guidelines of the European Society of Cardiology, the European Society of Hypertension and the European Arteriosclerosis Society concerning cardiovascular prevention, as well as actions taken by these organizations in the European Parliament. Epidemiological research and prevention programs should be supported by modern and effective marketing policy. Its task should be to reach the opinion and decision makers in Poland with reliable and current information on threats associated with and prevention methods against cardiovascular diseases. That is why the authors of the NATPOL projects, in cooperation with the Institute of Cardiology in Warsaw and other Polish organizations (Polish Society of Cardiology and Polish Society of Arterial Hypertension) launched a programme of activities that addressed major Polish trade union headquarters, representatives of local governments and health care financing authorities, people in charge of health marketing in Poland, print media and radio. Owing to the fact that modern marketing is a specialized area of knowledge, we asked sociology and psychology experts to join our team. An example of our lobbying for fight against HT and other cardiovascular disease risk factors may by a screening carried out in the Polish Parliament in May 2000, which yielded results very similar to those obtained in nationwide projects. It was preceded by a special information and education program and its results fully confirmed the sense of purpose of such actions.25

treated BP <140/90 treated BP >140 or 90 100% 14 80%

detected not treated not detected

10

37 60% 51 13 40% 8 20% 27 0% Females Males

Figure 3 Control of arterial hypertension according to sex in Poland in 2002. Results of the NATPOL PLUS project.

40

Concluding remarks
Arterial hypertension represents a serious medical, social and economic problem in Poland. Owing to a small number of studies concerning HT epidemiology in Poland and large differences in methodology, it is difficult to make an objective verification of the changes regarding principal parameters in our country within the last decade. Important programme for the assessment of the situation in our country is NATPOL PLUS, carried out in the year 2002 on a representative sample of over 3000 adult Polish residents aged between 18 and 93 years, using the current diagnostic criteria for arterial hypertension (blood pressure readings obtained at three separate visits in cases of newly detected HT, different cuff sizes for different arm circumference, age range 1893 years, rejection of first measurement during initial screening visit). Prevalence of HT in Poland is 29%, awareness67%, and effectiveness of treatment12% (Figure 3). This means that while

HT affects about 8.4 million adult Poles, only 1 million of them get effective treatment. Moreover, as much as 8.7 million Poles have high normal blood pressure and they should apply active prevention, due to a danger of developing HT. The awareness, detection and control of hypertension is much worse in men than in women. A series of NATPOL studies indicated over the period 19942002 a significant and rapid decrease in the awareness of ones own blood pressure among the adult Polish population, which calls for urgent and effective preventive measures to be implemented on the national scale, especially in small towns and villages, among less educated people, and in males. Improvement in the situation will depend on a better organization of the health care system, implementation of integrated and consistent prevention measures, sharp increase in public awareness of the causes and effects of hypertension, as well as on intensive cooperation between medical professionals, local governments and opinion-making circles, in order to fight the epidemic of cardiovascular diseases in Poland. Other essential measures include also changes in existing legal regulations and in the approach taken by doctors, politicians and decision-makers to the issue of modern prevention. One has to stress that its needed not only for medical but also for economic reasons. As already shown by the experience of many countries, modern prevention represents a highly efficient and cost-effective course of action, compared to the required outlays.
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Arterial hypertension in Poland in 2002 T Zdrojewski et al 562

Acknowledgements
The NATPOL PLUS project was prepared in cooperation with the Ministry of Health from the funds of the National Stroke Prevention and Treatment Program and with the support of the following sponsors: Polpharma, MSD, Polfa Kutno and Dade Behring. The NATPOL PLUS project was carried out under the auspices of the Minister of Health, Rector of the Medical University in Gdansk, the boards of the Polish Society of Cardiolology, Polish Society of Hypertension, Polish Diabetes Society, Polish Society on Atherosclerosis Research, and with the endorsement of the European Society of Cardiology and the Joint European Societies Cardiovascular Prevention Committee.
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