Journal of Human Hypertension (2004) 18, 581–585 & 2004 Nature Publishing Group All rights reserved 0950-9240/04 $30.00 www.nature.com/jhh ORIGINAL ARTICLE Work-site hypertension prevalence and control in three Central European Countries

JG Fodor1, J Lietava2, A Rieder3, S Sonkodi4, H Stokes1, T Emmons1 and P Turton1 1University of Ottawa Heart Institute, Heart Check, Ottawa, Ontario, Canada; 2Second Medical Clinic, Bratislava, Slovakia; 3Institute for Social Medicine, Faculty of Medicine, University of Vienna, Vienna, Austria; 4Faculty of Medicine, University of Szeged, Albert Szent-Gyorgyi Medical University, Szeged, Hungary

Compared to Austria, cerebrovascular stroke (CVS) Austria, 600 in Hungary, and 751 in Slovakia. The mean mortality is three times higher in Hungary, and twice ages of the respondents ranged from 35 to 42 years. The as high in Slovakia. We hypothesized that this is due to prevalence of hypertension was 29% in Austria, 28% in better treatment and control of hypertension in Austria. Hungary and 40% in Slovakia. Of those identi- To test this hypothesis, we carried out a cross-sectional fied as hypertensive, 73% in Austria, 45% in Hungary survey of ‘blue collar’ employees on work sites in each and 67% in Slovakia were newly diagnosed as a result of of these countries. Blood pressure screening was this screening. Of those treated for hypertension, 10% in carried out at three work sites in Austria, one in Hungary Austria, 15% in Hungary and 5% in Slovakia were and one in Slovakia. A standardized protocol was controlled. The differences in CVS mortality cannot be followed in each of these countries. The Bp-TRUTM explained by better control of hypertension in Austria measuring instrument was used to provide accurate but indicate the involvement of other determinants. reproducible readings and eliminate interobserver error. Journal of Human Hypertension (2004) 18, 581–585. After the exclusion of missing data and women, the doi:10.1038/sj.jhh.1001685 study population included 323 males screened in Published online 19 February 2004

Keywords: blood pressure; cerebrovascular stroke; Central Europe; environmental factors

Introduction these countries. Austria remained a free country with a market economy that has enjoyed economic Since the fall of communism in 1989 in Central and prosperity in contrast to Hungary and Slovakia. This Eastern Europe, increasing attention is being paid to is reflected in the differences between the gross the poor state of health in postcommunist societies. national income per capita in these three countries, The worst health indicators are found in areas of the where Austrian incomes are six to eight times higher former Soviet Union, where the probability of early than in Slovakia or Hungary (Table 1). mortality before 65 years is twice that of Western 1 The standard death rate comparing all causes of Europe. In Central European countries, the overall death for all ages per 100 000 population per year health situation is somewhat better, albeit there are shows that Hungarian mortality rates are about 70% significant differences between countries. Life ex- higher than Austrian rates, while mortality rates in pectancy at birth is 75 years in the Czech Republic, the Slovak Republic are about 50% higher (Table 2). somewhat less in the Slovak Republic (73 years) and 2,3 The mortality rates from cerebrovascular stroke (CVS) worse in Hungary (71 years). mortality are of particular interest. In Slovakia and We were particularly interested in comparing data even more in Hungary, CVS mortality is significantly between Austria, the Slovak Republic and Hungary. higher than that of Austria or Canada (Figure 1). Before World War I, these neighbouring countries Since hypertension is the most important risk were part of the Austria-Hungarian monarchy. At the factor for CVS4,5 and successful treatment of hyper- end of World War II, the political system changed in tension results in significant reduction of these events,6 we hypothesized that the differences seen between these three countries are due either to Correspondence: JG Fodor, University of Ottawa Heart Institute, Heart Check, First Floor, 40 Ruskin St., Ottawa, Ontario, Canada, differences in the prevalence of hypertension, or as a K1Y 4W7. E-mail: [email protected] result of better treatment of hypertension in Austria Published online 19 February 2004 compared to Hungary and Slovakia. Prevalence and control of work-site hypertension JG Fodor et al 582 Table 1 Demographical overview of Austria, Hungary and respondents were recruited from a large bakery in Slovakia Vienna, from labourers in Vienna Harbour and from auxiliary staff from the Vienna General Hospital Austria Hungary Slovakia (orderlies, cleaners, etc). In Hungary, respondents Population (million) 8 9.9 5.4 were recruited from employees of the ‘Pick’ salami Life expectancy (years) 78 71 73 factory in Szeged. The Slovak study was carried out in the city of Sala, in a factory for producing Gross national income $25 220 $4 740 $3 700 chemicals and fertilizers (Duslo). Respondents were (per capita) (USD) invited to participate in examinations through announcements by the management, unions and posters that explained the purpose of the investiga- tion. Ethical approval was obtained from the Table 2 Standard death rate, all causes, all ages, per 100 000 respective universities in the three countries. The investigation was carried out by a team of physi- Country Standard death rate cians and nurses. The respective teams in each country visited the worksites and held a special Austria 658 hypertension detection clinic. Upon arrival, the Hungary 1124 respondents were interviewed using a short, stan- Slovakia 990 dardized questionnaire (see Appendix 1); these contained identical questions in all of the partici- pating countries, translated into the Hungarian, Slovak and German languages. The subjects were asked not to eat or smoke for at least 30 min before their examination. Prior to the blood pressure measurement, they rested quietly for a minimum of 5 min. The participant’s right arm was held at the level of the heart. The Bp-TRUt blood pressure measuring instrument was used to deter- mine blood pressure. This instrument measured the systolic and diastolic blood pressure (SBP and DBP, respectively) six times at 1-min intervals, discarded the first value, and calculated the average SBP and DBP based on the remaining five consecutive measurements. The instrument also recorded the Figure 1 Male cerebrovascular stroke mortality, age standardized, heart rate. All data were sent to the University of per 100 000 individuals (Source: WHO Europe, HFA Database, Ottawa Heart Institute and entered into a database. January 2002, Statistics Canada 2001). Standard parametric and nonparametric tests were applied using SAS and Excel statistical programs. Hypertensives were classified as those respon- To gain a better insight into this problem, we dents who had an SBP X140 mmHg and/or DBP decided to carry out a pilot study in these three X90 mmHg, or those who were taking antihyperten- countries. The primary objective was to establish the sive medication, regardless of their blood pressure prevalence of hypertension and treatment status in level. ‘Controlled’ hypertensives were classified as each of these countries. The secondary objectives those treated with antihypertensive drugs and with were to assess the awareness and the level of control SBPo140 mmHg and DBPo90 mmHg. Respondents of hypertension, and to test the feasibility of who were identified as newly discovered hyperten- international comparative studies in this part of sives were referred to a physician for further the world. Comparative studies of blood pressure treatment, as were those respondents who were levels in different populations attempted in the past treated but whose blood pressure was not con- have been difficult to evaluate because of large inter- trolled. and intraobserver error when using standard mer- cury manometers or random zero instruments. The availability of a new Canadian blood pressure measuring instrument, the Bp-TRUt, made it pos- Results sible to avoid measurement errors and to obtain In Austria, 372 respondents were screened in total reliable BP values.7 (323 male, 48 female and one missing gender data); in Hungary, 1021 in total (600 male, 412 female and Methods nine missing gender data); and in Slovakia, 1190 (751 male, 439 female). Given the small number of In all the three countries, the studies were carried women screened in Austria, the comparative ana- out in ‘blue collar’ work settings. In Austria, lyses were performed only on males. The mean ages

Journal of Human Hypertension Prevalence and control of work-site hypertension JG Fodor et al 583 of the respondents ranged from 35 to 42 years. The ease and fast acquisition of valuable data. However, prevalence of hypertension in males is 29% in the primary objective of this study was to investigate Austria, 28% in Hungary and 40% in Slovakia whether the relatively low CVS mortality in Austria, (Table 3); of these, 73% in Austria were newly as compared to Slovakia and Hungary, is a result of diagnosed as were 45% in Hungary and 67% in better awareness and treatment of hypertension in Slovakia. Of those aged 39 years or less, 19% were Austria. The work site settings were chosen with hypertensive and of those aged 40 years or more, regard not only to the feasibility of the study but also 50% were hypertensive. There are significant differ- because we expected that in low socioeconomic ences (Po0.05) in the SBP and DBP between the groups the lack of awareness and treatment would three countries (Table 4). Of those who were be more accentuated. The fact that the socioeco- classified as hypertensive and who were on anti- nomic gradient is inversely related to health status is hypertensive medication, hypertension control was amply documented,8 as is the fact that treatment of achieved in only 9.7% in Austria, 14.9% in Hungary hypertension results in a significant reduction of and 5.3% in Slovakia (Table 5). stroke mortality and morbidity.9 There were no Our results indicate that although Hungary has significant differences in the control of hypertension the highest level of CV mortality, it also had the best between the three countries; in fact, the level of level of hypertension control (14.9%), demonstrated hypertension control was comparable to statistics in by mean SBP and DBP below 140/90 mmHg in the Canada.10 treated group (Table 4). Slovakia had the lowest The striking differences in morbidity and mortal- level of control at 5.3% and the highest mean SBP ity of postcommunist societies have been studied in and DBP at 152.2/95.8 mmHg in the treated group. the past decade by many authors. Kesteloot11 Despite having the lowest CV mortality, Austria also had a low level of hypertension control with the Table 5 Percentage of control in those identified with hyperten- mean SDP and DBP at 141.2/93.1 mmHg in the sion treated group (Table 4). Country Total Total Total participants participants participants with identified with treated for HT HT controlled Discussion hypertension (HT) This study set out to establish the prevalence of hypertension and treatment status in work sites in Austria 93 26 (28%) 9 (9.7%) Austria, Hungary and Slovakia, and to test the feasibility of international comparative studies in Hungary 168 53 (32%) 25 (14.9%) this part of the world. We have documented that it is Slovakia 303 100 (33%) 16 (5.3%) possible to implement such studies with relative

Table 3 Prevalence of hypertension

Country Total numbers of male respondents Hypertensive (HT) Of those with HT, newly diagnosed

Austria 323 93 (29%) 68 (73%) Hungary 600 168 (28%)a 76 (45%) Slovakia 751 303 (40%)b 202 (67%)b aThere were 2 HT variables missing for Hungary. bThere was one HT variable and 28 newly diagnosed variables missing for Slovakia.

Table 4 Mean systolic and diastolic blood pressure in those treated and those nontreated for hypertension

Country Subgroup Treated Nontreated

Austria Mean SBP (mmHg) 141.2 142.9 Mean DBP (mmHg) 93.1 95.6 Hungary Mean SBP (mmHg) 136.7 148.4 Mean DBP (mmHg) 87.7 88.5 Slovakia Mean SBP (mmHg) 152.2 143.4 Mean DBP (mmHg) 95.8 95.3a aThere was one DBP variable missing in the nontreated category for Slovakia. SBP represents systolic blood pressure and DBP, diastolic blood pressure.

Journal of Human Hypertension Prevalence and control of work-site hypertension JG Fodor et al 584 considers nutritional factors as a major cause for the 6 Dahlo¨f B, Devereux RB, Kjeldsen SE. Cardiovascular observed differences between Hungary, Austria and morbidity and mortality in the losartan intervention for Switzerland. Hungarian authors,12 comparing cardi- endpoint reduction in hypertension study (LIFE): a ovascular disease risk profile in a rural population randomized trial against atenolol. Lancet 2002; 359: sample in Hungary with German data from the 995–1003. 13 7 Wright JM, Mattu GS. Validation of a new algorithm for PROCAM study, concluded that, while the Hun- the BPM-100 electronic blood pressure monitor. Blood garian population is more obese and nutrition is Pressure Monit 2001; 6: 161–165. characterized by a high fat and meat content, the 8 Ginter E. Cardiovascular risk factors in the former traditional cardiovascular disease risk factors are not communist countries: Analysis of 40 European MON- strikingly different between the two countries. Our ICA populations. Eur J Epidemiol 1995; 11: 199–205. findings are in line with these observations in that 9 Blood Pressure Lowering Treatment Trialists’ Colla- the prevalence and control of hypertension, which boration. Effects of ACE inhibitors, calcium antago- is a significant cardiovascular disease risk factor, do nists, and other blood-pressure-lowering drugs: results not differ greatly between countries with a relatively of prospectively designed overviews of randomized low cardiovascular mortality (Austria) and countries trials. Lancet 2000; 355: 1955–1964. 10 Joffres M et al. Awareness, treatment and control of with a high cardiovascular mortality (Hungary and hypertension in Canada. Am J Hypertens 1997; 10: Slovakia). Thus, our study indicates that neither the 1097–1102. awareness of hypertension nor the intensity of 11 Kesteloot H. Regional differences in mortality: a treatment of hypertension provides an explanation comparison between Austria, Hungary and Switzer- for the differences in the CVS mortality between land. Acta Cardiol 1999; 54: 299–309. Austria, Hungary and Slovakia. It is evident that 12 Mark L, Kondacs A, Hanyecz V. Cardiovascular risk determinants such as nutrition, psychosocial stress factor profile: Comparison of a Hungarian community and other as yet unidentified factors may play a role. with Germany. Wien Klin Wochenschr 1997; 109: In summary, despite dramatic differences in 683–687. cerebrovascular stroke mortality between Austria, 13 Assmann G, Schulte H. The Prospective Cardiovascu- lar Mu¨ nster (PROCAM) study: prevalence of hyperli- Hungary and Slovakia, our study establishes that pidemia in persons with hypertension and/or diabetes this gradient is not due to better treatment and mellitus and the relationship to coronary heart disease. control of hypertension in Austria, and highlights Am Heart J 1988; 116: 1713–1724. the need for further research to determine the cause of this mortality gradient in Eastern Europe. Appendix A Acknowledgements CLINICAL CHART We gratefully acknowledge the significant support we have received from Dr A Dukat, Bratislava, Austria–Hungary–Slovakia International Blood Slovakia; Dr T Dorner, Wien, Austria; Dr G Lencse, Pressure Study Szeged, Hungary and Dr M Caprnda, Bratislava, Slovakia. This project was supported by CIDA Canada, the Austrian Red Cross Society, and the ID ...... City of Wien Healthy Heart Program. The Bp-TRUt Male & Female & instruments to all participating sites were donated Age (yr) ...... by Dr Mark Gelfer, Medical Director VSM Corpora- Body Weight (kg) ...... tion, Vancouver, Canada. Body Height (cm) ...... Waist Circumference (cm) ...... Blood Pressure (as determined by VMS instrument References according to protocol) 1 McKee M, Shkolnikov V. Understanding the toll of Systolic BP (mmHg) ...... premature deaths among men in Eastern Europe. Br Diastolic BP (mm Hg) ...... Med J 2001; 323: 1051–1055. HR (beats/min) ...... 2 Statistics Canada. Canadian statistics information. Accessed May 2002. Available from: URL: http:// Have you had your blood pressure measured ever? www.acdi.cida.gc.ca. Yes & No & 3 World Health Organization, Regional Office for Eur- ope. European health for all database. Accessed Have you had your blood pressure measured in January 2002. Available from: URL: http:// the past year? www.who.dk/hfadb. Yes & No & 4 Kannel WB. Blood pressure as a cardiovascular risk factor. JAMA 1996; 275: 1571. 5 MacMahon S et al. Blood pressure, stroke, coronary If yes heart disease. Part 1, Prolonged differences in blood Have you been told that you have high blood pressure: prospective observational studies corrected pressure? for the regression dilution bias. Lancet 1990; 335: 765. Yes & No &

Journal of Human Hypertension Prevalence and control of work-site hypertension JG Fodor et al 585 If yes If you are currently on treatment with drugs to Have you been prescribed drugs to reduce high lower your blood pressure, tick one of the blood pressure? following statements which most accurately Yes & No & describes you:

If yes & I take my blood pressure pills every day Do you know the name(s) of the prescribed regularly. I never forget to take them. drug(s)? & I take my blood pressure pills almost Yes & No & every day. Occasionally I forget. & Sometimes I either forget or decide not to If yes take my blood pressure pills, for short What is/are the name(s) of the drug(s) you were periods of time (days) prescribed for treating your high blood pressure? & I frequently forget or decide not to take my ______blood pressure pills for extended periods ______of time (weeks or months) ______and finally Did you smoke even one cigarette during the past Do you take these drugs now? 7 days? Yes & No & Yes & No &

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