Palliative Medicine & Care: Open Access

Objective: To evaluate the effects of duration of hypertension on relationship between hypertension and its clinical signs and symptoms in hypertensive patients.

Methods: A cross-sectional study was carried out in the outpatient department of a secondary care hospital of Karachi. A total of 304 patients were included in the study by employing convenient sampling technique. All data were collected by using a structured questionnaire designed specifically for the study whereas the blood pressure level was measured by a sphygmomanometer and stethoscope. Statistical package for social sciences version 20 was used for data analysis. Chisquare test was applied for inferential analysis whereas the duration of study was 6 months.

Results: The study results showed that among patients with hypertension duration of up to 3 years smoking history (p=0.009), vision problems (p=0.018), sleep apnea (p=0.018) and palpitation (p=0.011) were significantly associated with systolic hypertension whereas only vision problems (p=0.034) and palpitation (p=0.005) were significantly associated with diastolic hypertension. The study results further showed that among patients with hypertension duration of 4 years or more vertigo (p=0.014), increased urinary frequency (p=0.013), sleep apnea (p=0.006), palpitation (p=0.002) and confusion (p=0.038) were significantly associated with systolic hypertension whereas only increased urinary frequency (p=0.033) was significantly associated with diastolic hypertension.

Conclusion: Based on study results it can be concluded that the symptomatology of hypertensive patients differed with the duration of their disease, albeit slightly. Further evaluation of study findings with more rigorous research designs is recommended for generation of more credible evidence with broader generalizability.

Keywords: Hypertension; Signs and Symptoms; Cross-sectional analysis.

Hypertension has been defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive medication [1]. As per 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 hypertension and stage 2 hypertension: Normal (systolic< 120 mm Hg, diastolic< 80 mm Hg);Prehypertension (systolic 120-139 mm Hg, diastolic 80-89 mm Hg);Stage 1 Hypertension (systolic 140-159 mm Hg, diastolic 90-99 mm Hg) and Stage 2 Hypertension (systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater)[2].

The types of hypertension have been defined to be two, essential and secondary. Essential hypertension is a rise in blood pressure of unknown cause that increases risk for cerebral, cardiac, and renal events [3].Secondary hypertension is an increased systemic blood pressure due to an identifiable cause [4].

It was recently reported that in 2010, 31.1% of the world’s adults had hypertension; 28.5% in high-income countries and 31.5% in low and middle-income countries [5]. In 2010, the East Asia and Pacific region had the highest burden of hypertension in the world, with 439 million people suffering from it[6].It has also been reported recently that from 1990 to 2015, the rate of systolic blood pressure of at least 110 to 115 mm Hg increased from 73 119 to 81 373 per 100 000, and systolic blood pressure of 140 mm Hg or higher increased from 17 307 to 20 526 per 100 000; the annual death rate per 100 000 associated with systolic blood pressure of at least 110 to 115 mm Hg increased from 135.6 to 145.2 while that for systolic blood pressure of 140 mm Hg or higher increased from 97.9 to 106.3; the loss of disability adjusted life years associated with systolic blood pressure of 140 mm Hg or higher increased from 95.9 million to 143.0 million, and that for systolic blood pressure of 140 mm Hg or higher increased from 5.2 million to 7.8 million[7]. Worldwide, 7.6 million premature deaths and 92 million disability adjusted life years are attributed to high blood pressure while over 80% of the attributable burden of this disease is seen in low-income and middle-income countries of the world [8]. Its high prevalence and poor control are significantly implicated in the increasing epidemic of cardiovascular diseases in developing countries [9].

The global prevalence of hypertension is not uniform however, and this heterogeneity has been linked to various factors, including urbanization with its associated lifestyle changes, racial and ethnic differences, and nutritional status and birth weight of an individual [10]. Locally in Pakistan, the available prevalence estimates about hypertension are scarce at best. A metaanalysis published in 2014 reported the pooled prevalence of hypertension to be 17% (95% CI 13.08% to 20.92%) in Pakistan based on data gathered prior to 2014 in Pakistan [11]. The World Health Organization however recently estimated that25.2% of the Pakistani population suffered from raised blood pressure in 2014[12].

Several factors may potentially influence the clinical presentation of hypertension in hypertensive patients like their age, gender, severity and duration of their disease. A through literature search by the authors did not reveal any relevant literature exploring the influence of hypertension duration on relationship between hypertension and its signs and symptoms. This study was therefore intended to evaluate the effects of duration of hypertension on relationship between hypertension and its clinical signs and symptoms in hypertensive patients.

A cross-sectional study was carried out in the outpatient department of a secondary care hospital of Karachi after taking necessary ethical approval. Patients aged 18 or above, with selfreported history of hypertension and taking anti-hypertensive medication were included in the study. Patients with history of diabetes, cardiac events, neurological disorders, cluster headache, gastrointestinal disease, visual problems, and morbid obesity were excluded from the study. After checking eligibility, patients were included in the study using convenient sampling technique.

All necessary data were collected from the participants after taking verbal informed consent by using a structured questionnaire designed specifically for the study. Their blood pressure levels were measured by a sphygmomanometer and stethoscope. The data were cleaned, entered and analyzed on SPSS version 20. The inferential analysis was performed using chi-square test whereas the significance level was kept at 0.05. The study duration spanned over 6 months.

Data of total 304 patients were analyzed for the study. 51.6% of the patients were male whereas 70.7% of them aged 41 years or above.

The study results showed that among patients with hypertension duration of up to 3 years smoking history (p=0.009), vision problems (p=0.018), sleep apnea (p=0.018) and palpitation (p=0.011) were significantly associated with systolic hypertension where patients with a positive history of smoking, complain of vision problems, sleep apnea and palpitation were more likely to have stage 1/stage 2 systolic hypertension than those who did not (100% vs. 61.4%, 73.7% vs. 55.3%, 79.1% vs. 58.7% and 77.8% vs. 57.1% respectively) (table 1A). Moreover, only vision problems (p=0.034) and palpitation (p=0.005) were significantly associated with diastolic hypertension where patients with complain of vision problems and palpitation were more likely to have stage 1/stage 2 diastolic hypertension than those who did not (52.6% vs. 35.5% and 59.3% vs. 35.7% respectively) (Table 1B).

The study results further showed that among patients with hypertension duration of 4 years or more vertigo (p=0.014), increased urinary frequency (p=0.013), sleep apnea (p=0.006), palpitation (p=0.002) and confusion (p=0.038) were significantly associated with systolic hypertension where patients with complain of vertigo, increased urinary frequency, sleep apnea, palpitation, and confusion were more likely to have stage 1/stage 2 systolic hypertension than those who did not (76.5% vs. 57.4%, 78.9% vs. 60.5%, 82.8% vs. 61.7%, 83.6% vs. 60.4% and 75.0% vs. 58.3% respectively) (Table 2A). Moreover, only increased urinary frequency (p=0.033) was significantly associated with diastolic hypertension where patients with complain of increased urinary frequency were more likely to have stage 1/stage 2 diastolic hypertension than those who did not (65.8% vs. 48.7%) (Table 2B).

This study was an attempt to evaluate the effect of duration of hypertension on symptomatology of hypertensive patients in a Pakistani population. A cross-sectional survey was performed among known hypertensive outpatient department patients in this context. The study results showed that among patients with hypertension duration of up to 3 years smoking history, vision problems, sleep apnea and palpitation were significantly associated with systolic hypertension whereas only vision problems and palpitation were significantly associated with diastolic hypertension. The study results further showed that among patients with hypertension duration of 4 years or more vertigo, increased urinary frequency, sleep apnea, palpitation and confusion were significantly associated with systolic hypertension whereas only increased urinary frequency was significantly associated with diastolic hypertension.

Duration of hypertension is known to negatively influence various hypertension related outcomes. It has been found to be an independent predictor of anxiety symptoms in hypertensive patients [13]. Moreover, it has been found to negatively affect the survival in such patients [14].It has also been reported to be a predictor in surgical cure of Reno-vascular hypertension [15]. Both short and long term durations of elevated blood pressure have also been found to be possibly crucial in the pathogenesis related to carotid arteries [16].Literature also relates longstanding hypertension with presence of white matter lesions and suggests that adequate treatment of hypertension may prevent white matter lesions and the associated cognitive decline in hypertensive patients [17].

Agrawal B et al., in 1996 reported qualitative micro albuminuria to be significantly associated with duration of hypertension in hypertensive patients [18]. Also, Carlsson AC et al., in 2013 reported that participants with greater duration of hypertension had higher circulating endostatin, a biologically active derivate of collagen XVIII and a relevant marker for extracellular matrix turnover and remodeling, that significantly associated with higher left ventricular mass, worsened endothelial function, and higher urinary albumin/creatinine ratio[19].

As published literature confirms that blood pressure control while on anti-hypertensive medications can vary considerably among hypertensive patients, from 5.4% to 58%20; it is plausible that such uncontrolled hypertension, by virtue of continued vascular damage, may increase the number and severity of clinical manifestations in a hypertensive patient with poor blood pressure control. Unfortunately, with regard to the study findings about differences in symptomatology of hypertensive patients with regard to duration of their disease, a direct and meaningful comparison could not be made as even an exhaustive literature search did not reveal any relevant published data. In any case, such observed differences are worth exploring further as they may help in defining a risk profile of hypertensive patients based on the duration of their disease which could prove useful in their targeted management.

Use of convenient sampling technique due to resource constraint and potential limitation in recall because of a crosssectional design are acknowledged as the main limitations of this study.

Based on study results it can be concluded that the symptomatology of hypertensive patients differed with the duration of their disease, albeit slightly. Further evaluation of study findings with more rigorous research designs is recommended for generation of more credible evidence with broader generalizability.

The authors report no conflict of interests.

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