Diagnostic evaluation of people with hypertension in low income country: cohort study of "essential" method of risk stratification

doi:10.1136/bmj.a1387

Published 19 September 2008, doi:10.1136/bmj.a1387
Cite this as: BMJ 2008;337:a1387

Research

Diagnostic evaluation of people with hypertension in low income country: cohort study of "essential" method of risk stratification

Gregorio Montalvo, clinical epidemiologist¹, Fausto Avanzini, clinical cardiologist², Mariella Anselmi, health care unit coordinator¹^,3, Rosanna Prandi, health manager¹, Samuel Ibarra, general practitioner⁴, Monica Marquez, community epidemiologist¹, Daniela Armani, general practitioner¹, Juan-Martín Moreira, clinical epidemiologist¹, Cynthia Caicedo, community epidemiologist¹^,4, Maria Carla Roncaglioni, head², Fabio Colombo, senior statistician², Paola Camisasca, clinical cardiologist², Valentina Milani, statistician⁵, Simon Quimì, general practitioner⁴, Felix Gonzabay, general practitioner⁴, Gianni Tognoni, director⁶

¹ Centro de Epidemiología Comunitaria y Medicina Tropical (CECOMET), Esmeraldas, Ecuador, ² Laboratorio di Ricerca in Medicina Generale, Istituto di Ricerche Farmacologiche Mario Negri, 20156 Milan, Italy, ³ Centro Malattie Tropicali, Ospedale S. Cuore, 37034 Negrar, Verona, Italy, ⁴ Sistema Local de Salud, Ministerio de Salud Pública, Borbón, Ecuador, ⁵ Laboratorio di Statistica Medica, Istituto di Ricerche Farmacologiche Mario Negri, Milan, ⁶ Consorzio Mario Negri Sud, 66030 Santa Maria Imbaro, Chieti, Italy

Correspondence to: F Avanzini, Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa 19, 20156 Milan, Italy avanzini{at}marionegri.it

Objectives To explore the predictive power of a risk stratificationmethod for people with hypertension based on "essential" procedures(that is, available in economically less developed areas ofthe world), comparing it in the same population with the resultsgiven by the method suggested by the 1999 World Health Organization-InternationalSociety of Hypertension (WHO-ISH) guidelines.

Design Prospective cohort study of outcomes according to cardiovascularrisk profile at baseline.

Setting Primary care in a poor rural area of the Ecuadorianforest.

Participants 504 people with hypertension prospectively monitoredfor a mean of 6.7 (SD 2.3) years.

Interventions Essential data included blood pressure, medicalhistory, smoking, age, sex, and diagnosis of diabetes; the WHO-ISHmethods additionally included measurement of fasting blood glucose,total cholesterol, and creatinine, urinalysis, and electrocardiography.

Main outcome measures Cardiovascular events and total deaths.

Results With both methods there was a highly significant associationbetween the level of predicted risk and the incidence of cardiovascularevents and of total deaths: up to three quarters of all cardiovascularevents and two thirds of all deaths were reported among peopleclassified as at high or very high risk with either method.The predictive discrimination of the essential method is comparablewith the WHO-ISH with C statistics (95% confidence interval)of 0.788 (0.721 to 0.855) and 0.744 (0.673 to 0.815), respectively,for cardiovascular events and 0.747 (0.678 to 0.816) and 0.705(0.632 to 0.778) for total mortality.

Conclusions The risk stratification of patients with hypertensionwith an essential package of variables (that is, available andpracticable even in the economically less developed areas ofthe world) serves at least as well as the more comprehensivemethod proposed by WHO-ISH.

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