Indian Heart Journal 74 (2022) 484e487

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Indian Heart Journal

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Original Article

Uncontrolled hypertension in a rural population of Jammu and

Kashmir
Priyadarshini Arambam a, Rishabh Khashoo b, Dhruv Tewari b, Zubair Saleem c,
Sudhir Shekhawat d, Upendra Kaul e, *
a
General Manager Academics & Research, Batra Hospital and Medical Research Centre, New Delhi, India
b
MBBS Intern, UCMS and GTB Hospital, Dilshad Garden, New Delhi, India
c
Geriatric Medicine, JLNM Hospital, Srinagar, J&K, India
d
Independent Consultant, Biostatistics, India
e
Gauri Kaul Foundation, New Delhi, India

a r t i c l e i n f o a b s t r a c t

Article history: Aim: Evaluation of the status of uncontrolled hypertension in diagnosed hypertensives who had been
Received 2 September 2022 advised drug treatment in the rural areas of 6 districts in Jammu & Kashmir (J&K) and also the risk
Received in revised form factors associated with it.
18 November 2022
Methods: The study was a cross-sectional observational study conducted between August 2020 to July
Accepted 21 November 2022
Available online 30 November 2022
2021 in the form of health camps in six government health centres in 6 different rural districts. The
camps were focussed on patients with hypertension, diabetes with or without heart disease. The areas
included Machil in Kupwara, Khan Sahib in Budgam, Rajpora and Hawal in Pulwama, Rainawari in the
Keywords:
Antihypertensive therapy
Srinagar, Banihal in Ramban, and Jagti in Jammu.
Uncontrolled hypertension Enrolled patients were examined for body weight, blood pressure (BP), random blood sugar and serum
Risk factors lipid profile. The definition of hypertension was as per the eighth Joint National Committee (JNC-8)
Rural population guidelines.
Results: A total of 600 patients (50.1% males) were evaluated. Of these 335 (55%) had history of being
diagnosed hypertension and had been recommended drugs for BP control Male: Female ratio
1:0.8.211(63.5%) of these had un controlled blood pressures on measurement.
Two or more drugs had been prescribed in 65 (30.8%) patients, 34 (16%) were taking only single drug and
112(53%) were not on any drug. Uncontrolled hypertension was seen more often in age group of 40e60
years (49%), subjects more than 60 years had it in 40%.
The comparison of risk factors between patients with diagnosed hypertension with those without it
revealed use of tobacco, consumption of salted tea, presence of diabetes, dyslipidaemia as significant
factors for the presence of uncontrolled hypertension.
Conclusion: Uncontrolled hypertension in known patients prescribed drugs is highly prevalent in the
rural population of J&K. Steps to mitigate this problem are needed on top priority.
© 2022 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Cardiological Society of India.
This is an open access article under the CC BY-NC-ND license ([Link]
nc-nd/4.0/).

1. Introduction deaths and 24% of coronary heart disease (CHD) deaths.2 In 2017,
hypertension was the leading risk factor for vascular disease ac-
High blood pressure is a leading risk factor for morbidity and counting for 218 disability-adjusted life years (DALY's), followed by
mortality globally.1 It is directly responsible for 57% of all stroke smoking.1 It often has no early symptoms and is referred to as a
“silent killer".3
India has hypertension in 29% of its population4 and the ratio of
adults diagnosed and treated adequately is low,5 especially in
* Corresponding author. Cardiology and Dean Academics and Research, Batra
Hospital and Medical Research Center, 1. M B Road, Tughlakabad Institutional Area, resource-poor settings like rural and remote areas. The prevalence
New Delhi, 110062, India. varies significantly between urban (33.8%) and rural (27.6%)
E-mail address: [Link]@[Link] (U. Kaul).

[Link]
0019-4832/© 2022 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND
license ([Link]
P. Arambam, R. Khashoo, D. Tewari et al. Indian Heart Journal 74 (2022) 484e487

regions. The limited disease awareness of hypertension in 25% of 3. Definitions Used

rural and 35% of urban populations is an additional problem. In the
union territory of Jammu & Kashmir (J&K), hypertension was found Bodyweight was recorded on a digital weighing scale. Body
in 24.9% of males and 12.3% of females6 It was reportedly higher in mass index was calculated (in kg/m2). A BMI of 25e29.9 was taken
tribal population as it was found that tribals had a prevalence of as overweight, and BMI
30 kg/m2 was defined as obese.13 History
41.4%.7 It is estimated that 874 million people worldwide had a of tobacco was defined as cigarettes or chewing tobacco or both.
systolic blood pressure of 140 or higher in 2015,8 and by 2025, this Salted tea consumption was defined as noon chai more than 2 cups
number will reach 1.56 billion.9 The enormity of the problem be- a day. All patients were allowed to rest for at least 5 min, and B.P.
hoves optimal management of hypertension which can directly was recorded in the right arm in the sitting position. Blood pressure
affect the mortality and morbidity of the population. In a study was measured using a table-top digital non-invasive blood pressure
conducted in Nigeria, gender, age, number of drugs used, educa- (NIBP) instrument. Circa Microlife Premier Exclusion. It is a reliable
tional level, and presence of co-morbidities did not affect compli- and clinically validated digital self-calibrating machine that calcu-
ance. Major contributors (60%) were related to both patient's lates the average of three readings for accurate B.P. measurements.
attitudes and beliefs and consultation failure on the part of patients. Blood pressure was categorized as normotensive, pre-
Lack of finances and side effects of medications accounted for 23.8% hypertension, and hypertension as per the eighth joint national
and 16.2% of non-compliances respectively.10 committee on prevention, detection, evaluation, and management
Dietary and personal habits, geographical constraints related to of hypertension (JNC-8).14 Random blood glucose was measured
the place of residence, and occupational factors create risk factors using a glucometer on a finger-prick blood sample. All patients also
for hypertension11,12 undermining the importance of studying un- had a venous blood sample collected for lipid profile determination.
diagnosed and undermanaged hypertension. Recently published Dyslipidaemia was defined as having total cholesterol >200 mg/dl,
literature has described the absolute prevalence of hypertension in LDL >130 mg/dl), HDL<35 mg/dl, triglycerides >150 mg/dl ac-
several parts of India, but studies on adequacy of management of cording to the American Heart Association classification.15
hypertension are lacking. Our study aims to ascertain the preva-
lence of uncontrolled hypertension in a population residing in rural
4. Statistical Analysis
areas of J and K which had been prescribed medications and
identification of risk factors associated with it.
Descriptive analysis was performed on the collected data.
Discrete variables were presented as numbers and percentages. The
association of risk factors with a history of hypertension and
increased blood pressure was evaluated using the Chi-square test or
Fisher's exact test, whichever was applicable. A p-value of <0.05
2. Material and Methods
was considered significant. All statistical data analysed were per-
formed using IBM SPSS Statistics software version 22.
Data was collected from 6 rural locations spread over the union
territory of J &K). The areas included Machil and outskirts of Kup-
wara district, Khan Sahib in Budgam district, Rajpora and Hawal in 5. Results
Pulwama district, Rainawari in the Srinagar district, Banihal in
Ramban district, Jagti township near Katra in Jammu. Medical Our study reveals that of the 600 patients whose data was
camps were conducted over 1e2 days at these locations between complete 335 (55.8%) were diagnosed with hypertension who had
August 2020 to July 2021. been prescribed medicines. The district wise percentages of hy-
The study had a cross-sectional design with data collection in pertensive subjects seen ranged from 58.9% to 69% and it was
pre-designed proforma developed by the medical research unit of comparable in both Jammu and Kashmir areas respectively. From
our foundation. The analysis proforma had eight sections taking Kashmir valley, Kupwara (50, 60%), Pulwama (81,64%), Rainawari
note of patient demographics, income, vital parameters, risk factors (29,62%), Budgam (62,67.8%). From Jammu area, Banihal (34,58.9%),
for cardiovascular diseases, current medications, lifestyle habits, Jagti (79,69%). The sex distribution was Male: Female ratio of 1.2 : 1.
previous investigations, and overall impression. All patients were The comparison of risk factors between patients with diagnosed
examined for weight, blood pressure (B.P.), and random blood hypertension with those without it revealed consumption of to-
glucose (RBG). People of all age groups and both genders presenting bacco (25.3% vs 14.9%; P ¼ 0.002) salted tea (Noon Chai) (12% vs
to the PHC satisfying the eligibility criteria were enrolled. Each 11%; p ¼ 0.001), presence of diabetes (25% vs 15.3; p ¼ 0.004),
camp aimed at enrolling at least 100 eligible patients. dyslipidaemia (36.4% vs 10.8%; p ¼ 0.001) and presence of a stroke
Inclusion Criteria: or a TIA (3.6% vs 0.4%; p ¼ 0.013) had a significant corelation with
the presence of uncontrolled hypertension. On the other hand,
1 Patients being treated for hypertension from govt health centers obesity (26.1% vs 24.1%), consumption of non-vegetarian diet (47.0%
2. Patients being treated for diabetes vs 55.6%), low physical activities (47% vs 53.4%) had no correlation.
3. Patients being treated for heart diseases. Alcohol consumption and chronic kidney disease was present in
very small numbers in the studied population.
Patients meeting any two of the three inclusion criteria were Uncontrolled hypertension was seen more often in ages of
included in the study. 40e60 years (49%), subjects more than 60 years had it in 40%. Of the
Exclusion criteria: patients prescribed 2 or more drugs, only 65 (30.8%) were taking it,
while only one drug was being taken by 34 (16.1%) of them. 112
1. Patients with incomplete data of the main variables patients (53.1%) were not on any drugs despite being recommended
2. Patients with decompensated heart failure drug treatment (Table 1).
3. Patients on renal replacement therapy There were 76 patients with proven coronary artery disease
with or without heart failure. Of these 61% had hypertension. On
Six hundred patients were enrolled through these six medical the other hand, of the 18 patients with valvular heart disease only
camps. 33% had hypertension (Table 1).
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P. Arambam, R. Khashoo, D. Tewari et al. Indian Heart Journal 74 (2022) 484e487

Table 1 We observed that nearly 50% of the population consume non-

Hypertension details in the enrolled patients. vegetarian diet in J& K is significant. Red meat is associated with
Hypertension details Numbers (N) Percentage (%) an increased risk of developing hypertension.24 This association did
Past history of hypertension 335/600 55.3
not assume significance possibly because of high meat consump-
Raised office BP noted 211/335 63.6 tion in 64% of the population which also included persons without
Two or more Anti-hypertensives 65/211 30.8 hypertension and belonged to the valley. Banihal and Jagti town-
Single oral antihypertensive drug 34/211 16.1 ship were the only areas from Jammu region in our study which has
No oral antihypertensive drug 112/211 53.1
lower consumption of meat.
Age group of patients with Raised office BP
 >60 years 86/211 40.7 This study can considerably impact the optimization of the
 40e60 years 104/211 49.2 management of pre-diagnosed hypertensives in rural milieu of
 < 40 years 21/211 10.1 India. According to studies, the prevalence of hypertension was
Hypertension and other cardiac disease
found to be around 24.9% in males and 12.3% in females.25 Treating
 Coronary heart disease 45/73 61.7
 Valvular heart disease 6/18 33.3
hypertension can be an arduous task in a rural or tribal population
where people generally consider taking medications only when
Abbreviations: BP¼Blood pressure.
they have symptoms which could also be a possible explanation as
to why tribals had higher prevalence of hypertension in the val-
6. Discussion & Conclusion ley.26 Clinical hypertension, which can remain asymptomatic for
years, can be challenging to follow up in such a population. A recent
Our study evaluated a rural population of 6 districts of J&K. The study from North India has also highlighted the prevalence of un-
prevalence of uncontrolled hypertension was seen in 63% of this controlled hypertension in 46.2% with several risk factors which
population. The highest incidence of raised office B.P. was seen in have many things common with our observations.27 Our study in
the age group of 40e60 (49%), followed by the participants above rural areas of J&K had an even higher prevalence of 63.5%.
the age group of 60 (40%). Of the patients prescribed 2 or more Prevalence of participants consuming salted tea more than 2
drugs, only 65 (30.8%) were taking it, while only one drug was cups daily was seen much higher in hypertension group 277(83%)
being taken by 34 (16.1%) of them while 112 (53.1%) were not on any as compared to the non-hypertension group 192(71%). The local
drugs despite being recommended drug treatment. dietary practice of people of the Kashmir valley of non-vegetarian
The high prevalence of uncontrolled hypertension suggests that diet and consuming salted tea, which has high content of sodium
a number of cardiovascular complications can be prevented by in each cup, further contributes to hypertension. In addition to the
improved blood pressure control. Hypertension control reduces the well-accepted fact that dietary sodium leads to increased B.P., it is
risk of stroke by 30%, coronary heart disease by 10%e20% conges- also independently associated with an increased risk of CVD28 and
tive heart failure by 40e50% and total mortality by 10%.16 According stroke.29 Nearly 83% of study participants having history of hy-
to the latest AHA guidelines, all patients with a systolic blood pertension consumed salted tea each day. Educating patients to
pressure
160 mmHg or diastolic blood pressure
100 mmHg limit the consumption of salted tea as a part of dietary modification,
should be treated with a combination of at least 2 antihypertensive increasing dietary fibre intake, and lowering the intake of red meat,
agents.17 trans fatty acids and saturated fats can significantly lower blood
The comparison of risk factors between patients with diagnosed pressure.28
hypertension with those without it revealed tobacco use and con- Out of 73 participants with coronary heart disease with or
sumption of salted tea, presence of diabetes, dyslipidaemia had a without heart failure, 45(61%) had hypertension, and 6(33%) out of
significant corelation with the presence of uncontrolled 18 patients with valvular heart diseases had hypertension. Hyper-
hypertension. tensive heart disease is responsible for roughly one-fourth of all
Consumption of tobacco was seen in 25% of the population and causes of heart failure. According to the Framingham Heart Study,
it was strongly associated with un controlled hypertension in the hypertension has a 2-fold increase in the development of heart
studied population (p ¼ 0.002). Heavy smoking, especially in older disease leading to heart failure in men and a 3-fold increase for
men, is associated with elevated SBP.18 These results are compatible women when adjusted for specific risk factors and age. The SPRINT
with effects expected in chronic atherogenesis of large capacitance trial also demonstrated a reduced risk of progression to heart fail-
vessels with which smoking is associated and produces isolated ure in patients with more intensive blood pressure control with a
systolic hypertension.19 target systolic blood pressure of 120 mmHg (1.3%) compared with
Obesity, which was present in almost one quarter of our popu- 140 mmHg (2.1%). Proper management of hypertension correlates
lation, is a well-established risk factor for hypertension but it being with a 64% reduction in the development of heart failure.30
present in almost same proportion in non-hypertensives did not We conclude that uncontrolled hypertension in known patients
attain a statistical significance. According to the Framingham study, prescribed drugs is highly prevalent in the rural population of J & K.
people with the highest body mass quartile had a 16 mmHg higher This seems to be an important cause of the reportedly increasing
systolic blood pressure and a 9 mmHg higher diastolic blood vascular events, heart failure and chronic kidney disease. Reasons
pressure than persons with the lowest BMI quartile.19 The Nurses' could be several including lack of motivation, non-affordability,
health study suggests that obesity may be responsible for about side effects and non -availability of drugs. Authorities need to
40% of hypertension.20 take cognition of this phenomenon and take steps to improve
Dyslipidaemia, which represents 36% is a known and robust management strategies.
predictor of cardiovascular disease.21 It is responsible for endo-
thelial dysfunction,22 which may manifest as increased blood 7. Strengths and limitations of the study
pressure. Our study is in agreement with this. Prevalence of dia-
betes mellitus was seen in a significantly higher population in the All the patients included were diagnosed subjects with hyper-
hypertension group 83 (25%) as compared to the non-hypertension tension and had been prescribed drugs for treatment in the gov-
group 41(14%). This is an accepted association with hypertension ernment health centres and were visiting PHC's only for follow up.
being reported in 20%e40% of diabetics.23 This gives us the information that in spite of being advised treat-
ment more than 60% had uncontrolled hypertension. There was no
486
P. Arambam, R. Khashoo, D. Tewari et al. Indian Heart Journal 74 (2022) 484e487

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