Introduction
Hypertension (HTN) is the key cardiovascular disease (CVD) risk factor leading to premature mortality worldwide [1]. It is expected to remain so for at least the next 20 years [2]. Theoretically, HTN is a modifiable state and a cornerstone of strategies aimed to improve cardiovascular health. From a pathophysiological perspective, it is obvious that HTN is not purely an increase of blood pressure (BP) values, but rather a sophisticated web of neurohormonal and haemodynamic interactions. However, high-quality scientific data show that the “silent killer” could be stopped by decreasing BP values in the first place [3].
Despite the fact that the detection of raised BP is very simple and cheap, average awareness is about 50% worldwide [4]. Furthermore, available therapeutic options with proven efficacy and promising device-based procedures are not enough to control high BP in Europe adequately. This applies in particular to the Russian Federation (Russia) and Eastern Europe.
This overview aims to address the current epidemiological status of the prevalence of HTN in the region and to highlight the most common reasons for suboptimal BP control.
Hypertension in Russia
Regional and national multisite studies and registries, global reports and the unprecedented May Measurement Month (MMM) campaign [5] have given an opportunity to look at the real-world data regarding HTN.
One of the first national surveys in Russia was the Federal Target Program “Prevention and treatment of arterial hypertension in the Russian Federation” [6] which took place between 2003 and 2010 with more than 30,000 participants. HTN prevalence was 39.7%, higher in women (40.5%) than in men (38%). Overall, 77.9% of men and 82.9% of women were aware of their diagnosis. Of patients receiving antihypertensive drugs (67% women and 62% men), only 27% of women and 18.3% of men were treated effectively.
The most recent and comprehensive epidemiological study across the Russian Federation of the last decade, called ECVD-RF (Epidemiology of Cardiovascular Diseases and their Risk Factors in Regions of the Russian Federation [ESSE-RF]) was held in the mid 2010s [7]. The ECVD-RF investigators assessed multiple CVD risk factors, particularly HTN, in 12 regions of Russia with more than 15,000 inhabitants. The epidemiological situation in Russia demonstrated a higher prevalence in comparison with a previous study [6], as 44% of participants were affected (higher in rural areas [51.8% in males and 42.9% in females] than in cities [47.5% and 40.2% for males and females, respectively]).
Among all participants, 67.5% of men and 78.9% of women were aware of HTN. Women were more likely to receive treatment than men (60.9% versus 39.5%). In those who were prescribed drugs, again women were more likely to have tight BP control (53.5% versus 41.4%). However, this situation tended to be more dire when observing BP control in all hypertensives (only 23%, with 14.4% in men and 30.9% in women).
On the other hand, some positive trends have been observed in awareness and control from the mid 1990s, when only one third of men and a little more than half of women were aware of HTN, 46.7% of women and 21.6% of men were receiving treatment and treatment efficacy was only 17.5% and 5.7% among women and men, respectively.
According to the results of MMM17 [5], the prevalence of HTN in Russia was 35.4% and comparable to the global level (34.9%). However, only 17.3% of patients were receiving treatment and the lack of reaching the target BP level was 46.3%. Of all hypertensive patients, only 26% were in the target BP range. Twelve percent (12%) of screened participants never measured BP at all, half of the participants measured BP less than one year ago, and one third of them (high and very high risk) regularly measured their blood pressure.
The disparities between awareness and control were thoroughly analysed in the abovementioned studies. The authors assumed that the treatment failure in HTN was due to poor education. For example, the only factor associated with the rate of treatment efficacy was the level of education as BP control is significantly better in educated hypertensives. Low adherence to antihypertensive treatment, alcohol abuse, the presence of multiple interfering CVD risk factors (obesity, dyslipidaemia) and lack of patient awareness were identified as the most common obstacles to sufficient BP control.
Hypertension in Eastern Europe
Newly updated, the 2018 ESH/ESC Guidelines report 150 million hypertensives in Central and Eastern Europe: the prevalence is expected to rise up to 2025 [8]. Based on data from the WHO Monitoring Trends and Determinants in Cardiovascular Diseases (MONICA) study, the prevalence of HTN, and the proportion of uncontrolled HTN, is clearly higher in Eastern Europe (up to 65%) [9]. Since 1970, substantial decreases have occurred in age-specific mortality from CVD in Western European countries, whereas a continuous increase was noted in East European countries up to the early 1990s [10]. To date, regional variations in cardiovascular mortality have been observed both between and within countries in Eastern Europe. This overview covers the status of HTN predominantly in post-Soviet states (Ukraine, Republic of Belarus), Poland, Czech Republic, Bulgaria and Romania.
A systematic analysis [11] of population-based studies reports a relatively high rate of awareness of HTN in high- and middle-income Eastern European countries, while this rate is significantly lower in the European countries of the former Soviet Union (Ukraine, Belarus). Results of The Blood Pressure control rate and CArdiovascular Risk profilE (BP-CARE) study from East and Central Europe showed that of 7,860 hypertensive patients only 25% had a regular BP check while 27% of treated hypertensive persons achieved tight BP control [12]. In 2010 the household survey (a part of the HITT study) in over 18,000 respondents from countries of the former Soviet Union showed a prevalence of HTN of 39.4% in Belarus, 32.3% in Moldova, and 33.4% in the Ukraine [13]. According to the European Cardiovascular Disease Statistics report for 2017, higher BP levels are generally found in Central and Eastern European countries and lower levels in Southern, Western and Northern European countries without a significant positive trend towards decrease.
The Ukraine has one of the highest rates of CVD morbidity and mortality in the region. High BP is a serious public health problem in the Ukraine. In the first-ever Ukrainian Demographic Health Survey (UDHS) in 2007 [14], the prevalence of HTN was about 25-32% among the adult population (aged 15-49 years), with the majority of them (up to 77%) being unaware of their BP status. As expected, HTN increases dramatically with ageing in the Ukrainian population. Over half of women and men aged 45 or older are diagnosed with HTN. Hypertensive men are much less aware of their condition than women (23% in males versus 50% in females). Only 3% of hypertensive treated men have their BP adequately controlled. Hypertensive men are more likely than hypertensive women to be aware that they have elevated blood pressure but are not being treated (12% versus 6%, respectively).
In 2014, premature mortality from the main CVDs in Belarus was among the highest in Europe, at 605 per 100,000 persons 30–69 years of age. Biological risk factors such as HTN account for 48% of CVD mortality, and behavioural risk factors account for another 45%. According to the Grodno stroke register, among the risk factors for stroke, HTN was the most prevalent comorbidity (87.5%) [15]. Awareness increased from 14.1% in 2000 to 21.2% in 2009. At the beginning of the 2010s it was expected that there would be over 1.5 million hypertensive individuals in the state.
The national STEPS survey held in 2016 under the aegis of the World Health Organization [16] provided an objective view of the current prevalence of non-communicable disease risk factors. A total of 5,760 adults aged 18–69 years were sampled for the survey, and 5,010 participated, giving a response rate of 87.0%. Overall, 34.9% of respondents indicated that they had HTN. Adherence to antihypertensive treatment was inadequate (57.3%), mainly among men (47.5% versus 64.6% in women). In comparison with Russian surveys, only 1.5% of participants in STEPS never had their BP measured. Interestingly, 2.1% of respondents with HTN reported that they had consulted a traditional healer (not a physician) and 9.0% were taking herbs or other folk remedies instead of evidence-based antihypertensive therapy at the time of the survey.
The Polish Society of Hypertension, in their official Guideline that was updated in 2017 [17], suggests a relatively high prevalence of HTN in the overall adult population (18-79 years) of up to 33% (over 10 million) according to the NATPOL study and 42.1% and 32.9% in men and women, respectively, in WOBASZ (Polish population-National Multicentre Health Survey). According to the results of the POLSENIOR study, there are about one million elderly hypertensive patients (above 80 years). Polish experts report an about 70% awareness of HTN in the population. Thus, 30% of Polish people do not know their BP values at all. In the last decade, screening programmes resulted in a decrease in the proportion of untreated people from 18% to 13% and an increase in adequate BP control from 12% to 26% (from 24% to 42% in treated subjects). However, the means of initial and primary prevention techniques are working and should be adopted more actively across the whole country.
Despite the undoubted and remarkable decline in total and CVD mortality in the Czech Republic, in absolute numbers, the country still belongs to those countries with high CVD mortality within Europe. Czech investigators conducted national cross-sectional surveys (MONICA and post-MONICA) in the late 1990s to early 2000s with almost 14,000 participants. They showed the high prevalence of HTN (50.2% in men and 37.2% in women) with 58% of hypertensive patients on antihypertensive treatment. This extremely high prevalence can be partly explained by the high rates of obesity, particularly in males, and the high salt intake in the overall population.
While the prevalence of HTN decreased from 47% to 43% in the entire population, awareness, treatment, and control of HTN improved significantly in both sexes in the Czech Republic in the period from 1985 to 2007/2008 [18]. As per awareness of HTN in both sexes (men, from 41.4 to 68.4%; women, from 58.9 to 71.4%), the number of individuals on treatment increased (men, from 21.1 to 58.2%; women, from 38.9 to 58.9%) as did control (from 3.9 to 24.6%), with particular improvement in the male population (2000/2001, 13.1%; 2007/2008, 24.4%). Notably, the prevalence of HTN decreased only in women with no change in the male population. There was a significant increase in fresh fruit and vegetable consumption. Lower consumption of total and saturated fat is also documented. Favourable changes are supported by a significant decrease in population mean total and non-high-density lipoprotein cholesterol.
In 2015 Bulgarian investigators published a review with actual data on epidemiology of HTN in the country [19]. HTN was found in 38.9% of the studied subjects and was significantly more prevalent in men (45.1%) than in women (33.5%). Almost half of the hypertensive subjects (44.6%) were elderly. HTN was found in up to half of the rural population (49.5%) while only one third were city residents (33.5%). In this population, the study investigators found associations of high HTN prevalence with age and gender with stress and lifestyle having a much lesser effect.
The first Romanian national survey, the Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk in the Adult Population in Romania (SEPHAR) [20] which took place in 2005, revealed that the total prevalence of HTN was 45%, significantly higher in men (50%) than in women (41%) and in rural areas (49.5%) as compared to urban areas (41.6%). The general rate of awareness was 44.6%, higher in women (52.8%) than in men (34.6%). Only 38.9% of subjects were receiving antihypertensive treatment. The rate of treated HTN was again in favour of women (46.6% versus 30.1% in men). Of all hypertensives, only 7.7% had target BP values. This number was slightly higher in those who were on treatment (up to 20%). Notably, there was no difference in this indicator between gender or area of residence. Anyway, a higher rural prevalence of HTN was not commented on by the authors but could be explained by some deleterious habits in lifestyle such as excessive salt or alcohol consumption or the concomitant predominance of obesity in rural zones.
What are the future perspectives?
It is well understood that HTN is not purely a medical problem but a great societal and resource-intensive issue. Therefore, it is crucial to act according to the lessons learnt from epidemiological studies and to work out a strategy to limit the further rise in the incidence of HTN and to enhance its controllability. Public awareness is important, but it should be said that in most countries there are no longitudinal registries such as the Swedish and Danish ones. Building such databases is a long-term and labour-intensive process but the pay-off is obtaining up-to-date information on prevalence and treatment efficacy. Only uniformly organised studies will permit obtaining comparable data, for example, the Finnish national system of countrywide five-year monitoring.
In the last few years both in Russia and in most nations emerging from Communism, healthcare systems are restructuring to overcome the challenges of the increasing need for health services under limited financial resources. These lead to a paradigm shift from former evidence-based medicine to a value-based approach. Thus, the medical community is trying to look at both clinical efficacy and patient-perceived values in the continuum of care, particularly in patients with non-communicable chronic diseases. It seems that patient-oriented care and fee-for-value systems will become more common in the near future to help improve performance.
National registries raise the problem of low public understanding of the negative role of high BP. Therefore, the medical community faces the task of popularising information about HTN in order to diagnose early. The next major challenge is to convey to patients the importance of treatment and proactively struggle against low health literacy. Given the high burden of concomitant CVD risk factors, it is crucial to conduct patient schools. Easy-to-read and clear information booklets are also likely to have a huge impact. As non-adherence is one of the most crucial problems in treated patients, widespread adoption of at least indirect methods of adherence control (i.e., questionnaires) and active use of fixed-dose combinations of antihypertensive drugs might also be helpful. Virtually all major surveys in the region show a significantly higher prevalence of HTN in rural areas. Therefore, it is important to expand telehealth support and counselling.
On the other hand, public health faces the challenge of therapeutic inertia, which is one of the causes of pseudo resistance. Continuous medical education programmes designed for specialists promote their attendance at scientific congresses and symposia. Strong English-language and internet skills in young doctors help them to read a lot of specialist literature and stay up to date with high-quality scientific evidence. These proactive individuals help to cultivate a culture of continuous training by translating guidelines into their native languages, sharing them on social media.
Conclusion
Hypertension represents a huge societal and healthcare problem in Russia and Eastern Europe due to low awareness rates and insufficient blood pressure control. Among the specific issues in terms of poor efficacy are relatively outdated health services leading to therapeutic inertia, low health literacy and therefore high rates of non-compliance. Local registry-based researches and epidemiological studies, increasing interest in patient-centred care and a gradual shift to value-based medicine present possible ways for the high-risk East to become as low as the West.
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