Hypertension and Cardiovascular Health in Venezuela and Latin American Countries

Home , Barquisimeto, Health in Venezuela

Journal of Human Hypertension (2000) 14, Suppl 1, S2–S5  2000 Macmillan Publishers Ltd All rights reserved 0950-9240/00 $15.00 www.nature.com/jhh Hypertension and cardiovascular health in Venezuela and Latin American countries

R Hernańdez-Hernańdez1, MC Armas-Padilla1, MJ Armas-Hernańdez1 and M Velasco2 1Clinical Pharmacology Unit, Center of Biomedical Research, School of Medicine, Universidad Centroccidental Lisandro Alvarado, Barquisimeto, Venezuela; 2Clinical Pharmacology Unit, Vargas Medical School, Central University of Venezuela, Caracas, Venezuela

Since 1950 all countries of the Latin-American sub- adult population, but on average 20 to 23% of the adult continent have experienced very important changes in population have elevated blood pressure. This preva- several health indicators, in the demographic, epidemi- lence is similar to reports in the developed world. How- ological, socio-cultural and way of living proﬁles. The ever there is considerable variability in each country proportion of the population over 65 years old tend to and its regions so it is important that local studies of be low in the Latin American countries in contrast to prevalence and local factors in the development of developed countries. Cardiovascular diseases are the hypertension are investigated. The degree of aware- main cause of death in most of the Latin American coun- ness, treatment and control of hypertension is lower tries at a similar rate to that of the developed world. As than that reported in the developed world, and it is infectious diseases are reduced, cardiovascular dis- important to establish programmes to attend to this eases takes their place as the main cause of death in public health problem, from prevention to treatment, Latin American countries. Prevalence of hypertension in from primary care to higher levels of attention. Journal different reports show variations from 40 to 8% in the of Human Hypertension (2000) 14, Suppl 1, S2–S5.

Keywords: hypertension prevalence; mortality rate; stroke; coronary heart disease

Introduction to the aging population.2 In Latin America, 31 out of 35 countries have cardiovascular disease as the Since 1950, all countries of the Latin American sub- most important cause of death. Between 1968 and continent have experienced important changes in 1987, the proportion of annual deaths due to cardio- several health indicators, in the demographic, epide- vascular disease increased from 20% to 27%.4,5 miological, socio-cultural and way of living profiles. Hypertension is the main risk factor to coronary Internal migrations from rural to urban areas and the heart disease and stroke. The risk of hypertension subsequent change in lifestyle are similar to has been determined from large-scale epidemiolog- developed countries in their relationship to seden- ical surveys. MacMahon et al6 performed a meta- tary way of living and food consumption. On the other hand, mortality due to infections, tropical and analysis of all available major prospective obser- parasitic diseases and nutritional deficiency have vational studies relating diastolic blood pressure been constantly reduced in most countries of the level to the incidence of stroke and coronary heart sub-continent. Life expectancy and size of the aging disease. They estimate that a diastolic blood press- population have increased substantially.1 ure that is persistently higher by only 5 mm Hg is Cardiovascular diseases account for about 25% of associated with at least a 34% increase in stroke risk all deaths worldwide, and it is the highest pro- and 21% increase in coronary heart disease. portion of all causes of death. In the developed Important differences in rate of hypertension and countries about 50% of all deaths are due to cardio- risk are found in different ethnic populations. In the vascular diseases; meanwhile in developing coun- Multiple Risk Factor Intervention Trial (MRFIT), tries that proportion is about 16%. However, the which involved black and white men who were fol- absolute number of death occurs in the developing lowed up for 10 years, found that the mortality rate countries. Therefore, according to the World Health was lower in black men with diastolic blood press- Organization,2 78% of all cardiovascular death ure above 90 mm Hg than in white men (relative risk occurs in those countries. 0.84), but mortality rate of cerebrovascular disease In the United States of America the mortality of was higher in black men (relative risk 2.0).6,7 The cardiovascular diseases have consistently reduced relative risk of hypertension differs among other eth- in the past 30 years,3 while there is a clear concern nic groups such as Hispanic and white or black about the emerging epidemic of cardiovascular dis- patients.8 eases in developing countries which is partially due The aim of this revision is to summarise different aspects of prevalence of hypertension and the cardiovascular health state in Venezuela and surround- Correspondence: Dr Rafael Hernańdez Hernańdez, Clinical Phar- ing countries. macology Unit, School of Medicine, Universidad Centroccidental Lisandro Alvarado, Ave. Libertador, Barquisimeto, Venezuela Hypertension and CV health in Venezuela and Latin American countries R Hernańdez-Hernańdez et al S3 Table 1 Distribution of age groups in selected countries population from 0 to 14 years old range from 28.7% (Argentine) to 36.7% (Venezuela) in the Latin Amer- Country Population 0–14 15–64 Ͼ65 ican countries, and 16.5% (Spain) to 22.0% in the (millions) years years years (%) (%) (%) United States. The adult population (15 to 64 years old) range from 59.4% in Venezuela to 63.8% in Venezuela 21 378 36.7 59.4 4.0 Chile in the Latin American countries and 65% in Colombia 34 545 33.4 62.1 4.4 the UK to 68.6% in Spain in developed countries. Brazil 159 143 32.7 62.1 5.1 Trinidad and 1292 32.9 61.4 5.7 Tobago Hypertension Guyana 10 322 32.5 63.6 3.9 Mexico 93 674 35.9 59.9 4.2 Methodological and ethnical considerations Costa Rica 3424 35.0 60.3 4.7 Argentine 34 587 28.7 61.8 9.5 Proper diagnosis of hypertension requires at least Chile 14 262 29.5 63.8 6.6 three sets of readings over several weeks;3 hyperten- Spain 39 621 16.5 68.6 14.9 sion is then categorised by either systolic or dia- United States 260 631 22.0 65.3 12.7 stolic gradation into one of three stages, as defined of America United 58 091 19.5 65.0 15.5 by the Sixth Joint National Committee on Detection, Kingdom Evaluation, and Treatment of High Blood Pressure (JNC-VI) and 1999 WHO-ISH Guidelines for the From: World Health Statistics Annual. World Health Organiza- management of hypertension.4 However through the tion, Geneva, 1995.2 years the level to be considered hypertensive has changed for the same American JNC and to other Population national committees. This one fact can change the interpretation of the level of hypertension in each Aging over 65 years is rapidly increasing, and in less study and nation. than 50 years, one of every five people in the United Most of the studies reported in Latin American States will be older than 65 years.9 In other countries countries had only one blood pressure reading; and the same situation is occurring but at a different rate. some of them were carried out in public (markets, Blood pressure tends to increase progressively with streets, etc) or specialised clinic areas. This situation age, and elderly people with hypertension tend to introduces some important bias to properly estimate have a greater risk of cardiovascular disease and the levels of hypertension. On the other hand, there complications.10 are very few national programmes that study the The proportion of the population over 65 years of situation of hypertension and other cardiovascular age for the year 1994, range from 3.9% (Guyana) to risk factors such as dislipidaemia or diabetes mel- 9.5% (Argentine) in the Latin American countries; litus. Most of the studies reported from these coun- meanwhile in the USA and UK it is 12.7 and 15.5% tries cover the methodological technique for measur- respectively (Table 1). Meanwhile the younger ing blood pressure, phase I and V Korotkoff sounds

Table 2 Prevalence of hypertension in some Latin-American countries

Country and Year Sample Age Sex Prevalence Author (years) (%)

Brazil Salas-Martin I11 1997 1976 20–88 Both 41.3 (median) INCLEN Group12 1992 406 20–88 Both 19.5 (median) Ribeiro A13 1986 796 35–44 Men 30.0 Women 18.0 Amaro de Lolio14 1990 1190 15–74 Men 32.0 Women 25.3

Colombia INCLEN Group12 1992 200 20–88 Both 6.0 Bermeo and Rodrı´guez15 1984 1250 15–64 Both 12.8

Mexico Yamamoto-Kimura L et al22 1998 825 20–90 Both 19.4 Gonzalez Villapando C et al23 1999 2282 35–64 Men 17.2 Women 18.1

Venezuela Mun˜ oz S et al16 2809 6–15 Men 7.0 Women 13.3 Orellana K17 1993 5005 15–70 Both 8.1 Sukerman-Voldman E18 1989 745 18–70 Both 21.2 Herna´ndez-Herna´ndez R et al19 1994 15000 у20 Men 27.75 Women 21.39 Sulbaran T et al20 1997 7 424 у19 Men 45.2 Women 28.9

Journal of Human Hypertension Hypertension and CV health in Venezuela and Latin American countries R Herna´ndez-Herna´ndez et al S4 Table 3 Cardiovascular mortality rate in Ibero-American countries

Total cardiovascular Hypertension Coronary heart Stroke diseases disease

No. (%)a No. (%)a No. (%)a No. (%)a

Brazil 1989 228589 35.1 1542 1.9 50998 6.25 77399 9.5 Brazil North-east 1989 39749 27.3 2990 2.05 6978 4.8 15385 10.6 Colombia 1990 45899 30.7 4867 3.2 1463 9.5 9882 6.4 Peru 1990 10011 11.9 983 1.1 1731 2.1 2538 3.0 Trinidad and Tobago 1990 3068 38.4 319 3.9 872 10.6 932 11.4 Chile 1990 21568 27.5 1183 1.5 7841 10.0 6999 8.9 Mexico 1993 90665 21.8 7813 1.9 34016 8.2 21559 5.2 Argentine 1991 111205 43.78 4224 1.7 22042 8.7 25323 10.0 Costa Rica 1989 3238 28.7 210 1.86 1670 14.8 807 7.16 Venezuela 1990 23286 25.9 2256 2.5 9772 10.8 5.521 6.12 Spain 1992 132653 40.02 3301 1.0 35305 10.6 42.081 12.7

From WHO, Geneva, 1989–1995.2 aPercentage of total mortality rate.

are measured to estimate systolic and diastolic and 3784 females collected by means of domiciliary blood pressure respectively. visits with a history of hypertension and physical Latin American countries have a profound mix- examination; the consideration to include patients ture of ethnic groups from European, African and was similar to the above study. A prevalence of Amerindian, which have been deﬁned as Hispanic, hypertension for both sexes of 36.9% with a pre- and there is huge variability from one country to dominance in male (45.2%) over female (28.9%) another as well as in the same country. There are was found. Only 4.5% of hypertensive patients were also important variances in nutritional, salt intake well controlled, 41.2% of patients diagnosed as and drinking habits between the regions. Therefore hypertensive, were not well controlled (diastolic the prevalence of hypertension in the same country blood pressure Ͼ90 mm Hg), and 54.3% hyperten- can vary from one region to another. sives did not know about their condition. The degree of awareness, treatment and control of hypertension was similar to those found in the Prevalence NHANES II survey in United States between 1976– The prevalence of hypertension in selected Latin 1980;21 but were below the values found in American countries are summarised in Table 2. The NHANES III, in phase I or phase II between 1988 reported prevalence range from 6% in a sample of and 1994;3 indicating the necessity to establish pro- 200 adults in Colombia to 41.3% in Brazil. In the grammes of attention and treatment of hypertension. Salas-Martin et al11 study from Brazil, high blood pressure tends to be more severe in the lower social stratum, classiﬁed as hypertension according to JNC- V3 or WHO-ISH standards.9 Cardiovascular mortality In Mexico the prevalence of hypertension is about 18% to 19% for both sexes in the adult popu- In the comparative mortality for all cardiovascular lation.22,23 diseases, hypertension was reported as the primary In Venezuela the prevalence of hypertension is cause of death, coronary heart disease and stroke are 10.5% for children from 6 to 15 years old16 and presented in Table 3, for selected Ibero-American adults range from 8.1%17 to 23.58%19 for both sexes. countries; also presented are the percentages of car- The largest study has been reported in Venezuela, diovascular disease in relationship to total number with a sample of 15 000 inhabitants on home vis- of deaths. Cardiovascular disease represent the main its;19 blood pressure was taken on two occasions cause of death in Argentine, Brazil, Trinidad and during the visit with a 20-min interval; those con- Tobago, Colombia, Chile, Costa Rica, Venezuela sidered hypertensive were patients with a blood and Spain. pressure over 140 mm Hg systolic and/or 90 mm Hg Argentine has the higher cardiovascular mortality diastolic and those known to be hypertensive and rate, and 43.78% of all death corresponds to cardio- receiving pharmacological treatment even with nor- vascular diseases, comparable to Spain with mal blood pressure. Elevated blood pressure tend to 40.02%. The lowest rate corresponds to Peru, and be higher in men until they are 50 years old, after- only 11.9% of all death is due to cardiovascular dis- wards its prevalence decreases and females tend to eases. be more hypertensive from age 50. A total of 61.3% The mortality rate for hypertension reported as of the hypertensives were aware of their condition; the main cause of death are higher in Trinidad and 45.9% was taking treatment and only 14% of the Tobago, Colombia and Venezuela. Stroke is more total hypertensives had their blood pressure under prevalent in Spain followed by North-east of Brazil, control. Trinidad and Tobago, and Argentine. The lowest Sulbaran et al20 reported a survey in 3640 males prevalence corresponds to Peru followed by Mexico.

Journal of Human Hypertension Hypertension and CV health in Venezuela and Latin American countries R Hernańdez-Hernańdez et al S5 Conclusions Multiple Risk Factor Intervention Trial (MRFIT). Cir- culation 1989; 80 (Suppl II): 11300. Cardiovascular diseases are the main cause of death 9 Schneider EL, Guralnik JM. The aging of America. in most of the Latin-American countries at a similar Impact on health care cost. JAMA 1990; 263: 2335– 2340. rate as that in the developed world. As infectious 10 Glynn RJ et al. Evidence for a positive linear relation diseases are reduced, cardiovascular diseases are between blood pressure and mortality in elderly taking their place as the main cause of death in Latin people. Lancet 1995; 345: 825–829. American countries. 11 Salas-Martins I et al. Doencas cardiovasculares ateros- Prevalence of hypertension in different reports clero´ticas, dislipidemias, hipertensao, obesidade e dia- show variations from 40 to 8% in the adult popu- betes melito em populacao da a´rea metropolitana da lation, but on average 20 to 23% of the adult popu- regiao Dudeste do Brasil. III—Hipertensao Rev. Sau´ de lation have elevated blood pressure. This prevalence Publica 1997; 31: 466–471. is similar to that reported in the developed world. 12 INCLEN Multicentre Collaborative Group. Risk factors However there is considerable variability in each for cardiovascular disease in the developing world. A multicentre collaborative study in the international country and its regions so it is important that local clinical epidemiology network (INCLEN). J Clin Epide- studies of prevalence and local factors in the devel- miol 1992; 45: 841–847. opment of hypertension are investigated. 13 Ribeiro A, Debert Ribeiro M. Epidemiological and The degree of awareness, treatment and control of demographic considerations—hypertension in unde- hypertension is lower than that reported in the veloped countries. Drugs 1986; 31: 23–28. developed world, and it is important to establish 14 Amaro de Lolio C. Prevalencia da hipertensao arterial programmes to attend to this public health problem, em Araraquara, Brazil. Arg Bras Cardiol 1990; 55: from prevention to treatment, from primary care to 167–173. higher levels of attention. 15 Bermeo D, Rodrı´guez J. Hipertensioń arterial in Jamend, Valle del Cauca, Colombia. Colomb m, d. 1984; 15: 18–22. 16 Mun˜ oz S, Nun˜ ez H, Zambrano F. Systemic arterial References hypertension in children. Mayo Clinic, March 4, 1980. 17 Orellana K. Estudio epidemiologico de la hipertension 1 Pan American Health Organization. Health conditions arterial y otros factores de riesgo en el Estado Lara. Rev in the Americas. Scientific Publication. 524. Wash- Fed Med Venezolana 1993; 1: 105–115. ington DC, PAHO/WHO, 1990. 18 Sukerman-Voldman E et al. El asesino silencioso. 10 2 World Health Statistic Annual. World Health Organi- an˜ os despue´s. Gaceta Me´dica de Caracas 1989; XCVII: zation. Geneva, 1989–1995. 237–243. 3 The Sixth Report of the Joint National Committee on 19 Hernańdez-Hernańdez R et al. Estudio de la prevalen- Prevention, Detection, Evaluation, and Treatment of cia de la hipertensioń arterial en Barquisimeto, Vene- High Blood Pressure. Arch Int Med 1997; 157: 2413– zuela. BoletıńMe´dico de Postgrado X 1994; 3: 223– 2446. 233. 4 1999 World Health Organization—International 20 Sulbaran T, Vargas AM, Calmoń GE. Epidemiology of Society of Hypertension Guidelines for the Manage- arterial hypertension in the adult population of ment of Hypertension. J Hypertens 1999; 17: 151–183. Maracaibo, Venezuela. Invest Clin 1997; 38 (Suppl 2): 5 Nicholls ES, Peruga A, Restrepo HE. Cardiovascular 3–11. disease mortality in the Americas. World Health Stat 21 Burt VL et al. Trends in the prevalence, awareness, Q 1993; 46: 134–150. treatment, and control of hypertension in the adult US 6 MacMahon S et al. Blood pressure, stroke, and coron- population: data from the health examination surveys. ary heart disease. Part 1. Prolonged differences in 1960 to 1991. Hypertension 1995; 26: 60–69. blood pressure: prospective observational studies cor- 22 Yamamoto-Kimura L et al. Prevalence of high blood rected for the regression dilution bias. Lancet 1990; pressure and associated coronary risk factors in an 335: 765–774. adult population of Mexico City. Arch Med Res 1998; 7 The MRFIT research group. Multiple Risk Factor Inter- 29: 341–349. vention Trial. Risk factor changes and mortality 23 Gonzalez-Villapando C et al. Prevalence of hyperten- results. JAMA 1982; 248: 1465–1477. sion in a Mexican population according the Sixth 8 Neaton JD et al. Comparison of 10-year coronary and Report of the Joint National Committee on Prevention, cerebrovascular disease mortality rate by hypertensive Detection, Evaluation and Treatment of High Blood status for black and non-black men screened in the Pressure. J Cardiovasc Risk 1999; 6: 177–181.

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