Introduction
In the Polish population, according to the WOBASZ II (Multicenter National Population Health Examination Survey; Polish, Wieloośrodkowe Ogólnopolskie Badanie Stanu Zdrowia Ludności), the prevalence of hypertension in adults above 20 years of age is 46% and 40% and the prevalence of dyslipidemia is 70% and 64.3% in men and women, respectively.1,2
In the 2011 Polish NATPOL (Arterial hypertension and other CVD risk factors in Poland; Polish, Nadciśnienie Tętnicze oraz inne czynniki ryzyka chorób serca i naczyń w Polsce) study, in the general population aged 18 to 79 years, the prevalence of hypercholesterolemia was estimated at 61.1% and the efficacy of treatment (achieving total cholesterol [TC] <4.9 mmol/l) at 10.9%.3 In POLFOKUS, another Polish study, elevated level of low-density lipoprotein cholesterol (LDL-C) was observed in 49.2%, 61.6%, and 61.5% patients with controlled, uncontrolled, and resistant hypertension, respectively.4 The prevalence of other modifiable risk factors for cardiovascular disease in the WOBASZ II study population was described elsewhere.5-8
The Framingham study showed that the incidence of CVD increases 2- to 3-fold in patients with hypertension—with the highest risk of stroke, heart failure, and all forms of coronary heart disease (CHD): angina pectoris, myocardial infarction, sudden cardiac death. In patients aged 40 to 69 years, mortality due to stroke or CHD doubled with each increase in systolic blood pressure (SBP) of 20 mm Hg and diastolic blood pressure (DBP) of 10 mm Hg.9 A relationship with CVD risk was seen in a wide range of TC and LDL-C concentrations. This applies to men and women, both with and without diagnosed CVD.10 It has been proved that changes in SBP in the range of 110 to 170 mm Hg are associated with an approximately 6-fold increase in CHD risk. Similarly, an increase in TC level in the range of 4.0 to 8.0 mmol/l results in an approximately 8-fold increase in the risk of CHD. And an increase in the range of 110 to 170 mm Hg SBD and 70 to 105 mm Hg DBP also increases the risk of stroke nearly 8-fold.11 The implementation of antihypertensive treatment reduces the risk of CHD by approximately 25%.12 The inclusion of lipid-lowering treatment in patients with hypertension reduces the residual risk of CHD by more than 35%,13 as confirmed by the AFCAPS/TexCAPS (Air Force/Texas Coronary Atherosclerosis Prevention Study)14 and the ASCOTLLA (AngloScandinavian Cardiac Outcomes Trial-Lipid Lowering Arm) study.15
Patients with multiple CVD risk factors are at higher risk of incident CVD than persons exposed to only 1 risk factor. The CVD risk resulting from concomitant hypertension and hypercholesterolemia is typically greater than the sum of risk from individual exposure to hypertension or hypercholesterolemia alone.16,17 It was found that in patients with hypertension and concomitant hyperlipidemia, the risk of CVD doubles, and in patients with normal cholesterol levels, the coexistence of hypertension results in a 3-fold increase in the risk of CVD.14 In people with SBP of 195 mm Hg and TC level of 8.5 mmol/l, the risk of CVD increases as much as 9-fold.18 Data on men aged 35 to 64 years from the POL-MONICA (Polish part of the Monitoring of Trends and Determinants in Cardiovascular Disease) study showed that the coexistence of hypertension and hypercholesterolemia increases the risk of death caused by CHD over 4.5-fold.19 The assessment of the overall cardiac risk can be made using the Systematic Coronary Risk Evaluation (SCORE) tables. For example, in the Polish population, a nonsmoking 70-year-old man with SBP of 180 mm Hg and TC of 8 mmol/l has a 50% risk of cardiovascular death within 10 years, and, respectively, with SBP of 120 mm Hg and TC of 4 mmol/l, only 10%.20
Results of the analyses in the Polish population published so far do not indicate to what extent exposure to hypertension and hypercholesterolemia occurs in the same person.
The objectives of the study were: 1) to assess the prevalence of comorbid hypertension and hypercholesterolemia in participants of the nationwide WOBASZ II study; 2) to assess the prevalence of hypercholesterolemia in the Polish hypertensive population; 3) to evaluate the control of blood pressure and cholesterol levels in patients with hypertension and hypercholesterolemia; and 4) to assess the factors related to the control.
Patients and methods
The WOBASZ II study was a cross-sectional survey conducted from 2013 to 2014 in 6170 people (3410 women and 2760 men) from all 16 voivodships (108 communes) in Poland. The reporting rate was 45.5%. The sampling method used a 3-stage scheme, stratified by voivodship, commune category, and sex. The study was approved by the Ethics Committee at the Institute of Cardiology in Warsaw, Poland (no. 1344). Each respondent was informed in writing about the purpose of the study and the range of activities (including blood pressure measurements and blood collection for laboratory tests). All participants signed informed consent form. The study methods have been presented in detail elsewhere.21 Blood pressure was measured 3 times in 1 visit in a sitting position in accordance with the 2013 European Society of Cardiology/European Society of Hypertension guidelines22 and the 2015 Polish Society of Hypertension23 guidelines. An UA631(AND Co., Tokyo, Japan) automatic device was used. The mean of the second and third measurements was used for analysis. Clinical chemistry tests were performed at the Central Laboratory “Diagnostyka” at the Institute of Cardiology in Warsaw, which has been certified by the Centre for Disease Control – Lipid Standardization Program in Atlanta, United States, and has the European quality certificate, Random International Quality Assessment Scheme. The sequence of procedures was as follows: first, blood pressure measurements were performed, then the survey was taken, and finally, blood was collected for laboratory tests. Details of the methodology for measuring blood pressure, blood collection, and clinical chemistry tests have been described elsewhere.1,2
Hypertension was defined as SBP of 140 mm Hg or higher, or DBP of 90 mm Hg or higher, or use of blood pressure-lowering medication (regularly for the last 2 weeks). Hypercholesterolemia was diagnosed if TC levels were 5 mmol/l or higher, or LDL-C levels were 3 mmol/l or higher, or the participant was taking a lipid-lowering medication (regularly for the last 2 weeks). Treated hypertension was defined as patients with hypertension who reported taking medication for high BP (affirmative response to the question, “Have you taken these medicines regularly during the last 2 weeks?”). Treated hypercholesterolemia was defined as patients who reported taking medication for high cholesterol level (affirmative response to the question, “Have you taken these medicines regularly during the last 2 weeks?”). Controlled hypercholesterolemia was defined as patients with hypercholesterolemia who had TC of less than 5 mmol/l and LDL-C of less than 3 mmol/l for people with intermediate or low cardiovascular risk; LDL-C of less than 2.5 mmol/l for people with high CVD risk; LDL-C of less than 1.8 mmol/l for people with very high CVD risk. The target treatment thresholds have been adopted according to risk categories based on the 2016 European guidelines for CVD prevention in clinical practice.24 Controlled hypertension was defined as patients with hypertension who had SBP of less than 140 mm Hg and DBP of less than 90 mm Hg. CVD risk was assessed according to the SCORE risk charts as follows: less than 1%, low risk; from 1% up to 5%, intermediate risk; from 5% up to 10%, high score; 10% and higher, very high risk. Diabetes was defined as patients who gave an affirmative response to the question, “Have you ever been diagnosed with diabetes?” or those taking a hypoglycemic medication (regularly for the last 2 weeks). Smoking was defined as at least 1 cigarette per day. Comorbid CVD was defined as previously diagnosed coronary artery disease, past myocardial infarction, myocardial revascularization, previous stroke, peripheral atherosclerosis. Physical activity was defined as at least 30 minutes of uninterrupted activity, for example, a walk, gymnastic exercises at least 4 d/wk. Alcohol drinkers were defined as patients who gave an affirmative response to the question, “Have you drunk any vodka, wine or beer in the last 12 months at least once?” High education was defined as more than vocational education. Obesity was defined as body mass index (BMI) of 30 kg/m2 or higher; overweight, as BMI of 25 to 30 kg/m2; and normal weight, as BMI of less than 25 kg/m2. High income income per person in the household of more than 1000 PLN (>250 EUR).
Statistical analyses
Continuous variables such as blood pressure values and age were presented as arithmetic mean (95% CI). Concentrations of TC, LDL-C, HDLC, and TG were presented as median and (95% CI). Qualitative variables were presented as percentages (95% CI). Crude prevalence of hypertension and hypercholesterolemia, and the prevalence of both hypertension and hypercholesterolemia control were described as percentages (95% CI) for the following age ranges 20 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 years and older. The results were standardized25 for age of the Polish population based on data from the Central Statistical Office report of December 31, 2014. The standardization method has been described in detail earlier.21 The prevalence of the analyzed features was compared using the χ2 test for trend. The influence of various parameters (age, sex, BMI, diabetes, HDL-C concentration, TG concentration, smoking, alcohol consumption, education, physical activity, coexisting CVD, marital status, the SCORE, number of visits and income) on the control of blood pressure, hypercholesterolemia, and simultaneous control of both blood pressure and hypercholesterolemia was evaluated by univariate logistic regression. The influence of selected parameters on the control of hypertension, hypercholesterolemia, and simultaneous control of both hypertension and hypercholesterolemia was evaluated by multivariable logistic regression with adjusted odds ratios. The logistic regression model took into account the simultaneous influence of age (increase by 10 years), HDL-C and TG concentrations (increase by 1mmol/l) as well as sex, diabetes, obesity, smoking, coexistence of other cardiovascular diseases, frequency of visits (<4 visits a year vs ≥4 visits a year), level of education (vocational education vs secondary and higher), and income (above 1000 PLN vs below 1000 PLN). All statistical tests were 2-tailed, and significance was accepted for P values of less than 0.05. The statistical analysis was performed with Statistica 12.5 (StatSoft Inc., Tulsa, Oklahoma, United States), Excel (Microsoft Corp., Seattle, Washington, United States), and PQStat (PQStat Software, Poznań, Poland).
Results
The analysis included 5939 participants aged 19 to 99 years (2647 men and 3292 women). A total of 231 people with no measurements of blood pressure or cholesterol levels were excluded from the analysis. Mean (SD) age was 49.5 (16.3) years (men, 48.9 [16.3] years; women, 50.0 [16.3] years).
In the whole WOBASZ II population, hypertension was found in 2784 (crude data 46.9%) persons (1365 men and 1419 women). Mean (SD) age was 58.4 (13.9) years (men, 55.8 [14.4] years; women, 60.9 [13.0]).
Comorbid hypertension and hypercholesterolemia was found in 2037 patients (982 men and 1055 women). Mean age was 58.8 (12.9) years (men, 56.1 [13.4] years; women, 60.5 [11.8] years). Descriptive statistics of the study group are summarized in Tables 1 and 2.
| Variable | Hypertension and hypercholesterolemia | |
|---|---|---|
Age, y, mean (95% CI); n | 58.8 (58.2–59.3); 2037 | |
Male sex, mean (95% CI); n | 48.3 (45.1–51.4); 982 | |
BMI kg/m2, % (95% CI); n | 17.3 (13.4–21.3); 353 | |
SBP, mm Hg, mean (95% CI); n | 144.7 (143.8–145.5); 2037 | |
DBP, mm Hg, mean (95% CI); n | 86.2 (85.7–86.7); 2037 | |
TC, mmol/l, median (95% CI); n | 5.6 (5.5–5.6); 2012 | |
LDL-C, mmol/l, median (95% CI); n | 3.5 (3.4–3.6); 2008 | |
HDL-C, mmol/l, median (95% CI); n | 1.4 (1.3–1.4); 2009 | |
TG, mmol/l, median (95% CI); n | 1.5 (1.4–1.6); 2010 | |
Hypertension treatment, % (95% CI); n | 59 (56.2–61.7); 1201 | |
Hypercholesterolemia treatment, % (95% CI); n | 31.3 (27.7–34.9); 637 | |
Diabetes, % (95% CI); n | 14 (10.0–18.0); 286 | |
Smoking, % (95% CI); n | 21.7 (17.9–25.6); 443 | |
Alcohol drinkers, % (95% CI); n | 80.3 (78.4–82.2); 1636 | |
Education, % (95% CI); n | 75.2 (73–77.4); 15,32 | |
Physical activity, % (95% CI); n | 56.9 (54–59.7); 1159 | |
Coexisting CVD, % (95% CI); n | 27.6 (23.9–31.3); 562 | |
Married, % (95% CI); n | 23.7 (19.9–27.5); 483 | |
SCORE, % (95% CI); n | <5% | 54.6 (51.7–57.5); 1112 |
≥5% and <10% | 26.9(23.1–30.6); 547 | |
≥10% | 18.6(14.6–22.5); 378 | |
Visits, number/year, % (95% CI); n | 0 | 11.3 (7.2–15.4); 230 |
| 1 | 25.6 (21.8–29.3); 521 | |
2–4 | 25.9 (22.2–29.7); 528 | |
5–6 | 7 (2.8–11.2); 143 | |
>7 | 30.2 (26.6–33.8); 615 | |
Income, % (95% CI); n | <1000 PLN (<250 EUR) | 43 (39.5–46.5); 453 |
>1000 PLN (>250 EUR) | 57 (53.9–60.1); 998 | |
Abbreviations: BMI, body mass index; CVD, cardiovascular disease; DBP, diastolic blood pressure; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; SBP, systolic blood pressure; SCORE, Systematic Coronary Risk Evaluation; TC, total cholesterol; TG, triglycerides | ||
| Variable | Controlled hypertension and hypercholesterolemia | Controlled hypertension; uncontrolled hypercholesterolemia | Controlled hypercholesterolemia; uncontrolled hypertension | Uncontrolled hypertension and hypercholesterolemia | |
|---|---|---|---|---|---|
Age, y, mean (95% CI); n | 64.1 (62.4–65.7); 151 | 57.3 (56–58.5); 411 | 46 (45.4–46.6); 171 | 58 (48–66); 1275 | |
Male sex, % (95% CI); n | 39.1 (26.6–51.5); 59 | 38 (30.3–45.6); 156 | 44.4 (33.3–55.6); 76 | 53.4 (49.7–57.2); 681 | |
BMI kg/m2, % (95% CI); n | <25 | 13.9 (–0.9 to 28.7); 21 | 15.1 (6.2–24); 62 | 9.4 (0–23.6); 16 | 19.7 (14.8–24.6); 251 |
25–30 | 41.7 (29.5–53.9); 63 | 44 (36.8–51.2); 181 | 42.7 (31.3–54); 73 | 45.6 (41.6–49.7); 582 | |
>30 | 44.4 (32.5–56.3); 67 | 40.9 (33.4–48.3); 168 | 48 (37.1–58.8); 82 | 34.7 (30.2–39.1); 442 | |
SBP, mm Hg, mean (95% CI); n | 124.3 (122.7–125.9); 151 | 144.2 (142.8–145.6); 411 | 120.2 (119.7–120.6); 171 | 149 (141.5–161.5); 1275 | |
DBP, mm Hg, mean (95% CI); n | 75.8 (74.4–77.1); 151 | 85.9 (85.1–86.7); 411 | 76.1 (75.7–76.4); 171 | 90.5 (84.5–96.5); 1275 | |
TC, mmol/l, median, (95% CI); n | 4.1 (3.9–4.2); 151 | 5.7 (5.5–5.8); 411 | 4.1 (3.8–4.4); 171 | 5.9 (5.8–5.9); 1275 | |
LDL-C, mmol/l, median, (95% CI); n | 2.1 (2–2.2); 151 | 3.6 (3.5–3.7); 411 | 2.1 (2–2.2); 171 | 3.7 (3.7–3.8); 1274 | |
HDL-C, mmol/l, median, (95% CI); n | 1.2 (1.2–1.3); 151 | 1.3 (1.3–1.4); 411 | 1.3 (1.1–1.4); 171 | 1.4 (1.4–1.4); 1275 | |
TG, mmol/l, median, (95% CI); n | 1.3 (1.1–1.4); 150 | 1.6 (1.5–1.7); 411 | 1.3 (1–1.5); 171 | 1.6 (1.5–1.6); 1274 | |
Hypertension treatment, % (95% CI); n | 100 (100–100); 151 | 100 (100–100); 411 | 77.2 (70–84.4); 132 | 37.7 (33.4–42.1)’ 481 | |
Hypercholesterolemia treatment, % (95% CI); n | 100 (100–100); 151 | 27.3 (19–35.5); 112 | 95.9 (92.9–98.9); 164 | 14.3 (9.2–19.4); 182 | |
Diabetes, % (95% CI); n | 23.8 (9.9–37.8); 36 | 14.6 (5.7–23.5); 60 | 26.9 (14.1–39.7); 46 | 10.7 (5.6–15.9); 137 | |
Smoking, % (95% CI); n | 9.9 (0–25.1); 15 | 19.2 (10.5–27.9); 79 | 12.3 (0–26.3); 21 | 25.5 (20.8–30.2); 352 | |
Alcohol drinkers, % (95% CI); n | 81.5 (74.6–88.3); 123 | 74 (69–78.9); 304 | 80.1 (73.4–86.8); 137 | 82.7 (80.5–85); 1055 | |
Education, % (95% CI); n | 68.9 (60–77.8); 104 | 75.7 (70.9–80.4); 311 | 68.4 (60–76.8); 117 | 77 (74.4–79.7); 982 | |
Physical activity, % (95% CI); n | 55 (44.3–65.7); 83 | 55.7 (49.3–62.2); 229 | 58.5 (48.8–68.1); 100 | 57.3 (53.7–60.9); 731 | |
Coexisting CVD, % (95% CI); n | 55.6 (45–66.3); 84 | 33.6 (25.7–41.5); 138 | 50.9 (40.4–61.4); 874 | 18.8 (13.9–23.8); 240 | |
Married, % (95% CI); n | 30.5 (17.2–43.8); 46 | 23.1 (14.6–31.6); 95 | 31 (18.5–43.4); 53 | 21.9 (17–26.7); 279 | |
SCORE, % (95% CI); n | SCORE ≥5 | 72.8 (64.5–81.2); 110 | 71.8 (66.2–77.3); 254 | 55 (43.9–66.1); 77 | 51.9 (47.8–56.1); 556 |
SCORE ≥5% and <10 | 9.9 (0–25.1); 15 | 27.1 (18.2–36); 96 | 43.6 (31.1–56); 61 | 34.8 (30–39.7); 373 | |
SCORE ≥10% | 17.2 (2.7–31.7); 26 | 1.10–11.5); 4 | 1.4 (0–17.9); 2 | 13.3 (7.7–18.8); 142 | |
Visits, number/year, % (95% CI); n | 0 | 16.6 (2–31.1); 25 | 14.6 (5.7–23.5); 60 | 34.5 (22.4–46.6); 59 | 9 (3.8–14.3); 115 |
| 1 | 2.6 (0–18.4); 4 | 8.3 (0–17.5); 34 | 9.9 (0–24.2); 17 | 36.4 (32–40.8); 464 | |
2–4 | 24.5 (10.6–38.4); 37 | 27 (18.7–35.3); 111 | 4.7 (0–19.3); 8 | 26.1 (21.4–30.8); 333 | |
5–6 | 14.6 (0–29.3); 22 | 8.5 (0–17.8); 35 | 4.7 (0–19.3); 8 | 5.8 (0.5–11.1); 74 | |
>7 | 41.7 (29.5–53.9); 63 | 41.6 (34.2–49); 171 | 46.2 (35.2–57.2); 79 | 22.7 (17.8–27.5); 289 | |
Income, % (95% CI); n | 42.6 (29.9–55.4); 58 | 41.3 (33.5–49.1); 152 | 35.1 (22.2–48.1); 52 | 45 (40.5–49.4); 482 | |
> PLN 1000 (> EUR 250) | 57.4 (46.4–68.3); 78 | 58.7 (52.1–65.3); 216 | 64.9 (55.3–74.4); 96 | 55 (51–59.1); 59 | |
Abbreviations: see Table 1 | |||||
Age-standardized prevalence of coexisting hypertension and hypercholesterolemia in WOBASZ II population was 32.2% (95% CI, 30.8–33.7); in men, 34.5% (95% CI, 32.3–36.7); and in women, 31% (95% CI, 29.1–32.9) (Table 3).
| Age group, y | Total | Men | Women |
|---|---|---|---|
19–49 | 15 (13.7–16.3); 432 | 20.9 (18.8–23.1); 278 | 9.9 (8.4–11.4); 154 |
50–59 | 46.7 (44–49.5); 596 | 50.9 (46.7–55.1); 278 | 43.7 (40.1–47.2); 320 |
60–69 | 58.2 (55.2–61.2); 613 | 58.3 (53.9–62.7); 280 | 58.1 (54.1–62.2); 333 |
70–79 | 60.4 (56–64.8); 290 | 56.6 (49.8–63.4); 116 | 63.3 (57.6–69); 174 |
≥80 | 52 (45.1–58.8); 106 | 41.6 (30.6–52.6); 32 | 58.3 (49.7–66.8); 74 |
Age standardized | 32.2 (30.8–33.7), 2037 | 34.5 (32.3–36.7); 982 | 31 (29.1–32.9); 1055 |
Data are presented as percentage (95% CI); number of patients. | |||
Age-standardized prevalence of hypercholesterolemia in patients diagnosed with hypertension in the entire study sample was 69.7% (95% CI, 65.9–73.4); in men, 70% (95% CI, 64.9–75.2); and in women, 68.6% (95% CI, 63.1–74.2). The highest prevalence (crude data) was observed in women aged 50 to 59 years (83.3% [95% CI, 79.6–87.1]) and in men aged 60 to 69 years (76.2% [95% CI, 71.9–80.6]) (Table 4).
| Age group, y | Total | Men | Women |
|---|---|---|---|
19–49 | 64.9 (61.2–68.5); 666 | 67.3 (62.8–71.8); 413 | 60.9 (54.9–66.9); 253 |
50–59 | 79.9 (77–82.8); 746 | 76.2 (71.9–80.6); 362 | 83.3 (79.6–87.1); 384 |
60–69 | 77.6 (74.7–80.5); 790 | 77.3 (73–81.7); 362 | 77.8 (73.9–81.7); 428 |
70–79 | 71.3 (66.9–75.7); 407 | 69.5 (62.5–76.4); 167 | 72.5 (66.9–78.1); 240 |
≥80 | 60.9 (53.7–68.2); 174 | 53.3 (40.7–66); 60 | 64.9 (56.2–73.7); 114 |
Age standardized | 69.7 (65.9–73.4); 2037 | 70 (64.9–75.2); 982 | 68.6 (63.1–74.2); 1055 |
Data are presented as percentage (95% CI); number of patients. | |||
Among patients with coexisting hypertension and hypercholesterolemia, the highest control rate of hypertension, hypercholesterolemia, and both hypertension and hypercholesterolemia (crude data) was observed in patients older than 80 years of age (37.7%, 29.2%, and 17%, respectively). Age-standardized control of hypertension, hypercholesterolemia, and both hypertension and hypercholesterolemia in the entire sample (age range,19–99 years) was 24.3%, 11.2%, and 5.4%, respectively (Table 5).
| Population | Age group, y | P value for trend | |||||
|---|---|---|---|---|---|---|---|
| 19–49 | 50–59 | 60–69 | 70–79 | ≥80 | Age standardized | ||
Controlled hypertension | |||||||
Total | 18.8 (15.1–22.4); 81 | 30.5 (26.8–34.2); 182 | 31.6 (28–35.3); 194 | 27.6 (22.4–32.7); 80 | 37.7 (28.5–47); 40 | 24.3 (21.7–26.9); 557 | <0.001 |
Men | 16.2 (11.9–20.5); 45 | 25 (19.9–30.1); 69 | 26.1 (20.9–31.2); 73 | 20.7 (13.3–28.1); 24 | 25 (10–40); 8 | 19.7 (16.5–22.9)a; 219 | 0.01 |
Women | 23.4 (16.7–30.1); 36 | 35.3 (30.1–40.5); 113 | 36.3 (31.2–41.5); 121 | 32.2 (25.2–39.1); 56 | 43.2 (32–54.5); 32 | 29.5 (25.1–33.9); 358 | <0.001 |
Controlled hypercholesterolemia | |||||||
Total | 4.9 (2.8–6.9); 21 | 14.1 (11.3–16.9); 84 | 20.9 (17.7–24.1); 128 | 20 (15.4–24.6); 58 | 29.2 (20.6–37.9); 31 | 11.2 (9.7–12.7); 322 | <0.001 |
Men | 6.5 (3.6–9.4); 18 | 15.6 (11.3–19.9); 43 | 15.7 (11.5–20); 44 | 19 (11.8–26.1); 22 | 25 (10–40); 8 | 10.8 (8.6–13)b; 135 | <0.001 |
Women | 1.9 (0–4.1); 3 | 12.8 (9.2–16.5); 41 | 25.2 (20.6–29.9); 84 | 20.7 (14.7–26.7); 36 | 31.1 (20.5–41.6); 23 | 11 (9.1–12.8); 187 | <0.001 |
Controlled hypertension and hypercholesterolemia | |||||||
Total | 2.3 (0.9–3.7); 10 | 7.4 (5.3–9.5); 44 | 9.3 (7–11.6); 56 | 7.6 (4.5–10.6); 22 | 17 (9.8–24.1); 18 | 5.4 (4.3–6.4); 151 | <0.001 |
Men | 2.9 (0.9–4.8); 8 | 6.5 (3.6–9.4); 18 | 6.8 (3.8–9.7); 19 | 9.5 (4.2–14.8); 11 | 9.4 (–0.7 to 19.5); 3 | 4.7 (3.3–6.1)c; 59 | 0.09 |
Women | 1.3 (0–3.1); 2 | 8.1 (5.1–11.1); 26 | 11.4 (8–14.8); 38 | 6.3 (2.7–9.9); 11 | 20.3 (11.1–29.4); 15 | 5.7 (4.3–7.1); 92 | <0.001 |
Data are presented as percentage (95% CI); number of patients. a Men vs women (P <0001); b Men vs women (P = 0.95); c Men vs women (P = 0.79) | |||||||
Age, comorbid diabetes, comorbid CVD, frequent medical visits, and CVD risk according to the SCORE of less than 5% were positively associated with controlled hypertension, hypercholesterolemia, and both. Female sex, obesity, income above 250 EUR per person in the household were not associated with controlled hypercholesterolemia, but related with controlled hypertension and a controlled both hypertension and hypercholesterolemia. Education higher than vocational was associated only with improvement in hypertension. Conversely, smoking was associated with worse control of hypertension, hypercholesterolemia, and both. Alcohol consumption was inversely associated with controlled hypertension (Table 6).
| Variable | Controlled hypertension | Controlled hypercholesterolemia | Controlled hypertension and hypercholesterolemia |
|---|---|---|---|
Age, per 10 years | 1.22 (1.15–1.3) | 1.06 (1–1.13) | 1.31 (1.2–1.43) |
Sex (female) | 1.72 (1.45–2.04) | 1.17 (1–1.38) | 1.48 (1.16–1.88) |
BMI (>30 kg/m2) | 1.31 (1.1–1.55) | 1.17 (0.99–1.38) | 1.36 (1.07–1.74) |
Diabetes | 1.39 (1.1–1.74) | 1.75 (1.4–2.18) | 1.73 (1.28–2.33) |
HDL-C, per 1.0 mmol/l | 0.94 (0.48–1.84) | 1.62 (0.9–2.93) | 1.44 (0.67–3.1) |
TG, per 1.0 mmol/l | 0.87 (0.54–1.4) | 0.63 (0.33–1.18) | 0.73 (0.29–1.83) |
Smokers | 0.61 (0.49–0.76) | 0.56 (0.45–0.69) | 0.41 (0.28–0.6) |
Alcohol drinkers | 0.98 (0.96–0.99) | 0.99 (0.99–1) | 0.98 (0.96–1) |
Education | 1.2 (1.01–1.42) | 1.01 (0.86–1.19) | 1.1 (0.86–1.39) |
Physical activity | 1.02 (0.87–1.21) | 0.89 (0.75–1.04) | 1.04 (0.82–1.33) |
Coexisting CVD | 2.33 (1.95–2.78) | 2.15 (1.81–2.56) | 3.01 (2.36–3.83) |
Married | 1.06 (0.88–1.29) | 1.19 (0.99–1.44) | 1.16 (0.88–1.52) |
SCORE (<5%) | 1.72 (1.45–2.04) | 1.62 (1.37–1.91) | 2.08 (1.61–2.69) |
Data are presented as odds ratio (95% CI). Abbreviations: see Table 1 | |||
After adjustment for covariates, female sex, comorbid CVD, frequent medical visits, and high education increased the odds of controlled hypertension. The strongest effect was observed for comorbid CVD (odds ratio, 2.35; 95% CI, 1.93–2.86). Hypercholesterolemia control was positively related with comorbid diabetes, CVD, and with controlled hypertension. Hypercholesterolemia control was inversely related with smoking (odds ratio, 0.57; 95% CI, 0.45–0.71). The good control of both hypertension and hypercholesterolemia was more frequent in participants with comorbid CVD, frequent medical visits, and high education. Smoking decreased the odds of controlled of both hypertension and hypercholesterolemia 2-fold (Figure 1; Supplementary material, Tables S1 and S2).
Abbreviations: see Table 1
Discussion
Our results suggest that about one-third of the adult population have comorbid hypertension and hypercholesterolemia. Control of hypertension in this group appeared similar to the control in the general population, but control of hypercholesterolemia was better than in the general population.1,2 Nevertheless, proportion of patients with good control of both conditions was only about 5%.
Considering the more stringent thresholds of antihypertensive treatment in accordance with the 2018 European Society of Hypertension guidelines26 and the 2019 Polish Society of Hypertension guidelines27 (for patients below 65 years of age, the target pressure below 130/80 mm Hg; for those between 65 and 85 years of age, below 140/80 mm Hg; and for those over 80 years of age, below 150/80 mm Hg), blood pressure control in the WOBASZ II population would decrease from 23% to approximately 14%, and simultaneous control of hypercholesterolemia and blood pressure would only be achieved in 3.5% of patients.
Treatment targets for hypertension or hypercholesterolemia were more frequently achieved in women, participants with high education, nonsmokers, persons with comorbid CVD or diabetes, and in those who had more medical visits.
Some caution is recommended in the interpretation of the results of the present study due to relatively low (approximately 45.5%) participation rate which could have affected the representativeness of the sample. In previous WOBASZ II analysis, it was found that regional differences in the prevalence of hypercholesterolemia were related to the participation rate (0.4% increase in the percentage of people with hypercholesterolemia per 1% increase in reporting rate).2 Such relationship was not observed in case of hypertension prevalence.1 Moreover, our participation rates were similar to that recorded in other European studies, for example, the EHES (European Health Examination Survey) conducted from 2009 to 2012, in which the reporting rate ranged from 16% to 57% in men and from 31% to 74% in women.28 However, it is likely that low response rate might have contributed to some underestimation in the prevalence rates.29,30
Moreover, cross-sectional study design does not allow to address the problem of causality. Although multivariate models allow to control the effect of important covariates, residual confounding is still possible.
Nevertheless, the study has strengths. In contrast to most of the evidence collected in patients from the clinics, our study involved a large nationwide sample. Moreover, the research team applied standardized research procedures to ensure highest possible data quality.
Comparing our results with a large epidemiological study conducted in the United States from 2005 to 2010, NHANES (National Health and Nutrition Examination Survey), we found that the participants from the United States achieved the goal of lipid-lowering therapy more than 4-fold more often (11.2% vs 45.4%, respectively). Moreover, control of both hypertension and hypercholesterolemia was 6-fold more common than in our study (30.7% vs. 5.4%, respectively).31 These comparisons might indicate the gap in the effectiveness of risk factors control between Poland and the United States. However, the observed difference could also be explained by larger prevalence of obesity, diabetes, and lower prevalence of smoking in the NHANES sample. Our results indicate that these factors seem to improve hypertension and hypercholesterolemia control. The iSEARCH (Cardiovascular Risk Factors and Microalbuminuria in Hypertensive Individuals) study, which included over 17000 patients from 26 countries with treated hypertension, found lower prevalence of hypercholesterolemia (average 49%) than observed in our study. However, there was a large variation in hypercholesterolemia prevalence in different regions—the lowest prevalence was observed in Southern Europe (43.3%) and Asia (43.1%), and the highest, in North America (64.4%), the Middle East (56.1%), and Northern Europe (53%).32 In the Polish POSTER (Therapeutic Strategies in Poorly Controlled Hypertension in Outpatient Setting in Poland) study, which enrolled 8766 patients with poorly controlled hypertension, the prevalence of hypercholesterolemia was estimated at 64.8%.33
Our results are in accordance with findings from Polish part of the EUROASPIRE IV (European Society of Cardiology study of lifestyle, risk factors, and treatment approaches in patients with coronary artery disease) study, which showed better control of hypertension and hypercholesterolemia in patients after hospitalization due to CHD34 compared with the findings from the general population.1,2
In our study, in participants with comorbid hypertension and hypercholesterolemia, we found that blood pressure control was low and comparable to the general population (23% vs 24.3%), whereas hypercholesterolemia control was nearly twice higher than in the general population (11.2% vs 6%).1 Many patients with hypertension and hypercholesterolemia present low compliance and adherence to medical advising and do not achieve the therapeutic goals, which has significant clinical and economic consequences.35-37 Recently, a promoted way of improving blood pressure and hypercholesterolemia control could be use of a polypill—a single tablet containing a combination of several drugs (including antihypertensive and lipid-lowering agents) with proved efficacy and cardioprotective effect. It is suggested that in the population above 55 years of age such a combination product could prevent as many as 80% of cardiovascular events.38-42 Although combination pills containing both antihypertensive and lipid-lowering drugs exist, they are not often used in clinical practice. Their use on a larger scale could contribute to improved blood pressure control, as well as to the achievement of cholesterol targets; for this reason, the position of combination products has recently been strengthened in the European guidelines for the treatment of hypertension and hypercholesterolemia.43,44
It seems that introduction of polypill could contribute to solve the problem of not undertaking or discontinuing treatment (13% of patients with hypertension and 17% of patients with hypercholesterolemia) or the problem of ineffective doses (23% of patients with hypertension and 23% of patients with hypercholesterolemia).1,2 Still the final effect would be related largely to the level of motivation of patients to change their lifestyle (diet, physical activity) and adhere to the long-term treatment regime. However, the largest public health problem in Poland is poor detection of risk factors. Over 60% of people with hypercholesterolemia and about 40% with hypertension are not aware of the condition,1,2 which substantially limits the potentials of the available treatments.
In conclusion, hypertension and hypercholesterolemia were observed in one-third of the Polish population (included in WOBASZ II study). Only 5.4% have both risk factors controlled. After adjustment for covariates, female sex, nonsmoking, comorbid CVD or diabetes, frequency of medical visits and high education, appeared to increase the proportion of controlled hypertension or hypercholesterolemia.
Arkadiusz Niklas, MD, PhD, Department of Hypertension, Angiology and Internal Disease, Poznan University of Medical Science, ul. Długa 1/2, 61-848 Poznań, Poland, phone: +48618549090, email: aniklas@mp.pl
May 9, 2019.
October 5, 2019.
October 9, 2019.
The WOBASZ II project was financed by the resources available to the Minister of Health as part of the POLKARD National Program to Equalise Accessibility to Cardiovascular Disease Prevention and Treatment for 2010–2012, the goal of which was to monitor the epidemiological situation in Poland in the field of cardiovascular diseases.A complete list of members of the WOBASZ II Trial was published in Drygas W, Niklas AA, Piwońska A. Multi-centre National Population Health Examination Survey (WOBASZ II study): assumptions, methods, and implementation. Kardiol Pol. 2016; 7: 681-690.On behalf of the Steering Committee of the WOBASZ Study, we address words of heartfelt thanks for the participation in the study to all of our coworkers from research teams in 6 academic centers, nurses, doctors, and analysts from local research centers in all 16 Polish provinces.Special thanks to Professor Jerzy Głuszek for valuable comments in the formation of the initial version of the manuscript
AN conceived the idea for the manuscript, contributed to the study design, analyzed the data, interpreted the results, and wrote the paper. JM, MK, AP, TZ, WD, AP, MK, KK, and AT provided the data of WOBASZ II study and contributed to the writing of the paper. AN and JM performed the statistical analysis. MK and AP critically revised the manuscript. All authors read and approved the final manuscript.
AP received honoraria for consultations from Amgen (not directly related to the present paper).
Niklas A, Marcinkowska J, Kozela M, et al. Blood pressure and cholesterol control in patients with hypertension and hypercholesterolemia: the results from the Polish multicenter national health survey WOBASZ II. Pol Arch Intern Med. 2019; 129: 864-873. doi:10.20452/pamw.15013
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