Original Article

Journal of Human Hypertension (2009) 23, 316–324; doi:10.1038/jhh.2008.136; published online 13 November 2008

Inter-regional comparisons of the prevalence of cardiometabolic risk factors in patients with hypertension in Europe: the GOOD survey

C Farsang1, L Naditch-Brule2, S Perlini3, W Zidek4 and S E Kjeldsen5 on behalf of the GOOD investigators

  1. 1The Cardiometabolic Centre, St Imre Hospital, Budapest, Hungary
  2. 2sanofi-aventis, Paris, France
  3. 3Department of Internal Medicine, Fondazione IRCCS San Matteo, University of Pavia, Pavia, Italy
  4. 4Department of Endocrinology and Nephrology, Campus Benjamin-Franklin, Medizinische Klinik IV, Charité, Berlin, Germany
  5. 5Department of Cardiology, Ullevaal University Hospital, Oslo, Norway

Correspondence: Professor C Farsang, St Imre Teaching Hospital, Tétényi u. 12–16, Budapest H-1115, Hungary. E-mail: hunghyp@t-online.hu

Received 10 July 2008; Revised 9 October 2008; Accepted 11 October 2008; Published online 13 November 2008.

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Abstract

The GOOD survey investigated the global cardiometabolic risk profile in adult patients with hypertension across 289 sites in four European regions (Northwest, Mediterranean, Atlantic European Mainland and Central Europe). Demographic, lifestyle, clinical and laboratory data were collected from eligible patients (n=3370) during a single clinic visit. In Central Europe, represented by Hungary, 44% of the participants had type II diabetes compared with 33% in the Atlantic European Mainland, and 26% in the Northwest and the Mediterranean regions. The prevalence of metabolic syndrome was also significantly higher in Central Europe (68%) and the Atlantic European Mainland (60%) than in the Northwest and the Mediterranean regions (50 and 52%, respectively). Fasting blood glucose, total cholesterol and triglyceride levels were all highest in Central Europe compared with the other three regions (P<0.001). In the Atlantic European Mainland, more patients had uncontrolled blood pressure (80%) compared with the other three regions (70–71%). Declared alcohol consumption was highest in the Atlantic European Mainland and exercise lowest in Central Europe. The prevalence of congestive heart failure, left ventricular hypertrophy, coronary artery disease and stable/unstable angina was higher in Central Europe compared with the other regions, whereas a family history of premature stroke or myocardial infarction, stroke, coronary revascularization and transient ischaemic attacks was all highest in the Atlantic European Mainland. These data indicate that many hypertensive patients across Europe have multiple cardiometabolic risk factors with the prevalence higher in Central Europe and the Atlantic European Mainland compared with Northwest and Mediterranean regions.

Keywords:

cardiovascular disease, metabolic syndrome, diabetes, Europe, prevalence, cardiovascular risk factors

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Introduction

Hypertension, which currently affects approximately a billion people worldwide,1 is a major cause of cardiovascular and cerebrovascular morbidity and mortality.2, 3 It has been estimated that as many as 7.1 million deaths per year may be attributable to hypertension.3 Studies have also shown that blood pressure (BP) remains inadequately controlled in the majority of patients with hypertension, including many of those receiving active antihypertensive treatments.3, 4, 5, 6 Importantly, with the prevalence of hypertension increasing rapidly in developing countries and the earlier trend for a reduction reversing in developed countries, the burden of disease is likely to increase still further in the future.1

The risk of hypertension is increased by a number of factors, including advancing age, obesity, smoking, excessive alcohol consumption and a sedentary lifestyle.7, 8 Hypertension frequently occurs in conjunction with other known cardiovascular risk factors, such as abdominal obesity, elevated fasting glucose or diabetes, and atherogenic dyslipidaemia.9 These additional risk factors, commonly underpinned by insulin resistance, often occur in clusters. When a constellation of these risk factors occur together in one individual, they constitute the condition now referred to as ‘metabolic syndrome’ (MS).10, 11, 12 This syndrome is associated with an increased risk of all-cause mortality, cardiovascular disease and diabetes.13, 14, 15, 16, 17, 18 In addition, there has been a recent interest in associations between microalbuminuria, BP, cardiovascular disease and hyperuricaemia.19, 20

It is evident from epidemiological studies, however, that there are differences in cardiovascular and metabolic risk profiles between continents.7, 21 Moreover, inter-regional, intercountry and even intracountry differences in cardiovascular and metabolic risk profiles are emerging.22, 23, 24 For example, the unique MONitoring of trends and determinants In CArdiovascular disease (MONICA) project has reported differences in cardiovascular risk between former socialist countries of Eastern Europe and Western Europe. However, there is still a lack of data comparing risk factors between regions within Europe specifically in patients with hypertension. This study addresses this gap in the literature by describing the results of a large, observational, cross-sectional survey designed to determine and compare the global cardiometabolic risk profile of adult patients with essential hypertension across different regions of Europe.

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Materials and methods

The Global Cardiometabolic Risk Profile in patients with Hypertension Disease (GOOD) survey was a pan-European, observational, cross-sectional survey carried out at 289 sites in 12 European countries.25 The countries were categorized into four regions—Northwest (Norway, Sweden and the United Kingdom); Mediterranean (Italy, Portugal, Slovenia, Spain and Turkey); Atlantic European Mainland (Belgium, Germany and The Netherlands) and Central European (Hungary). Each region was required to enrol 600–1100 patients and each study centre had a 2-month inclusion period in which to recruit subjects. The objective of the study was to investigate the global cardiometabolic risk profile in adult outpatients with essential hypertension in different European regions by measuring the frequency of different risk factors/markers.

Inclusion criteria were male or female outpatients aged greater than or equal to30 years currently receiving treatment for hypertension or with newly diagnosed hypertension (defined as systolic BP (SBP)greater than or equal to140mmHg and/or diastolic BP (DBP)greater than or equal to90mmHg in non-diabetic patients, or SBPgreater than or equal to130mmHg and/or DBPgreater than or equal to80mmHg in patients with diabetes), assessed on two previous consultations and confirmed on the day of inclusion in the study. Patients gave written informed consent.

The following assessments were made during the patient's visit: measurement of weight, height, waist circumference, seated BP (two measurements taken after at least 3min of rest), heart rate at rest and microalbuminuria (30–300mg urine albumin per g creatinine). The investigator also collected information on demographics and cardiometabolic risk factors including duration of hypertension; history of diabetes, cardiovascular disease or stroke; lifestyle factors including alcohol consumption, physical exercise and smoking habits; and laboratory measurements of fasting blood glucose, fasting lipid profile and serum creatinine data (provided from the patient's file if data had been collected within the previous 6 months).

Data quality control was carried out on-site in 5% of active sites, selected at random in each country. The survey was conducted in accordance with the guidelines laid down by the Eighteenth World Medical Assembly (Helsinki 1984) and Good Epidemiology Practice, Proper Conduct in Epidemiologic Research (European Federation, IEA and Societies 2004). In addition, each participating country complied with local and data protection regulations.

Statistics

All patients with evaluable age, gender, BP and antihypertensive treatment data were included in the analyses. The characteristics of the population (including demographic and lifestyle data, personal medical history, cardiometabolic risk factors and current antihypertensive treatment) were summarized using descriptive statistics. Comparisons between regions were preformed using the χ2 test for unadjusted analysis and a logistic regression model for multivariate and adjusted analysis (data were adjusted for patient age and gender). All statistical analyses were performed using two-sided tests or two-sided confidence intervals and a 5% significance level.

Determination of sample size for the study was based on an estimate of the number of patients required from the four regions to detect significant differences between regions, based on the 95% confidence interval of the frequency of risk factors. Assuming a frequency of risk factors of around 50% and a precision of the 95% confidence interval of 3–4%, it was estimated that 600–1100 patients per region would be required, and the study aimed to recruit this number per region. If the frequency of the risk factors was less or more than 50%, the precision would be better.

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Results

Characteristics of the investigators

A total of 289 investigators were recruited into the study from the 12 European countries. The number of investigators included for each country was between 10 and 30 for most countries but was four for Belgium and the United Kingdom and 102 for Hungary. In the Northwest, Central Europe, the Mediterranean region and the Atlantic European Mainland, 73.3, 62.4, 51.0 and 53.8%, respectively, were general practitioners whereas the percentage of cardiologists ranged from 2–3% (Northwest and Central Europe) to 10.3% in the Atlantic European Mainland and 32% in the Mediterranean region. Most investigators per region (82–93%) had been in medical practice for over 10 years. Approximately three-quarters (66–88%) were working in urban practices and the rest in rural practices.

Patient demographics

In total, 3464 patients were included in the survey and 3370 patients were included in this analysis (the main reasons for exclusion from the analysis were lack of informed consent (0.9%) and type I rather than type II diabetes (1.2%)). Of these, 600 (17.8%) were from the Northwest, 1222 (36.3%) were from the Mediterranean region, 573 (17.0%) were from the Atlantic European Mainland and 975 (28.9%) were from Central Europe.

The demographic characteristics of the survey participants from the four regions are summarized in Table 1. The mean age ranged from 59.1 to 63.7 years across the four regions. Approximately half of the patients were men, with the proportion being slightly higher in the Atlantic European Mainland and Northwest and lower in Central Europe. Mean body weight was lower in participants from the Mediterranean region (78.9kg) compared with the other regions (84.8–85.4kg). Patient mean body mass index and waist circumference were highest in Central Europe.


Haemodynamic parameters

Mean SBP, DBP and pulse pressure values differed significantly between the four regions. For all the three parameters, values were highest for the Atlantic European Mainland and lowest for Central Europe (Table 2). Differences were more marked for SBP than for the other haemodynamic parameters. It follows that the percentage of patients with controlled BP was also lowest in the Atlantic European Mainland (20.1%) compared with the other three regions where controlled BP rates were 28.7% (Central Europe), 29.3% (Northwest) and 30.8% (Mediterranean). The mean duration of hypertension ranged from 7.7 years for the Atlantic European Mainland to 8.8 years for Central Europe, and the percentage of patients with newly diagnosed hypertension ranged from 4.0% in the Northwest to 8.4% in the Atlantic European Mainland. A further analysis of BP measurements for patients with and without type II diabetes showed that the regional differences were mainly due to the subgroup with no diabetes, as there were no significant inter-regional differences in mean values for SBP and DBP across the four regions for patients with diabetes.


Drug treatments

Cardiovascular, glucose- and lipid-lowering drug treatments differed between the four regions (Table 3). In Central Europe, there was more use of angiotensin-converting enzyme inhibitors compared with angiotensin receptor blockers and vice versa for the Northwest region. In Central Europe, there was also more use of calcium channel blockers compared with the other regions. Proportionately more patients in Central Europe were receiving glucose- and lipid-lowering drugs.


Metabolic parameters

Comparison of the values for laboratory metabolic parameters revealed statistically significant differences between regions with respect to most parameters, as summarized in Table 4. With regard to parameters relating to glucose and lipid metabolism, mean values for fasting blood glucose, triglycerides, total cholesterol and low-density lipoprotein cholesterol (in men only) were higher and high-density lipoprotein cholesterol levels were lower for patients from Central Europe compared with the other three regions.


Significant differences relating to renal function were also observed between regions (Table 4). Creatinine clearance rates were higher in patients from Central Europe and the Atlantic European Mainland compared with the other two regions, and serum creatinine levels were highest in the Atlantic European Mainland. Uric acid levels and the incidence of hyperuricaemia were particularly high in the Atlantic European Mainland and notably lower in patients from the Mediterranean region. However, microalbuminuria was more prevalent in Central Europe and the Mediterranean region (49.1 and 48.0%, respectively) compared with the other two regions (40.9 and 41.6% in the Northwest and Atlantic European Mainland, respectively).

Diabetes and MS

The prevalence of MS was higher in Central Europe (68.0%) and the Atlantic European Mainland (60.2%) than in the Mediterranean and Northwest regions (52.1 and 50.3%, respectively; Figure 1). These inter-regional differences were statistically significant (P<0.001). The prevalence of diabetes was also higher in Central Europe (44.3%) and the Atlantic European Mainland (33.2%) than in the Northwest and Mediterranean regions (25.7 and 25.5%, respectively) (Figure 1). In addition, 37.6% of patients from Central Europe and 26.3% from the Atlantic European Mainland had both diabetes and MS compared with 20.5 and 18.3% of participants from the Northwest and Mediterranean regions, respectively (Figure 1).

Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Prevalence (%) of diabetes and MS in the hypertensive survey participants according to geographical region. Values are unadjusted by age and sex. P<0.001 between regions.

Full figure and legend (51K)

Cardiovascular disease

The prevalence of cardiovascular disease differed significantly between the four regions, as summarized in Table 5. The prevalence of congestive heart failure, known left ventricular hypertrophy, coronary artery disease and stable/unstable angina were all markedly higher in patients from Central Europe compared with those from the other regions, whereas a family history of premature stroke or myocardial infarction, stroke, coronary revascularization and transient ischaemic attack were more prevalent in the Atlantic European Mainland than in the other regions. The prevalence of known left ventricular hypertrophy and carotid stenosis were comparatively low in the Northwest and the prevalence of stroke was comparatively low in the Mediterranean region. In general, the prevalence of cardiovascular disease was lower in the Northwest and Mediterranean regions compared with Central Europe and the Atlantic European Mainland.


Lifestyle factors

There were significant lifestyle differences across the four regions (Table 6). Only 29.6% of patients in Central Europe took regular physical exercise compared with 32.4% in the Mediterranean region, 43.6% in the Atlantic European Mainland and 47.3% in the Northwest. Declared alcohol consumption also differed significantly between the four regions with those in the Atlantic European Mainland drinking most; 49.3% of patients in the Atlantic European Mainland consumed less than one glass a day compared with 59.8–67.8% for the other three regions, and the percentage who consumed three or more glasses per day ranged from 5.3% for the Northwest to 8.6% for the Atlantic European Mainland (P<0.001; Table 6). There were some differences in smoking habits, with most non-smokers from the Mediterranean region and Central Europe.


Comparison of data adjusted for age and gender

For all parameters except the prevalence of myocardial infarction and creatinine clearance rate, adjusting for age and gender did not affect the significance of the differences across the four regions. The difference in prevalence of myocardial infarction, adjusting for age and gender, across the four regions was no longer statistically significant (P=0.13). Similarly, for creatinine clearance, the difference between regions became non-significant when adjusted for age and gender.

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Discussion

This large pan-European survey of outpatients with hypertension demonstrates that there are inter-regional differences in haemodynamic and cardiometabolic profiles, and in the prevalence of cardiovascular disease.

In general, cardiometabolic risk factors were more prominent among patients from Central Europe (Hungary) and the Atlantic European Mainland (Belgium, Germany and The Netherlands) than among patients from the Northwest regions of Europe (Norway, Sweden and the United Kingdom) and the Mediterranean region (Italy, Portugal, Slovenia, Spain and Turkey). This did not appear to equate to regional differences in drug therapy. Compared with the other regions, patients in Central Europe were younger, weighed more and had a higher body mass index and waist circumference, higher fasting blood glucose, triglycerides, total cholesterol and low-density lipoprotein cholesterol levels and lower high-density lipoprotein cholesterol levels. They also had the highest prevalence of microalbuminuria, another risk factor for cardiovascular disease.26, 27 The prevalence of type II diabetes and MS was also high in these patients, and they also took least regular exercise. These factors together put them at a higher cardiovascular risk9 and indeed the prevalence of congestive heart failure, left ventricular hypertrophy, coronary artery disease and angina in patients from this region was higher than in the rest of Europe.

In this study, although Central Europe had the highest prevalence of diabetes and/or MS, the rate of uncontrolled BP (71.3%) was better than in the Atlantic European Mainland (79.9%) and was comparable with the Northwest (70.7%) and Mediterranean (69.2%) regions. Uncontrolled BP and the prevalence of diabetes and MS were both comparatively high in patients from the Atlantic European Mainland. These patients had the highest prevalence of stroke, transient ischaemic attacks, myocardial infarction and coronary revascularization. Taken together, these data suggest that a more aggressive approach to the management of cardiometabolic risk factors may be particularly appropriate in these countries. Lifestyle factors also differed significantly across the regions, with alcohol consumption tending to be greater in the Atlantic European Mainland and regular physical exercise lowest in Central Europe, suggesting that these may be other factors that physicians could target to try to reduce cardiovascular risk in their hypertensive patients.

Microalbuminuria (the rate of urinary excretion of albumin between 30 and 300mg per 24h), which is an indicator of generalized endothelial injury,28 has been shown to be extremely common in hypertensive outpatients, especially if patients have a cluster of cardiovascular risk factors and/or the presence of concomitant coronary artery disease or diabetes.29 Accordingly, more than 40% of patients with hypertension in the present survey had microalbuminuria, rising to 48% in the Mediterranean region and 49% in Central Europe.

As reported earlier,25 the results of this survey showed that less than 30% of hypertensive patients have their BP controlled to current treatment goals (SBP of <140mmHg and DBP of <90mmHg for non-diabetic individuals and an SBP of <130mmHg and DBP of <80mmHg for patients with diabetes or renal impairment30), which is in broad agreement with other studies.31, 32 There is a high prevalence of other cardiovascular risk factors among this patient population, most of whom are receiving antihypertensive treatment: approximately a third of patients have type II diabetes, over half (57.8%) met the criteria for MS and approximately a quarter have both diabetes and MS.25 In this study, inter-regional differences in BP levels were seen in patients who did not have type II diabetes, whereas mean SBP and DBP values were similar across the four regions for patients with diabetes.

In the MONICA project,22 systolic and diastolic hypertension was found to be more prevalent in former socialist countries than non-socialist countries, as was the prevalence of alcohol consumption, smoking in men and being overweight in women, but the prevalence of hypercholesterolaemia was lower. Interestingly, in our study performed 10 years later, differences between Hungary and the other regions were not as marked22 although the prevalence of diabetes and MS was considerably greater and the percentage of patients taking regular physical exercise was lower compared with the Northwest and the Atlantic European Mainland (29.6 vs 47.3 and 43.6%, respectively). This suggests that changes in lifestyle and diet in Hungary over the past 10 years may have had an influence on cardiovascular risk. On the other hand, the prevalence of some cardiometabolic risk factors and hypertension-related target organ damage (stroke and acute myocardial infarction) may be related to the national gross domestic product and health-care expenditure, which is still lowest in the Central Europe region, as shown by the 2007 WHO data.33

Although intercountry and inter-regional differences in the prevalence of cardiovascular risk factors may, in part, be due to lifestyle factors,22, 23 other factors, such as genetic factors and the medical management of risk factors, may also contribute to the differences. Dietary practices also vary widely between countries and should be taken into consideration, particularly sodium intake with regard to BP control; however, this information was beyond the scope of this survey. Data from the current analyses adjusting for age and gender differed little from the primary analysis, suggesting that differences in age and gender between the regions did not significantly contribute to the differences in cardiovascular risk.

The results of our study suggest that there is a particular need to focus on improving BP control generally and particularly in the Atlantic European Mainland, whereas in Central Europe, reducing blood glucose, triglyceride and cholesterol levels may be more important. Such measures should help reduce the prevalence of MS and reduce the prevalence of cardiovascular disease.

There are some limitations to this survey relating to its design. First, the recruitment of the investigators was based on inviting physicians to participate in the study and replacing anyone who declined with other physicians from a comprehensive list of primary care physicians and specialists in each country. Thus, the investigators who took part in the study may not have been representative of all physicians in their country or region. Second, the investigators were asked to provide information on 10–15 patients. Although these were to be recruited by asking the first two patients of the working day who met the inclusion criteria to participate, again the patient population may not have been representative of hypertensive patients treated in each region. Third, the 12 study countries in Europe were assigned to four different regions. However, the number of countries, study sites and patients included in each region differed. Thus, the patient population for each region may not have been representative of the whole region. However, for all regions, data were collected from all patients in a standardized manner and therefore can be compared across the four regions.

In conclusion, many hypertensive patients across Europe have multiple cardiometabolic risk factors, with the prevalence higher in Central Europe and the Atlantic European Mainland compared with the Northwest and Mediterranean regions. A more aggressive management of hypertension and other cardiovascular risk factors is therefore warranted across Europe but particularly in Central Europe and the Atlantic European Mainland.

Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

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Notes

Conflict of interest

Csaba Farsang is a member of several scientific advisory boards (Pfizer, sanofi-aventis, Novartis, MSD, Richter GRt). Lisa Naditch-Brule is an employee of sanofi-aventis.

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Acknowledgements

We acknowledge the contribution of the members of the Global CardiOMetabOlic Risk Profile in Patients with Hypertension Disease (GOOD) Scientific Council and the Study Investigators to this study. The study was designed interactively between an advisory board (later the authors of this paper) and sanofi-aventis and Bristol-Myers Squibb. The sponsor managed the data and did all the analysis but we had the right to request analysis and publish. P Milner, PhD, of PAREXEL, Uxbridge, UK is acknowledged for making the first draft of this paper, which has been further developed by us. The sponsor was given the opportunity to review and comment on the paper before submission.

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