2MBBS, Medical Officer, Baqai Medical University, Karachi, Pakistan
3MBBS, Dow University of Health Sciences, Karachi, Pakistan
4MBBS, House Officer, Abbasi Shaheed Hospital, Karachi, Pakistan
5MBBS, M. Assistant, Musavvir Stem cell clinic and pathology laboratory
6MBBS, Senior Lecturer, Department of Physiology, Altibri Medical College Karachi, Karachi, Pakistan
7Manager Medical Affairs and Clinical Research Hilton Pharma Pvt ltd, Pakistan
8MBBS, MSBE Assistant Professor, Department of Community Medicine, Baqai Medical University, Karachi, Pakistan
9MBBS, MPH, Assistant Professor, Department of Community Medicine, Avicenna Medical College, Lahore, Pakistan
10MBBS, Resident Memon Hospital, Karachi, Pakistan
Objective: To identify and compare the hypertension associated neurological and non-neurological signs and symptoms among different age groups.
Methods: A cross-sectional multicenter study was carried out among patients with self-reported history of hypertension and on antihypertensive medication. The written informed consent was obtained from the patients after taking ethical approval. A total of 174 patients aged 18 years or above were included in the study using convenient sampling technique and the duration of study was from Jan 2017 till June 2017. Patients were divided in two groups according to their ages i.e. ≤40 years and >40 years old. A detailed history was taken from each patient about hypertension associated symptoms with the help of a structured questionnaire. Blood pressure was measured using sphygmomanometer with stethoscope to assess hypertension level. The patients with history of diabetes, thyrotoxicosis and liver diseases were excluded from the study. Date was analyzed by using SPSS version 20. Chi square and fisher exact test was used to assess the significance.
Results: A higher percentage of the patients in the >40 years age group had severe systolic and diastolic hypertension than patients in the ≤40years age group (4.0% vs. 1.4% and 9.0% vs. 1.4% respectively).Among the patients aged ≤40 years only fatigue (p=0.049) was significantly associated with systolic blood pressure while among patients aged >40 years severity of headache (p=0.026), dyspnea (p=0.022), fatigue (p=0.003) and confusion (p=0.006) were significantly associated with systolic blood pressure whereas edema (p=0.016) and fatigue (p=0.019) were significantly associated with diastolic blood pressure.
Conclusion: The symptoms significantly associated with systolic or diastolic hypertension increased with the increasing age of the patients. These findings give us local evidence emphasizing the need to focus more on the management of older hypertensive patients.
Keywords: Neurological and Non-neurological symptoms; Hypertension; Age Groups
Hypertension is defined as a systolic blood pressure (SBP) of 140 mmHg or more, or a diastolic blood pressure (DBP) of 90 mmHg or more, or taking antihypertensive medication.[7] Based on the recommendations of the Seventh Report of the Joint national committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), Blood Pressure for adults aged 18 years or older has been classified into four categories as normal, pre-hypertension, stage 1 and stage 2. Normal indicates a systolic blood pressure of < 120 mmHg; and a diastolic < 80 mmHg. Pre-hypertension means a systolic blood pressure of 120-139 mmHg; while a diastolic of 80-89 mmHg. Stage 1 reads a systolic of 140-159 mmHg; and a diastolic of 90- 99 mmHg. Stage 2 is considered to be severe and gives a systolic of 160 mmHg or greater; and a diastolic of 100 mmHg or greater. [8] WHO recognizes three levels of hypertension as levels 1, 2 and 3. Level 1 means a systolic BP between 140 and 159 mmHg and a diastolic BP between 90 and 99, level 2 means a systolic BP between 160 and 179 mmHg and a diastolic BP between 100-109 mmHg while level 3 means a systolic BP of 180 and above and a diastolic BP of 110 mmHg and above.[9]
There are two types of hypertension namely essential and secondary. Essential hypertension can be defined as a rise in blood pressure of unknown cause that increases risk for cerebral, cardiac, and renal events.[10] Secondary hypertension is defined as increased systemic blood pressure due to an identifiable cause. Only 5–10% of patients suffering from arterial hypertension have a secondary form, whereas the vast majority has essential (idiopathic or primary) hypertension.[11]
Hypertension can present with severe clinical presentation to an even asymptomatic picture depending upon the several factors such as age, gender, and severity of hypertension. Our objective was to find associations between the degree of hypertension and the severity of the associated symptoms among different age groups.
To classify hypertension, the British Hypertension Society Classification, consistent with the European Hypertension Society and World Health Organization International Society of Hypertension, was used.[12]Similar to WHO classification, it also recognizes three grades of hypertension as grade 1, 2 and 3. Grade I (Mild hypertension) means a systolic BP between 140 and 159 mmHg and a diastolic BP between 90 and 99, Grade II (Moderate hypertension) means a systolic BP between 160 and 179 mmHg and a diastolic BP between 100-109 mmHg whereas Grade III (Severe Hypertension) means a systolic BP of ≥ 180 mmHg and a diastolic BP ≥ 110 mmHg.
Patients with history of diabetes, cardiac events, neurological disorders, cluster headache, gastrointestinal disease, visual problems, epistaxis before they were diagnosed with HTN and morbid obesity were excluded from the study. Patients with isolated systolic hypertension were also excluded from the study
For statistical analysis, statistical package for social sciences (SPSS version 21) was used. Chi-square test was performed to assess associations between various study variables and hypertension across different age groups. P-values less than 0.05 were considered statistically significant. The duration of the study was 6 months.
Variables |
≤40 Years (n=74) |
>40 Years (n=100) |
|
Frequency(%)/ Mean±S.D. |
Frequency(%)/ Mean±S.D. |
||
Age (Years) |
31.19±7.44 |
54.34±9.13 |
|
Gender |
Male |
31(41.9) |
62(62.0) |
Female |
43(58.1) |
38(38.0) |
|
Systolic Blood Pressure |
Mild Hypertension |
63(85.1) |
71(71.0) |
Moderate Hypertension |
10(13.5) |
25(25.0) |
|
Severe Hypertension |
1(1.4) |
4(4.0) |
|
Diastolic Blood Pressure |
Mild Hypertension |
69(93.2) |
77(77.0) |
Moderate Hypertension |
4(5.4) |
14(14.0) |
|
Severe Hypertension |
1(1.4) |
9(9.0) |
|
Systolic Blood Pressure (mm Hg) |
148.23±13.62 |
146.11±16.74 |
|
Diastolic Blood Pressure (mm Hg) |
92.86±5.02 |
91.41±10.24 |
|
Hypertension Duration (Years) |
4.11±2.99 |
4.62±3.51 |
|
Smoking |
Yes |
6(8.1) |
15(15.0) |
No |
68(91.9) |
85(85.0) |
|
Clinical History of Headache |
Yes |
30(40.5) |
58(58.0) |
No |
44(59.5) |
42(42.0) |
|
Site of Heacache1 |
Temporal |
6(20.0) |
14(24.1) |
Parietal |
4(13.3) |
8(13.8) |
|
Occipital |
14(46.7) |
12(20.7) |
|
Frontal |
Nil |
5(8.6) |
|
Complete |
6(20.0) |
19(32.8) |
|
Severity of Headache1 |
Mild |
5(16.6) |
9(15.5) |
Moderate |
17(56.7) |
26(44.8) |
|
Severe |
8(26.7) |
23(39.7) |
|
Vertigo |
Yes |
16(21.6) |
44(44.0) |
No |
58(78.4) |
56(56.0) |
|
Severity of Vertigo2 |
Mild |
11(68.8) |
31(68.9) |
Moderate |
5(31.2) |
11(24.4) |
|
Severe |
Nil |
3(6.7) |
|
Edema |
Yes |
13(17.6) |
28(28.0) |
No |
61(82.4) |
72(72.0) |
|
Laterality of Edema3 |
Bilateral |
8(61.5) |
18(64.3) |
Unilateral |
5(38.5) |
10(35.7) |
|
Grading of Bilateral Edema3 |
Mild |
1(7.7) |
8(28.6) |
Moderate |
8(61.5) |
11(39.3) |
|
Severe |
4(30.8) |
9(32.1) |
|
Chest Pain |
Yes |
13(17.6) |
30(30.0) |
No |
61(82.4) |
70(70.0) |
|
Severity of Chest Pain4 |
Improves with rest |
7(53.8) |
8(27.6) |
Needs pain relieving medication |
4(30.8) |
17(58.6) |
|
Requires hospital visit |
2(15.4) |
4(13.8) |
|
Vision Problems |
Yes |
18(24.3) |
54(54.0) |
No |
56(75.7) |
46(46.0) |
|
Type of Vision Problem5 |
Loss of Central Vision |
2(11.1) |
6(12.0) |
Loss of Peripheral Vision |
5(27.8) |
13(26.0) |
|
Dark Spots in field of Vision |
8(44.4) |
20(40.0) |
|
Pain in Eyes |
3(16.7) |
11(22.0) |
|
Dyspnea |
Yes |
19(25.7) |
51(51.0) |
No |
55(74.3) |
49(49.0) |
|
Dyspnea Severity6 |
Mild |
4(21.1) |
8(15.7) |
Moderate |
9(47.4) |
25(49.0) |
|
Severe |
6(31.6) |
18(35.3) |
|
Nausea7 |
Yes |
16(21.9) |
19(19.0) |
No |
57(78.1) |
81(81.0) |
|
Sleep Apnea |
Yes |
20(27.0) |
52(52.0) |
No |
54(73.0) |
48(48.0) |
|
Irregular Heartbeat/Palpitation |
Yes |
17(23.0) |
43(43.0) |
No |
57(77.0) |
57(57.0) |
|
Fatigue7 |
Yes |
33(45.2) |
72(72.0) |
No |
40(54.8) |
28(28.0) |
|
Confusion7 |
Yes |
21(28.8) |
62(62.0) |
No |
52(71.2) |
38(38.0) |
2n=16 and 45 in ≤40 years and >40 years old respectively
3n=13 and 28 in ≤40 years and >40 years old respectively
4n=13 and 29 in ≤40 years and >40 years old respectively
5n=18 and 50 in ≤40 years and >40 years old respectively
6n=19 and 51 in ≤40 years and >40 years old respectively
7n=73 and 100 in ≤40 years and >40 years old respectively
Among patients aged >40 years severity of headache (p=0.026), dyspnea (p=0.022), fatigue (p=0.003) and confusion (p=0.006) were significantly associated with systolic blood pressure where those who had mild systolic hypertension were less likely to have mild/moderate headache, dyspnea, fatigue and confusion than those who had moderate/severe systolic hypertension (50.0% vs. 80.0%, 43.7% vs. 69.0%, 63.4% vs. 93.1% and 53.5% vs. 82.8% respectively) whereas edema (p=0.016) and fatigue (p=0.019) were significantly associated with diastolic blood pressure where those who had mild diastolic hypertension were less likely to have edema and fatigue than those who had moderate/severe diastolic hypertension (22.1% vs. 47.8% and 66.2% vs. 91.3% respectively).None of the other variables were found to be significantly associated with either systolic or diastolic blood pressure in this age group [Table 3]
Variables |
≤40 Years (n=74) |
||||
SBP |
DBP |
||||
Mild Hypertension |
Moderate/Severe Hypertension |
Mild Hypertension |
Moderate/Severe Hypertension |
||
Frequency (%) |
Frequency (%) |
Frequency (%) |
Frequency (%) |
||
Gender |
Male |
26(41.3) |
5(45.5) |
29(42.0) |
2(40.0) |
Female |
37(58.7) |
6(54.5) |
40(58.0) |
3(60.0) |
|
P |
0.523* |
0.653* |
|||
Smoking |
Yes |
6(9.5) |
Nil |
6(8.7) |
Nil |
No |
57(90.5) |
11(100) |
63(91.3) |
5(100) |
|
P |
0.367* |
0.647* |
|||
Clinical History of Headache |
Yes |
27(42.9) |
3(27.3) |
28(40.6) |
2(40) |
No |
36(57.1) |
8(72.7) |
41(59.4) |
3(60) |
|
P |
0.266* |
0.678* |
|||
Severity of Headache |
Mild/Moderate |
20(74.1) |
2(66.7) |
20(71.4) |
2(100) |
Severe |
7(25.9) |
1(33.3) |
8(28.6) |
Nil |
|
P |
0.621* |
0.531* |
|||
Vertigo |
Yes |
13(20.6) |
3(27.3) |
15(21.7) |
1(20.0) |
No |
50(79.4) |
8(72.7) |
54(78.3) |
4(80.0) |
|
P |
0.44* |
0.706* |
|||
Edema |
Yes |
12(19.0) |
1(9.1) |
13(18.8) |
Nil |
No |
51(81.0) |
10(90.9) |
56(81.2) |
5(100) |
|
P |
0.38* |
0.369* |
|||
Laterality of Edema |
Bilateral |
7(58.3) |
1(100) |
8(61.5) |
Nil |
Unilateral |
5(41.7) |
Nil |
5(38.5) |
Nil |
|
P |
0.615* |
…. |
|||
Grading of Bilateral Edema |
Mild/Moderate |
8(66.7) |
1(100) |
9(69.2) |
Nil |
Severe |
4(33.3) |
Nil |
4(30.8) |
Nil |
|
P |
0.692* |
…. |
|||
Chest Pain |
Yes |
12(19.0) |
1(9.1) |
13(18.8) |
Nil |
No |
51(81.0) |
10(90.0) |
56(81.2) |
5(100) |
|
P |
0.38* |
0.369* |
|||
Vision Problems |
Yes |
17(27.0) |
1(9.1) |
18(26.1) |
Nil |
No |
46(73.0) |
10(90.9) |
51(73.9) |
5(100) |
|
P |
0.189* |
0.237* |
|||
Dyspnea |
Yes |
17(27.0) |
2(18.2) |
19(27.5) |
Nil |
No |
46(73.0) |
9(81.8) |
50(72.5) |
5(100) |
|
P |
0.422* |
0.216* |
|||
Severity of Dyspnea |
Mild/Moderate |
12(70.6) |
1(50.0) |
13(68.4) |
Nil |
Severe |
5(29.4) |
1(50.0) |
6(31.6) |
Nil |
|
P |
0.544* |
…. |
|||
Nausea |
Yes |
14(22.6) |
2(18.2) |
15(22.1) |
1(20.0) |
No |
48(77.4) |
9(81.2) |
53(77.9) |
4(80.0) |
|
P |
0.549* |
0.700* |
|||
Sleep Apnea |
Yes |
17(27.0) |
3(27.3) |
19(27.5) |
1(20.0) |
No |
46(73.0) |
8(72.7) |
50(72.5) |
4(80.0) |
|
P |
0.621* |
0.589* |
|||
Irregular Heartbeat/Palpitation |
Yes |
15(23.8) |
2(18.2) |
17(24.6) |
Nil |
No |
48(76.2) |
9(81.8) |
52(75.4) |
5(100) |
|
P |
0.512* |
0.260* |
|||
Fatigue |
Yes |
31(50.0) |
2(18.2) |
31(45.6) |
2(40.0) |
No |
31(50.0) |
9(81.8) |
37(54.4) |
3(60.0) |
|
P |
0.049* |
0.592* |
|||
Confusion |
Yes |
18(29.0) |
3(27.3) |
19(27.9) |
2(40.0) |
No |
44(71.0) |
8(72.7) |
49(72.1) |
3(60.0) |
|
P |
0.609* |
0.448* |
|||
Variables |
>40 Years (n=100) |
||||
SBP |
DBP |
||||
Mild Hypertension |
Moderate/Severe Hypertension |
Mild Hypertension |
Moderate/Severe Hypertension |
||
Frequency (%) |
Frequency (%) |
Frequency (%) |
Frequency (%) |
||
Gender |
Male |
46(64.8) |
16(55.2) |
47(61.0) |
15(65.2) |
Female |
25(35.5) |
13(44.8) |
30(39.0) |
8(34.8) |
|
P |
0.369 |
|
0.717 |
|
|
Smoking |
Yes |
9(12.7) |
6(20.7) |
10(13.0) |
5(21.7) |
No |
62(87.3) |
23(79.3) |
67(87.0) |
18(78.3) |
|
P |
0.235* |
|
0.236* |
|
|
Clinical History of Headache |
Yes |
38(53.5) |
20(69.0) |
43(55.8) |
15(65.2) |
No |
33(46.5) |
9(31.0) |
34(44.2) |
8(34.8) |
|
P |
0.156 |
|
0.424 |
|
|
Severity of Headache |
Mild/Moderate |
19(50.0) |
16(80.0) |
23(53.5) |
12(80.0) |
Severe |
19(50.0) |
4(20.0) |
20(46.5) |
3(20.0) |
|
P |
0.026 |
|
0.071 |
|
|
Vertigo |
Yes |
29(40.8) |
15(51.7) |
34(44.2) |
10(43.5) |
No |
42(59.2) |
14(48.3) |
43(55.8) |
13(56.5) |
|
P |
0.32 |
|
0.954 |
|
|
Edema |
Yes |
17(23.9) |
11(37.9) |
17(22.1) |
11(47.8) |
No |
54(76.1) |
18(62.1) |
60(77.9) |
12(52.2) |
|
P |
0.157 |
|
0.016 |
|
|
Laterality of Edema |
Bilateral |
11(64.7) |
7(63.6) |
12(70.6) |
6(54.5) |
Unilateral |
6(35.3) |
4(36.4) |
5(29.4) |
5(45.5) |
|
P |
0.632* |
|
0.321* |
|
|
Grading of Bilateral Edema |
Mild/Moderate |
13(76.5) |
6(54.5) |
14(77.8) |
5(50.0) |
Severe |
4(23.5) |
5(45.5) |
4(22.2) |
5(50.0) |
|
P |
0.212* |
|
0.139* |
|
|
Chest Pain |
Yes |
19(26.8) |
11(37.9) |
21(27.3) |
9(39.1) |
No |
52(73.2) |
18(62.1) |
56(72.7) |
14(60.9) |
|
P |
0.269 |
|
0.276 |
|
|
Vision Problems |
Yes |
35(49.3) |
19(65.5) |
40(51.9) |
14(60.9) |
No |
36(50.7) |
10(34.5) |
37(48.1) |
9(39.1) |
|
P |
0.14 |
|
0.451 |
|
|
Dyspnea |
Yes |
31(43.7) |
20(69.0) |
37(48.1) |
14(60.9) |
No |
40(56.3) |
9(31.0) |
40(51.9) |
9(39.1) |
|
P |
0.022 |
|
0.281 |
|
|
Severity of Dyspnea |
Mild/Moderate |
19(61.3) |
14(70.0) |
23(62.2) |
10(71.4) |
Severe |
12(38.7) |
6(30.0) |
14(37.8) |
4(28.6) |
|
P |
0.525 |
|
0.392* |
|
|
Nausea |
Yes |
12(16.9) |
7(24.1) |
13(16.9) |
6(26.1) |
No |
59(83.1) |
22(75.9) |
64(83.1) |
17(73.9) |
|
P |
0.403 |
|
0.241* |
|
|
Sleep Apnea |
Yes |
33(46.5) |
19(65.5) |
37(48.1) |
15(65.2) |
No |
38(53.5) |
10(34.5) |
40(51.9) |
8(34.8) |
|
P |
0.084 |
|
0.148 |
|
|
Irregular Heartbeat/Palpitation |
Yes |
27(38.0) |
16(55.2) |
31(40.3) |
12(52.2) |
No |
44(62.0) |
13(44.8) |
46(59.7) |
11(47.8) |
|
P |
0.116 |
|
0.311 |
|
|
Fatigue |
Yes |
45(63.4) |
27(93.1) |
51(66.2) |
21(91.3) |
No |
26(36.6) |
2(6.9) |
26(33.8) |
2(8.7) |
|
P |
0.003 |
|
0.019 |
|
|
Confusion |
Yes |
38(53.5) |
24(82.8) |
45(58.4) |
17(73.9) |
No |
33(46.5) |
5(17.2) |
32(41.6) |
6(26.1) |
|
P |
0.006 |
0.18 |
|||
*Fisher's Exact Test |
The study findings further showed that in the younger age group only fatigue was found to be significantly associated with systolic blood pressure and none of the other variables were significantly associated with diastolic blood pressure whereas, as expected, in the older age group a number of signs and symptoms were found to be significantly associated with systolic hypertension, such as severity of headache, dyspnea, fatigue and confusion, as well as with diastolic hypertension, such as edema and fatigue.
As expected, the study results showed that the older patients had higher prevalence of severe systolic and diastolic hypertension than the younger patients, a finding well in line with the published literature. An earlier study also reported the prevalence of hypertension to increase with increasing age with 8% in patients aged 30-39 years to 38% in patients aged ≥60 years.[13] Another study found hypertension prevalence to show an increasing trend with age with 9.5% in patients aged 15-18 years to 42% in patients aged >60 years.[14] Another study showed the prevalence of hypertension to increase with increasing age of the study participants.[15] Yet another study reported age to be significantly associated with hypertension. [16]
The study results further showed that the signs and symptoms associated with hypertension increased with the increasing age of the study participants. At younger age, only fatigue was found to have a significant relationship with systolic blood pressure whereas at older age, severity of headache, edema, dyspnea, fatigue and confusion all were found to be significantly associated with either systolic or diastolic hypertension or both. An earlier study reported headache to be significantly more prevalent in hypertensive than in normotensive subjects (p< 0.05) but contrary findings have been reported as well as another study did not report headache to be significantly associated with hypertension (OR 1.02, 95% CI 0.79 to 1.30).[17,18] This difference in findings could be due to different methods of blood pressure measurement in both studies i.e. Direct versus indirect auscultatory method. Similarly, an earlier study also reported dyspnea to be associated with elevated blood pressure though irrespective of age of the study participants.[19] Unlike this study, an earlier study did not report any significant difference in prevalence of weakness among hypertensive and normotensive subjects though this difference in findings could be due to the use of different operational definitions of the terminology involved i.e. Fatigue versus weakness.[17] With regard to the study findings regarding association of edema, fatigue and confusion with hypertension, due to lack of relevant data, a comparison could not be made with the published literature.
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- Ezzati M, Lopez AD, Rodgers A, Vos T, Danaei G, Aryee M et al. Comparative risk assessment collaborative group: selected major risk factors and global and regional burden of disease. Lancet 2002; 360(9859):1347-1360
- He J, Whelton PK. Epidemiology and prevention of hypertension. Med Clin North Am 1997; 81(5):1077-1097
- Whelton PK. Epidemiology of hypertension. Lancet. 1994; 344(8915):101–106
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