Research Article Open Access
Prevalence of Clinical Signs and Symptoms of Hypertension: A Gender and Age Based Comparison
Hafsa K1, Ahsan AS2, Summaiya I3, Zarghoona W4, Sana N5, Maham R6, Uroosa S7, Faiza J8, Anum G9, Adnan A10*
1MBBS, Resident Emergency Medicine, King Fahad Specialist Hospital
2MBBS, Msc Public Health, Specialist Family Medicine, Ministry of Health, Riyadh
3MBBS, Hamdard College of Medicine and Dentistry, Hamdard University Hospital
4MBBS, M. Assistant, Musavvir Stem cell Clinic and Pathology Laboratory
5MBBS, MPH, Assistant Professor, Department of Community Medicine, Avicenna Medical College
6MBBS, Senior Medical officer, Community Health Services
7MBBS, House Officer, Liaquat National Hospital
8Pharm D, Hamdard University
9MBBS, Medical Officer, Ashfaq Memorial Hospital
10MBBS, M.Phil, Senior Lecturer Department of Physiology Al-Tibri Medical College Karachi
*Corresponding author: Adnan Anwar, MBBS, M.Phil, Senior Lecturer, Department of Physiology, Altibri Medical College Karachi, Pakistan. E-mail: @
Received: April 06, 2018; Accepted: April 20, 2018; Published: April 27, 2018
Citation: Adnan A, Hafsa K, Ahsan AS, Summaiya I, Zarghoona W, et al. (2018) Prevalence of Clinical Signs and Symptoms of Hypertension: A Gender and Age Based Comparison. Palliat Med Care 5(2): 1-8.
DOI: 10.15226/2374-8362/5/2/00155
AbstractTop
Objective: To compare the prevalence of clinical signs and symptoms of hypertension among different gender and age based groups of hypertensive patients.

Materials and Methods: A cross-sectional study was conducted with 372 patients aged 18 or above with self-reported history of hypertension and on anti-hypertensive medication. It was a multicenter study performed in urban health center and Myanmar health center for duration of 6 months from June 2017 till November 2017. Hypertension associated signs and symptoms were evaluated with the help of a questionnaire and clinical examination. Blood pressure was measured using sphygmomanometer with stethoscope.

Results: A higher percentage of males were smokers (18.2% vs. 1.4%) and gave a positive history of chest pain (49.3% vs. 38.2%), though a higher percentage of females gave a positive history of vision problems (57.0% vs. 49.3%), fatigue (74.8% vs. 70.3%) and confusion (66.7% vs. 60.6%). Moreover, a higher percentage of ≤40 years old patients gave a positive history of headache (80.7% vs. 69.4%) though a higher percentage of >40 years old patients were smokers (12.0% vs. 4.7%), gave a positive history of vertigo (59.3% vs. 47.7%), chest pain (49.3% vs. 32.2%), vision problems (57.4% vs. 44.2%), dyspnea (57.4% vs. 43.8%), increase in urinary frequency (45.5% vs. 30.6%), nausea (25.4% vs. 20.5%), sleep apnea (38.6% vs. 20.5%), irregular heartbeat/palpitation (39.9% vs. 33.0%), fatigue (74.8% vs. 67.0%) and confusion (68.6% vs. 52.3%).

Conclusion: The prevalence of smoking, chest pain, vision problems, fatigue and confusion were found to be different between both genders. Furthermore, the prevalence of smoking, headache, vertigo, chest pain, vision problems, dyspnea, increased urinary frequency, nausea, sleep apnea, irregular heartbeat/palpitation, fatigue and confusion were found to be different between both age groups.

Key words: Prevalence; Signs and Symptoms; Hypertension; Gender; Age
Introduction
Hypertension is regarded as an important public health challenge worldwide because of its high prevalence. [1,2] It is known to increases the risk of various medical conditions such as heart attack, stroke, kidney failure and blindness. [3] The Comparative Risk Assessment Collaborating Group has identified hypertension as the third leading risk factor for morbidity and as the leading risk factor for mortality worldwide. [4] More than a quarter of the world’s adult population has been reported to suffer from hypertension, two thirds of which belong to developing countries. [5] According to World Health Organization estimates, hypertension annually results in 7.5 million deaths. [3]

An analysis of global data revealed that the overall prevalence of hypertension is similar in both genders, and that it consistently increases with age worldwide. [5] A meta-analysis earlier reported 17% of the Pakistani population to be suffering from hypertension. [6] The World Health Organization recently estimated that 25.2% of the Pakistani population had high blood pressure. [7]

Hypertension is defined as a systolic blood pressure of ≥140 mm Hg, or a diastolic blood pressure of ≥90 mm Hg, or taking antihypertensive medication. [8] Hypertension can be of two types, 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. [9] Secondary hypertension is defined as increased systemic blood pressure due to an identifiable cause. [10]

Multiple factors such as age, gender, and level of high blood pressure can influence the way in which hypertension presents itself clinically but literature does not reveal substantial relevant data, both internationally and locally, making the task of assessing the effects of above mentioned factors in the clinical manifestation of hypertension difficult. Our objective therefore was to compare the prevalence of clinical signs and symptoms of hypertension among different gender and age based groups of hypertensive patients.
Materials and Methods
After taking ethical approval, a cross-sectional study was carried out among patients with self-reported history of hypertension and on anti-hypertensive medication. It was a multicenter study performed in Urban health center and Myanmar health center for a duration of 6 months from June 2017 till November 2017. By employing convenient sampling technique, a total of 372 patients aged 18 or above were included in the study. Patients with history of diabetes, cardiac events, neurological disorders, cluster headache, gastrointestinal disease, visual problems, epistaxis before being diagnosed with hypertension and morbid obesity were excluded from the study.

A detailed history was taken from each patient about hypertension associated symptoms with the help of a structured questionnaire. The questionnaire was designed based on 12 major or most frequently encountered symptoms by the hypertensive patients. The site, duration, and severity of each symptom were documented. Each symptom was graded from mild to severe to assess the severity of the symptoms. The presence of edema was noted with its laterality and grading. The appearance of chest pain was noted with its severity. The problems of vision were noted and classified according to the loss in field of vision. The history of epistaxis and urinary symptoms were noted with frequency. Few additional symptoms such as nausea, sleep apnea, palpitations, fatigue and confusion were also assessed subjectively. Blood pressure was measured using sphygmomanometer with stethoscope to assess hypertension level.

The collected data were coded, entered and analyzed on SPSS version 20. The descriptive analysis was performed by calculating means and standard deviations for continuous variables and frequencies and percentages for categorical variables. The duration of study was 6 months.
Results
The total data collected were of 372 patients but after excluding missing data for various study variables the final data analyzed were of 303 patients for gender wise comparison and of 299 patients for age wise comparison.

For gender wise comparison, the study results revealed that the mean age of male patients was slightly higher than that of female patients (50.36±11.93 years vs. 46.74±12.93 years) and therefore a higher percentage of them was above 40 years of age (79.9% vs. 60.0%). An almost equal percentage of both males and females had systolic hypertension (68.0% and 65.9% respectively) though the percentage of diastolic hypertension was slightly higher in females (53.1% vs. 48.1%). Both males and females had similar mean systolic blood pressure (141.13±13.94 mm Hg and 141.67±15.35 mm Hg respectively) though the mean diastolic blood pressure was slightly higher in females (86.09±9.65 mm Hg vs. 84.43±10.71 mm Hg). Both males and females had similar mean duration of hypertension as well (4.86±5.39 years and 4.78±5.39 years respectively). A much higher percentage of males were smokers (18.2% vs. 1.4%) though a slightly higher percentage of females gave a positive history of headache (75.3% vs. 70.8%). The mean duration of headache was found to be equal in both males and females (1.96±0.75 years and 1.96±0.68 years respectively) and the most common site of headache was similar in both genders as well i.e. complete headache (37.0% and 26.6% respectively). A majority of males reported their headache to be of moderate intensity whereas a majority of females reported it to be of severe intensity (53.7% and 41.4% respectively). An equal majority of both males and females gave a positive history of vertigo (55.0% and 55.9% respectively) and a majority of both genders reported it to be of mild intensity (60.4% and 65.0% respectively).An almost similar percentage of both males and females were found to have edema (40.5% and 43.0% respectively), a very high percentage of which was bilateral in both gender (84.6% and 80.4% respectively). The grading of bilateral edema of an almost similar percentage of both males and females was found to be severe (35.0% and 36.5% respectively). A higher percentage of males gave a positive history of chest pain (49.3% vs. 38.2%) though a higher percentage of females required a hospital visit for it to subside (16.4% vs. 5.4%). A higher percentage of females gave a positive history of vision problems (57.0% vs. 49.3%) though the most common type of vision problem was dark spots in field of vision in both males and females (47.9% and 45.0% respectively). A similar percentage of both males and females gave a positive history of dyspnea (53.0% and 52.7% respectively) and a majority of both genders reported it to be moderate in intensity (57.3% and 48.1% respectively). A very low percentage of both males and females gave a positive history of epistaxis (2.6% and 3.5% respectively). A slightly higher percentage of males reported an increase in urinary frequency (44.0% vs. 38.3%) though a majority of both males and females reported the change to be moderate (42.7% and 40.4% respectively). A slightly higher percentage of females gave a positive history of nausea (25.9% vs. 22.1%) whereas a slightly higher percentage of males gave a positive history of sleep apnea (34.2% vs. 32.0%). An almost similar percentage of both males and females gave a positive history of irregular heartbeat/ palpitation (38.3% and 37.0% respectively) though a higher percentage of females gave a positive history of both fatigue (74.8% vs. 70.3%) and confusion (66.7% vs. 60.6%) (Table 1).
Table 1: Descriptive Analysis: Gender wise comparison

Variables

Males (n=156)

Females (n=147)

Frequency(%)/ Mean ± S.D.

Frequency(%)/ Mean ± S.D.

Age (Years)

50.36 ± 11.93

46.74 ± 12.93

Age Group

≤ 40 Years

31(20.1)

58(40.0)

> 40 Years

123(79.9)

87(60.0)

Systolic Blood Pressure

Normotensive/ Prehypertensive

50(32.0)

50(34.1)

Stage 1/Stage 2 Hypertensive

106(68.0)

97(65.9)

Diastolic Blood Pressure

Normotensive/ Prehypertensive

81(51.9)

69(46.9)

Stage 1/Stage 2 Hypertensive

75(48.1)

78(53.1)

Systolic Blood Pressure (mmHg)

141.13 ± 13.94

141.67 ± 15.35

Diastolic Blood Pressure (mmHg)

84.43 ± 10.71

86.09 ± 9.65

Hypertension Duration (Years)

4.86 ± 5.39

4.78 ± 5.39

Smoking

Yes

28(18.2)

2(1.4)

No

126(81.8)

142(98.6)

Headache

Yes

109(70.8)

110(75.3)

No

45(29.2)

36(24.7)

Headache Duration (Years)

1.96 ± 0.75

1.96 ± 0.68

Site of Headache

Temporal

5(4.6)

18(16.5)

Parietal

17(15.7)

12(11.0)

Occipital

27(25.0)

24(22.0)

Frontal

19(17.6)

26(23.9)

Complete

40(37.0)

29(26.6)

Intensity of Headache

Mild

25(23.1)

28(25.3)

Moderate

58(53.7)

37(33.3)

Severe

25(23.1)

46(41.4)

Vertigo

Yes

83(55.0)

80(55.9)

No

68(45.0)

63(44.1)

Intensity of Vertigo

Mild

52(60.4)

52(65.0)

Moderate

28(32.6)

22(27.5)

Severe

6(7.0)

6(7.5)

Edema

Yes

60(40.5)

58(43.0)

No

88(59.5)

77(57.0)

Laterality of Edema

Bilateral

44(84.6)

45(80.4)

Unilateral

8(15.4)

11(19.6)

Grading of Bilateral Edema

Mild

16(26.7)

10(15.9)

Moderate

23(38.3)

30(47.6)

Severe

21(35.0)

23(36.5)

Chest Pain

Yes

75(49.3)

55(38.2)

No

77(50.7)

89(61.8)

Severity of Chest Pain

Improves with rest

29(39.2)

23(41.8)

Needs pain relieving medication

41(55.4)

23(41.8)

Requires hospital visit

4(5.4)

9(16.4)

Vision Problems

Yes

75(49.3)

81(57.0)

No

77(50.7)

61(43.0)

Type of Vision Problem

Loss of central vision

7(9.6)

5(6.3)

Loss of peripheral vision

14(19.2)

20(25.0)

Dark spots in field of vision

35(47.9)

36(45.0)

Pain in eyes

17(23.3)

19(23.8)

Dyspnea

Yes

80(53.0)

77(52.7)

No

71(47.0)

69(47.3)

Intensity of Dyspnea

Mild

14(17.1)

13(16.8)

Moderate

47(57.3)

37(48.1)

Severe

21(25.6)

27(35.1)

Epistaxis

Yes

4(2.6)

5(3.5)

No

148(97.4)

139(96.5)

Increased Urinary Frequency

Yes

66(44.0)

54(38.3)

No

84(56.0)

87(61.7)

Change in Urinary Frequency

Mild

25(33.3)

17(29.8)

Moderate

32(42.7)

23(40.4)

Severe

18(24.0)

17(29.8)

Nausea

Yes

34(22.1)

38(25.9)

No

120(77.9)

109(74.1)

Sleep Apnea

Yes

53(34.2)

47(32.0)

No

102(65.8)

100(68.0)

Irregular Heartbeat/Palpitation

Yes

59(38.3)

54(37.0)

No

95(61.7)

92(63.0)

Fatigue

Yes

109(70.3)

110(74.8)

No

46(29.7)

37(25.2)

Confusion

Yes

94(60.6)

98(66.7)

No

61(39.4)

49(33.3)

For age wise comparison, the study results revealed that a higher percentage of patients in >40 years age group were males (58.6% vs. 34.8%). A higher percentage of >40 years old patients had systolic hypertension (72.4% vs. 52.8%) though the percentage of diastolic hypertension was equal in both ≤40 years and >40 years age groups (49.5% and 50.0% respectively). Both the mean systolic and diastolic blood pressures were higher in >40 years age group (142.85±14.44 mm Hg vs. 137.69±14.70 mm Hg and 85.46±10.57 mm Hg vs. 84.36±9.47 mm Hg respectively). The mean duration of hypertension was higher in >40 years age group as well (5.66±5.78 years vs.2.85±3.74 years). A higher percentage of >40 years old patients were smokers (12.0% vs. 4.7%) where as a higher percentage of ≤40 years old patients gave a positive history of headache (80.7% vs. 69.4%). The mean duration of headache was found to be higher in >40 years old patients(2.01±0.74 years vs. 1.87±0.64 years) whereas the most common sites of headache were occipital and complete in both ≤40 years (27.5% each) and >40 years age groups (19.4% and 34.7% respectively).A majority of patients in both ≤40 years and >40 years age groups reported their headache to be of moderate intensity (35.7% and 46.9% respectively). A higher percentage of patients in >40 years age group gave a positive history of vertigo (59.3% vs. 47.7%) whereas a majority of patients in both ≤40 years and >40 years age groups reported it to be of mild intensity (66.7% and 61.8% respectively). An almost similar percentage of both≤40 years and >40 years old patients were found to have edema (40.2% and 42.6% respectively), a very high percentage of which was bilateral in both age groups (76.7% and 84.6% respectively). The grading of bilateral edema of a majority of both ≤40 years and >40 years age groups was found to be moderate (45.7% and 41.4% respectively). A higher percentage of >40 years old patients gave a positive history of chest pain (49.3% vs. 32.2%) though a higher percentage of ≤40 years old patients required a hospital visit for it to subside (22.2% vs. 6.9%). A higher percentage of >40 years old patients gave a positive history of vision problems (57.4% vs. 44.2%) though the most common type of vision problem was dark spots in field of vision in both ≤40 years and >40 years age groups (46.2% and 46.0% respectively). A higher percentage of >40 years old patients gave a positive history of dyspnea (57.4% vs. 43.8%) though a majority of patients in both ≤40 years and >40 years age groups reported it to be moderate in intensity (48.8% and 53.8% respectively).A very low percentage of both ≤40 years and >40 years old patients gave a positive history of epistaxis (2.4% and 3.4% respectively). A higher percentage of patients in >40 years age group reported an increase in urinary frequency (45.5% vs. 30.6%) though a majority of patients in both ≤40 years and >40 years age groups reported the change to be moderate (36.7% and 44.0% respectively). A higher percentage of patients in >40 years age group gave a positive history of nausea (25.4% vs. 20.5%), sleep apnea (38.6% vs. 20.5%), irregular heartbeat/palpitation (39.9% vs. 33.0%), fatigue (74.8% vs. 67.0%) and confusion (68.6% vs. 52.3%) (Table 2).
Table 2: Descriptive Analysis: Age wise comparison

Variables

≤ 40 Years (n=89)

>40 Years (n=210)

Frequency(%)/ Mean ± S.D.

Frequency(%)/ Mean ± S.D.

Gender

Male

31(34.8)

123(58.6)

Female

58(65.2)

87(41.4)

Systolic Blood Pressure

Normotensive/ Prehypertensive

42(47.2)

58(27.6)

Stage 1/Stage 2 Hypertensive

47(52.8)

152(72.4)

Diastolic Blood Pressure

Normotensive/ Prehypertensive

45(50.5)

105(50.0)

Stage 1/Stage 2 Hypertensive

44(49.5)

105(50.0)

Systolic Blood Pressure (mmHg)

137.69 ± 14.70

142.85 ± 14.44

Diastolic Blood Pressure (mmHg)

84.36 ± 9.47

85.46 ± 10.57

Hypertension Duration (Years)

2.85 ± 3.74

5.66 ± 5.78

Smoking

Yes

4(4.7)

25(12.0)

No

82(95.3)

183(88.0)

Headache

Yes

71(80.7)

145(69.4)

No

17(19.3)

64(30.6)

Headache Duration (Years)

1.87 ± 0.64

2.01 ± 0.74

Site of Headache

Temporal

7(10.1)

16(11.1)

Parietal

6(8.8)

23(16.0)

Occipital

19(27.5)

28(19.4)

Frontal

18(26.1)

27(18.8)

Complete

19(27.5)

50(34.7)

Intensity of Headache

Mild

23(32.9)

30(20.7)

Moderate

25(35.7)

68(46.9)

Severe

22(31.4)

47(32.4)

Vertigo

Yes

41(47.7)

121(59.3)

No

45(52.3)

83(40.7)

Intensity of Vertigo

Mild

28(66.7)

76(61.8)

Moderate

12(28.6)

38(30.9)

Severe

2(4.8)

9(7.3)

Edema

Yes

33(40.2)

84(42.6)

No

49(59.8)

113(57.4)

Laterality of Edema

Bilateral

23(76.7)

66(84.6)

Unilateral

7(23.3)

12(15.4)

Grading of Bilateral Edema

Mild

6(17.1)

20(23.0)

Moderate

16(45.7)

36(41.4)

Severe

13(37.1)

31(35.6)

Chest Pain

Yes

28(32.2)

101(49.3)

No

59(67.8)

104(50.7)

Severity of Chest Pain

Improves with rest

13(48.2)

39(38.6)

Needs pain relieving medication

8(29.6)

55(54.5)

Requires hospital visit

6(22.2)

7(6.9)

Vision Problems

Yes

38(44.2)

117(57.4)

No

48(55.8)

87(42.6)

Type of Vision Problem

Loss of central vision

1(2.5)

11(9.7)

Loss of peripheral vision

11(28.2)

23(20.4)

Dark spots in field of vision

18(46.2)

52(46.0)

Pain in eyes

9(23.1)

27(23.9)

Dyspnea

Yes

39(43.8)

117(57.4)

No

50(56.2)

87(42.6)

Intensity of Dyspnea

Mild

9(22.0)

18(15.4)

Moderate

20(48.8)

63(53.8)

Severe

12(29.2)

36(30.8)

Epistaxis

Yes

2(2.4)

7(3.4)

No

83(97.6)

200(96.6)

Increased Urinary Frequency

Yes

26(30.6)

92(45.5)

No

59(69.4)

110(54.5)

Change in Urinary Frequency

Mild

10(33.3)

32(32.0)

Moderate

11(36.7)

44(44.0)

Severe

9(30.0)

24(24.0)

Nausea

Yes

18(20.5)

53(25.4)

No

70(79.5)

156(74.6)

Sleep Apnea

Yes

18(20.5)

81(38.6)

No

70(79.5)

129(61.4)

Irregular Heartbeat/Palpitation

Yes

29(33.0)

83(39.9)

No

59(67.0)

125(60.1)

Fatigue

Yes

59(67.0)

157(74.8)

No

29(33.0)

53(25.2)

Confusion

Yes

46(52.3)

144(68.6)

No

42(47.7)

66(31.4)

Discussion
The study results revealed that a much higher percentage of males were smokers though the most common site of headache was similar in both genders i.e. complete headache. A majority of males reported their headache to be of moderate intensity whereas a majority of females reported it to be of severe intensity. A higher percentage of males gave a positive history of chest pain though a higher percentage of females required a hospital visit for it to subside. A higher percentage of females gave a positive history of vision problems though the most common type of vision problem was dark spots in field of vision in both genders. A higher percentage of females gave a positive history of both fatigue and confusion.

The study results further revealed that a higher percentage of >40 years old patients were smokers whereas a higher percentage of ≤40 years old patients gave a positive history of headache. The mean duration of headache was found to be higher in >40 years old patients though the most common sites of headache were occipital and complete in both age groups. A higher percentage of patients in >40 years age group gave a positive history of vertigo and chest pain though a higher percentage of ≤40 years old patients required a hospital visit for their chest pain to subside. A higher percentage of >40 years old patients gave a positive history of vision problems though the most common type of vision problem was dark spots in field of vision in both age groups. A higher percentage of >40 years old patients gave a positive history of dyspnea and reported an increase in urinary frequency. A higher percentage of patients in >40 years age group gave a positive history of nausea, sleep apnea, irregular heartbeat/palpitation, fatigue and confusion as well.

The study results revealed that both males and females had almost equal levels of systolic and diastolic blood pressures, though Dustan HP in 1996 reported males to have higher blood pressure levels than females, albeit slightly. [11] Likewise, Daugherty SL et al., in 2011 also reported males to have lower rates of hypertension control than females. [12] This difference in findings could be a result of several factors, such as gender specific age structure and compliance rate of the populations in question. The study results further revealed that the patients in >40 years age group had higher levels of systolic and diastolic blood pressures, a finding well in line with published literature as Jo I et al., in 2001 also reported age to be associated with prevalence of hypertension. [13]

Moreover, a very high percentage of study participants gave a positive history of headache, irrespective of their gender or age. Similarly, D Tullio M et al., in 1988 also reported headache to be more prevalent in hypertensive than normotensive subjects. [14] Literature though reveals contrary findings as well as reported by Fuchs FD et al., in 2003 and Sherif SM et al., in 2012. [15,16] This difference in findings could well be attributed to different methodologies of the studies in question.

The study results further showed that vision problems were more prevalent among patients who were female or of older age in the study. Sherif SM et al., in 2012 did not report visual disturbances to be associated with hypertension, though without consideration for the gender or age of the study participants. [16] Furthermore, a higher percentage of >40 years old patients gave a positive history of dyspnea in the study. Karras DJ et al., in 2005 reported dyspnea to be associated with elevated blood pressure though irrespective of the age of the study participants. [17] Due to dearth of pertinent published literature, a meaningful comparison could not be made for the study findings mentioned above.

Moreover, a very low percentage of study participants gave a positive history of epistaxis, irrespective of their gender or age. Likewise, D Tullio M et al., in 1988 also did not find epistaxis to be associated with hypertension. [14] Furthermore, a very high percentage of study participants gave a positive history of fatigue, again irrespective of their gender or age. Unlike the study results though, D Tullio M et al., in 1988 did not report weakness to be associated with hypertension. [14] Due to lack of relevant published data, a comparison of the rest of study findings could not be made with the previous literature.
Limitation and Recommendation
It is acknowledged that being a cross-sectional study, recall bias may have affected the study results. Because of their potential to effect the clinical manifestation of hypertension, further evaluation of the role of gender and age in hypertension screening and management is recommended.
Conclusion
The study results revealed that the prevalence of smoking, chest pain, vision problems, fatigue and confusion were different between both genders. Furthermore, the prevalence of smoking, headache, vertigo, chest pain, vision problems, dyspnea, increased urinary frequency, nausea, sleep apnea, irregular heartbeat/ palpitation, fatigue and confusion were different between both age groups.
Conflict of Interests
The authors report no conflict of interests.
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