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

Abstract

Cardiovascular diseases continue to be the main cause of death in Venezuela, and hypertension is the primary risk factor. The May Measurement Month (MMM) campaign has been conducted annually in Venezuela since 2017. In 2022 (MMM22), the campaign included 46 239 participants with a mean age of 57.3 (SD 14.9) years and 57.2% were female. The percentage of participants with hypertension was 59.0% (females: 56.1%; males: 62.9%); of those, 80.6% were aware of their condition and 78.9% were on antihypertensive medication. Among those receiving drug treatment, 58.8% were controlled to <140/90 mmHg, and of the overall hypertensive population, 46.4% were controlled. Of those taking antihypertensive medication, 58.5% received one antihypertensive drug, 31.7% two drugs, and 9.8% were on three or more drugs. When results were age-sex standardized, the prevalence of hypertension was lower at 39.9%. Other cardiovascular (CV) risk factors were also identified: 8.3% reported having diabetes, 21.0% were obese (body mass index (BMI) ≥ 30 kg m²), 36.3% were overweight (BMI ≥ 25 and <30 kg m²), 8.5% were current smokers, and 53.9% reported inadequate physical activity. Additionally, 53.1% of females and 25.4% of males had an abnormal abdominal circumference classified as abdominal obesity. Furthermore, a previous myocardial infarction, stroke, or heart failure was reported by 2.7%, 1.7%, and 2.4%, respectively. In conclusion, this study confirms the suitability of opportunistic screening in detecting large numbers with previously unknown hypertension, although the population prevalence of hypertension may be overestimated. It also identified overall poor control rates, highlighting the need for improved initiatives for blood pressure (BP) screening and management.

Introduction

Cardiovascular disease is the main cause of death and disability in Venezuela, with ischaemic heart disease, stroke, and heart failure as the major contributors. Hypertension is the most significant risk factor for cardiovascular disease, followed by diabetes, lipid abnormalities, smoking, and low physical activity.¹ According to World Health Organization (WHO), the prevalence of hypertension in subjects aged 30–79 years was estimated as 39.4% in Venezuela in 2019.²

May Measurement Month (MMM), an initiative of the International Society of Hypertension (ISH), has been conducted annually since 2017, except in 2020 due to the COVID-19 pandemic.

In Venezuela, MMM 2019 reported the frequency of hypertension as 48.9%, with a mean age of 54.7 years.³ In 2021, based on a sample of 46 732 subjects with a mean age of 56.4 years, MMM reported a frequency of hypertension of 60.3%, with 82.3% of participants aware of their condition, 80.2% on medication, and 55.8% of those on medications controlled.⁴ Among the overall hypertensive population, 44.7% had controlled BP.⁴

Given the continued burden of hypertension, the MMM campaign was conducted again in Venezuela in 2022 with the goal of raising awareness of raised BP. This report presents the findings from that campaign.

Methods

May Measurement Month is a cross-sectional-opportunistic survey of consenting adults aged 18 years and older. The programme in Venezuela was conducted under the auspices of Venezuelan Society of Hypertension and carried out mainly in various branches of the FARMATODO pharmacy chain (90.3%) across 98 sites in eight Venezuelan regions. Data collection at each site was handled by between three and five individuals who were previously trained by clinical pharmacists, using validated automatic devices, primarily made by Omron brand (Shiokoji Horikawa, Shimogyo-ku, Kyoto 600-8530, Japan). The campaign was advertised via social media, and participants volunteered from the public. The protocol was approved by the ethics committee of the Dean of Health Science at the University Centro-Occidental Lisandro Alvarado, Barquisimeto, Venezuela.

In accordance with the standard MMM22 protocol, participants had three seated BP readings measured at 1 min intervals.⁵ A questionnaire was also completed collecting information on demographics, comorbidities, lifestyle risk factors, and antihypertensive medication use. Abdominal obesity was defined as an abdominal circumference of >88 cm in female participants or >102 cm in male participants. Hypertension was defined as a raised BP (a systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 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 if necessary, were given a recommendation to visit medical centre for individual attention.

Data were collected using the MMM Microsoft Excel spreadsheet and submitted to the central MMM team for cleaning and analysis. In the 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.⁵ For comparison with other countries participating in MMM, results are also presented after age and sex standardization using the WHO world standard population, and assuming an equal gender split.⁶

Results

A total of 46 239 were screened during MMM22 in Venezuela. The mean age was 57.3 (SD 14.9) years, and 26 451 (57.2%) of the participants were female. The ethnicity distribution was as follows: 59.9% identified as Mixes, 29.1% as White, 3.3% as Black, and 6.7 as other. Only 343 (0.7%) participants reported never having had their BP measured, and 5.8 had participated in a previous MMM campaign. Educational attainment varied, with 49.3% of participants reporting more than 12 years of education, 34.7% having 7–12 years, 13.8% with 1–6 years, and 0.5% reporting no formal education.

Multiple imputation was used to estimate missing BP readings for 146 (0.3%) participants who were missing the second and/or third BP reading. Among all participants, 27 272 (59.0%) were found to have hypertension (females 56.1%; males 62.9%). Of those with hypertension, 21 983 (80.6%) were aware of their condition (females 84.0%; males 76.5%), and 21 522 (78.9%) were on antihypertensive medication (females 82.7%; males 74.4%) (Table 1). Among those on antihypertensive medication, 12 652 (58.8%) had controlled BP (females 62.8%; males 53.3%), and of all hypertensives, 46.4% had controlled BP (females 51.9%; males 39.7%). Among those participants not taking antihypertensive medication, 5750 (23.3%) were found to have raised BP (≥140/90 mmHg). In total, 14 620 (31.6%) participants had 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	46 239	27 272 (59.0)	21 983 (80.6)	21 522 (78.9)	12 652 (58.8)	12 652 (46.4)
Standardized	46 055a	18 377 (39.9)	12 450 (67.7)	12 089 (65.8)	7692 (63.6)	7692 (41.9)

^aStandardized total lower than actual total, as 184 participants did not have information recorded on age or sex.

After age and sex standardization using WHO data and assuming an equal gender distribution, 18 377 (39.9%) participants had hypertension, of whom 12 450 (67.7%) were aware, 12 089 (65.8%) were on antihypertensive medication, and 7692 (41.9%) were controlled (Table 1).

Among those receiving treatment, 58.5% were taking only one antihypertensive drug, 31.7% were on two drugs, and 9.8% were on three or more. Additionally, 15.6% of all participants were taking aspirin, 11.5% were taking statin, and 2.2 were on anticoagulants.

Other cardiovascular risk factors were also prevalent: 21.0% were classified as obese (BMI ≥ 30 kg m²), and 36.3% as overweight (BMI ≥ 25 and <30 kg m²). Abdominal obesity, as indicated by abnormal abdominal circumference, was found in 53.1% of females and 25.4% of males. In total, 8.5% of participants were current smokers, and 53.9% reported inadequate physical activity. Diabetes mellitus was reported by 8.3% (n = 3839 participants), of whom 77.3% also had hypertension. A history of myocardial infarction, stroke, or heart failure was reported by 2.7%, 1.7%, and 2.4% of participants, respectively.

Mixed effects linear regression models adjusted for age and sex (with interaction) and antihypertensive medication use were created to explore predictors of systolic and diastolic BP.

Compared to participants with no years of formal education, a greater number of years of education were associated with lower BP. Participants who completed 150 min of moderate (or 75 min of vigorous) physical activity per week had 1.3 mmHg (95% CI 0.9–1.6, P < 0.001) lower systolic and 0.7 (95% CI 0.5–0.9, P < 0.001) lower diastolic BP on average.

Within female participants, hypertension in a previous pregnancy was associated with 3.2 mmHg (95% CI 2.3–4.1, P < 0.001) higher systolic and 1.8 mmHg (95% CI 1.3–2.3, P < 0.001) higher diastolic BP. Meanwhile, female participants who reported taking hormone replacement therapy (n = 510) had 3.2 mmHg (95% CI 1.8–4.6, P < 0.001) lower systolic and 1.1 mmHg (95% CI 0.2–1.9, P = 0.013) lower diastolic BP compared to participants not taking hormonal replacement therapy.

Discussion

In the MMM22 campaign in Venezuela, 59.0% of participants were found to have hypertension, a figure very close to the 60.3% reported in MMM21,⁴ but higher than the 48.9% reported in MMM19, which included 24 732 participants, using the same methodology.³

In the present study, 19.4% of hypertensive individuals were unaware of their condition (compared to 17.7% in the MMM21).⁴ The proportion of participants on antihypertensive medication with controlled hypertension remained consistent with MMM21 at 55.8%, with females generally showing better awareness and control of their condition.⁴

As in global data, those with higher levels of formal education and increased levels of physical activity had lower mean BP values. Among women, pregnancy was associated with lower mean BP levels, but associated with higher values in those who had hypertension in a previous pregnancy.^3,4,7

Strengths and limitations

One of the strengths of the MMM campaign is the use of a standardized protocol across countries, which aids comparability of findings. However, participants in MMM were recruited opportunistically using convenience sampling and, as a result, prevalence estimates should not be interpreted as estimates of national prevalence. Furthermore, most of our sample (72.6%) were over 50 years old, a population known to have a higher prevalence of hypertension. Standardizing hypertension frequency according to the WHO age and sex population distribution allows for comparisons across countries and here, resulted in a substantially lower estimate of hypertension (39.9%).

Hypertension was defined based on three BP readings at a single visit for pragmatic reasons that is not compatible with optimal methods of diagnosis at the individual level recommended in guidelines.^7,8 Consequently, the percentage detected with hypertension is likely to represent an overestimate.

Conclusion

This study demonstrates the suitability of opportunistic screening to detect hypertension in those for whom it was previously undetected, and identified low rates of BP control amongst treated hypertensive participants; it also directly engages with the community and so increases awareness of the importance of taking BP to detect hypertension. But the implementation of specific government measures for the detection, treatment, and control of high BP on a national scale is required, as well as to carry out studies designed with representative samples to estimate the prevalence of hypertension.

Funding

None declared.

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.