May Measurement Month 2022: an analysis of blood pressure screening results from Armenia

Abstract

The May Measurement Month (MMM) campaign was carried out in Armenia in 2022 with the aim of raising awareness of raised blood pressure (BP). Here, we report on the findings of the campaign. Adults aged ≥18 years were recruited opportunistically in public areas, both indoor and outdoor, as well as in primary and secondary healthcare centres. Three seated BP readings were taken for each participant, along with completion of a questionnaire on demographics, lifestyle factors, and comorbidities. Hypertension was defined as a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or being on antihypertensive medication. Controlled BP was defined as being on antihypertensive medication with a BP <140/90 mmHg. Multiple imputation was used to estimate any missing BP readings. In total, 11 618 participants were screened, with a mean age of 52.4 (SD 16.5) years and 55.7% of whom were female. Of all participants, 5,999 (51.6%) had hypertension, of whom 3,729 (62.2%) were aware, and 3,203 (53.4%) were on antihypertensive medication. Of those on antihypertensive medication, 1,130 (35.3%) had controlled BP, and of all participants with hypertension, only 18.8% had controlled BP. In total, 4,869 (41.9%) were found to have either untreated or inadequately treated hypertension. The MMM campaign in Armenia identified significant numbers of participants with either untreated or inadequately treated hypertensives. We found that the percentage of hypertensives who are not adequately treated is still substantial in Armenia, which is a vital contributor to the growing burden of non-communicable diseases. May Measurement Month is a pragmatic and reasonably inexpensive tool to improve public awareness of BP in the general population.

Introduction

Elevated blood pressure (BP) is one of the largest contributors to the global burden of disease worldwide and is a critical risk factor for cerebrovascular and other cardiovascular diseases, the leading cause of mortality and disability-adjusted life years.¹ However, high BP is a modifiable risk factor and detecting arterial hypertension is essential for initiating treatment, achieving disease control, delaying the onset of and preventing cardiovascular diseases and important for improving the still poor statistics of mortality.²

May Measurement Month (MMM) is a global initiative and was initiated in 2017 by the International Society of Hypertension and has since run annually, except for 2020 due to the COVID-19 pandemic. In 2022, the MMM campaign continued, with the main aim of continuing to raise awareness of the dangers of raised BP and included 757 350 participants worldwide.³ Armenia joined MMM in 2017 and participated in 2017, 2018, 2019, and 2021. It was an excellent opportunity, not only to increase public awareness about high BP as one of the critical cardiovascular risk factors, but also on an annual basis to update the national data on high BP. In this article, we report on the findings of the MMM22 campaign in Armenia.

Methods

May Measurement Month is a cross-sectional opportunistic survey of consenting adults aged 18 years or over. The programme in Armenia was coordinated by the Armenian Union for the Prevention and Study of Hypertension led by Prof. Parounak Zelveian over the months of May–July. Screening sites were set up in public areas, both indoor and outdoor, as well as in primary and secondary healthcare centres. The study received approval from the Ethics Committee of the Institute of Cardiology. All investigator volunteers were trained in basic knowledge about hypertension and measurement techniques. The campaign was advertised using posters, banners, distribution of flyers, advertisements on TV and media, as well as advocacy on social media. The recruiting of the screeners was opportunistic, volunteer-based, and they were asked to participate in the study after a short introduction about the program and giving verbal informed consent.

In accordance with the standard MMM protocol, participants ideally had three seated BP readings measured at 1-min intervals, using certified Omron automated devices.³ A questionnaire was also completed, collecting information on demographics, comorbidities, lifestyle risk factors and antihypertensive medication use. Hypertension was defined as a raised BP [systolic BP (SBP) ≥ 140 mmHg and/or diastolic BP (DBP) ≥ 90 mmHg based on the mean of the second and third readings], or being on antihypertensive medication. Controlled BP was defined as being on medication with a BP <140/90 mmHg. Participants found to have raised BP were provided with diet and lifestyle advice and recommendations to attend appropriate healthcare services. Data collection was done via a phone-based app. Cleaning and transfer as well as analysis of data were implemented centrally by the MMM project team. In cases where any BP reading was missing, to ensure comparability between participants, the average of the second and third readings was estimated by multiple imputation using chained equations, based on global data as described previously.³ For comparison with other countries participating in MMM, results are also presented after age and sex standardization using the World Health Organization world standard population, and assuming an equal gender split.⁴

Results

In total, 11 618 were screened during MMM22 in Armenia. The mean (standard deviation) age was 52.4 (16.5) years, and 6,474 (55.7%) were female. A total of 2,307 (19.9%) participants reported having diabetes, 1,648 (14.2%) reported a history of myocardial infarction, 786 (6.8%) reported a history of stroke, 2,212 (19.0%) reported previous irregular heartbeat, and 932 (8.0%) reported a history of previous heart failure. A total of 2,560 (22.0%) respondents were current smokers, and 618 (5.3%) reported alcohol consumption once or more per week (see Supplementary material online, Table S1).

62.0% of screenees never participated in a previous MMM campaign. Of all participants, 2,171 (18.7%) reported never having had a BP measured before. In respondents with three BP readings (n = 7,338), BP decreased on average by 4.3/2.3 mmHg between the first and third readings. The mean values of the second and third readings were 132.6/82.1 mmHg (see Supplementary material online, Table S2 and Figure S1).

Multiple imputation was used to estimate missing BP readings for 4,280 (36.8%) participants missing data on the second and/or third BP reading. Of all participants, 5,999 (51.6%) were found to have hypertension, of whom 3,729 (62.2%) were aware, and 3,203 (53.4%) were on antihypertensive medication (Table 1). Of those on antihypertensive treatment, 1,130 (35.3%) had controlled BP, and of all hypertensives, 18.8% had controlled BP. Of participants who were not taking antihypertensive medication, 2,796 (33.2%) were found to have raised BP. In total, 4,869 (41.9%) were found to have either untreated or inadequately treated hypertension.

Table 1.

Total participants and numbers with hypertension, awareness, on medication and with controlled blood pressure, before and after age and sex standardization

	Total participants	Number (%) with hypertension	Number (%) of hypertensives aware	Number (%) of hypertensives on medication	Number (%) of those on medication with controlled BP	Number (%) of all hypertensives with controlled BP
Actual	11 618	5,999 (51.6)	3,729 (62.2)	3,203 (53.4)	1,130 (35.3)	1,130 (18.8)
Standardized	11 618	4,466 (38.4)	2,391 (53.5)	1,911 (42.8)	851 (44.5)	851 (19.0)

After age and sex standardization, 4,466 (38.4%) were found to have hypertension, of whom 2,391 (53.5%) were aware, 1,911 (42.8%) were on antihypertensive treatment and 851 (19.0%) were controlled (Table 1).

At the time of screening, 2,063 (17.8%) participants reported taking statins, 3,460 (29.8%) reported aspirin use, and 919 (7.9%) respondents were on anticoagulants (see Supplementary material online, Table S1).

After adjustment for age, sex, and treatment, statistically significantly higher BPs were apparent in participants with a history of previous diabetes [for SBP: 4.11 ± 0.50 mmHg higher (P < 0.001) and for DBP: 0.96 ± 0.29 mmHg higher (P = 0.001)] and in those reporting, heart failure [SBP: 2.54 ± 0.74 mmHg higher (P = 0.001)], amongst current smokers [SBP: 2.83 ± 0.53 mmHg (P < 0.001) and DBP: 1.49 ± 0.29 mmHg higher, (P < 0.001)], and among daily users of alcohol vs. never drinkers [SBP: 17.91 ± 1.21 mmHg higher (P < 0.001) and DBP: 6.77 ± 0.58 mmHg higher (P < 0.001)]. Participants with previous COVID-19 vaccination, compared with those without, had lower SBP [−5.42 ± 0.41 mmHg (P < 0.001)] and DBP [−2.12 ± 0.23 mmHg (P < 0.001)] (see Supplementary material online, Figures S2–S4).

Discussion

The MMM22 programme identified a total of 4,869 (41.9%) participants with untreated or inadequately treated hypertension. The percentage of participants with hypertension in MMM 2017, 2018, 2019, and 2021 were 33.9, 38.7, 41.6, and 45.7% respectively, vs. 51.6% in MMM22, highlighting that the scale of hypertension in Armenia remains concerning.^5-8

As in previous years, strong positive associations were found between high BP and risk factors such as smoking and alcohol consumption.^5-8 As in the preceding MMM21 campaign, participants with previous COVID-19 vaccination on average had lower SBP and DBPs.⁸

Of concern, those with diabetes mellitus were found to have higher average SBP and DBPs in comparison with the results of MMM21.⁸

Strengths and limitations

A strength of the MMM campaign is the use of a standardized protocol across countries, which aids comparability of findings. Participants in MMM were recruited opportunistically using convenience sampling and as a result, prevalence estimates should not be interpreted as estimates of national prevalence. Hypertension was defined based on three BP readings at a single visit for pragmatic reasons which is not the optimal method of diagnosis at the individual level recommended in guidelines.⁹ Consequently, the rate of hypertension detected is likely to represent an overestimate.

Conclusions

The MMM campaign in Armenia identified significant numbers of participants with either untreated or inadequately treated hypertension. We found that the percentage of hypertensives who are not adequately treated is still substantial in Armenia, which is a vital contributor to the growing burden of non-communicable diseases. May Measurement Month is a pragmatic and reasonably inexpensive tool to improve public awareness of BP in the general population, and potentially among health policymakers, and thereby could help to improve the prevention of major adverse cardiovascular events caused by hypertension.

Supplementary material

Supplementary material is available at European Heart Journal Supplements online.

Funding

STADA AG, KRKA d.d. Novo mesto, Egis Pharmaceuticals PLC, Recordati S.p.A., AS OlainFarm, Acino Pharma AG, and Abbot Laboratories GmbH representations in Armenia.

Data availability

Data are not publicly available but access can be requested with permission from the MMM Management Board, on request through the MMM website: maymeasure.org.