The downside of la dolce vita

Blood pressure in Europe is out of control;
Canada's levels are healthy, but men could do better

BY PATRICK SULLIVAN

Canada lags behind the United States in the control of blood pressure, and Canadian men in particular are being failed by the health system, according to research in the January 2004 issue of the journal Circulation.

An international team of researchers compared hypertension control in five European countries, Canada and the United States, among the 35 to 64-year-old population with a blood pressure of at least 140/90.

The authors found that 17% of Canadians with this blood pressure had their hypertension under control, compared to 29% of Americans. Canada still fared better than the European countries in this comparison, however.

"Only 5% of people in Spain and 10% of people in England with this blood pressure had it controlled," said study co-author Dr Richard Cooper of Loyola University Chicago. Control rates were 6% in Sweden, 8% in Germany and 9% in Italy.

"We found divergent views between countries on what blood pressure level requires treatment," said Dr Cooper. "Low treatment and control rates in Europe, combined with a higher prevalence of hypertension, could contribute to a higher burden of cardiovascular disease risk."

The study found that Canadian hypertensive men are only half as likely as women to have their blood pressure under control. This phenomenon was also seen in the US, Spain and Italy.

The authors argue that many of the international differences are due to treatment guidelines. Countries that only treat patients identified as high-risk for cardiovascular disease will see limited public health benefits, the authors say. Cardiovascular disease occurs in people who are considered low-risk, simply because there are so many of them.

Dr Andreas Wielgosz, a cardiologist and spokesperson for the Heart and Stroke Foundation of Canada, said Canada is "guilty on both counts" -- of failing to adequately control hypertension and failing to reach enough hypertensive men.

"Women are usually more careful of their health than men, have seen a physician more often in their reproductive years, and seem to adhere better to the advice and treatment recommendations of physicians," argued Professor Michel Joffres of Dalhousie University, the sole Canadian to coauthor this study. "Another important factor," he said, "may also be the overall higher levels of blood pressure in men than in women, and the relative greater difficulty to get under the 140/90 level in men than in women."

The authors said failure to control hypertension is the main reason why stroke deaths are more common in Europe than in the United States. But Canada appears to buck that trend, with a slightly lower mortality rate from stroke than its southern neighbour, according to the World Health Organization.

In fact, Canada has the second-lowest age-standardized stroke mortality rate in the world after Switzerland, and the United States comes in a close third. In terms of all-cause cardiovascular disease, Canada has the world's fourth-lowest age-standardized mortality rates, and the United States comes in 13th place with more deaths than Spain and Italy, whose hypertension control is found wanting in this study.

"I don't think that the gap between Canada and the US in blood pressure control is due to a lower level of the overall quality of our Canadian healthcare system," said Professor Joffres. "Our past hypertension guidelines for the definition and management of high blood pressure have been far more conservative than the US guidelines, less emphasis has been placed on dissemination of guidelines in Canada than in the US, and to a certain extent the level of malpractice suits in the US may have increased the adherence of US physicians to management and control standards."

"The pity is that this gap in management has resulted in preventable harm to a relatively large segment of the population with high blood pressure," he said. "It's time to adopt more aggressively some of the current international guidelines in defining and managing high blood pressure, such as the 1999 WHO recommendations."