Risk factors of previously undiagnosed and known untreated hypertension among patients with Type-2 diabetes mellitus

Objectives: To find the risk factors of previously undiagnosed and known untreated hypertension among patients with Type- 2 diabetes mellitus. Methods: The cross-sectional analytical study was conducted at Diabetes Clinic of Sir Ganga Ram Hospital Lahore during Oct–Dec 2021. Total 153 known diabetics were enrolled using convenience sampling. Patients (n=24) with ischemic heart disease, hepatitis or missing information excluded. Data from 129 cases of Type-2 diabetes presenting with and without hypertension analyzed using SPSS. Binary logistic regression analyses were performed to calculate the adjusted odds ratios. Result: Mean age of all diabetics (n=129) was 49.0±10.7 years. The participation of females was higher than males (65.1% vs. 34.9%). The frequency of hypertension, previously undiagnosed hypertension and known untreated hypertension was 58.1%, 25.3% and 19.6%, respectively. Among risk factors, frequency of high intake of salt was 67.4%, sedentary lifestyle was 65.1%, obesity was 37.2%, and poor glycemic control was 58.9%. Young age [aOR=2.01, 95.0% CI 0.53–7.61], low family income <20000 PKR/month [aOR=2.70, 95.0% CI 0.92–7.96], high intake of salt [aOR=3.22, 95.0% CI 0.98–10.61], elevated total cholesterol [aOR=3.68, 95.0% CI 0.85–15.85], poor glycemic control [aOR=3.28, 95.0% CI 0.51–21.13], and overweight/ obesity [aOR=9.07, 95.0% CI 1.6–51.39] had higher risk of previously undiagnosed or known untreated HTN. Conclusions: Prevalence of previously undiagnosed and known untreated hypertension is high among Type-2 diabetics. Strict compliance to diabetes care guidelines is much needed to minimize the risk of undiagnosed and untreated hypertension.


INTRODUCTION
Hypertension (HTN) is a well-known risk factor of heart and kidney diseases and its coexistence with diabetes mellitus (DM), particularly if the blood pressure (BP) levels are not controlled, can further add to this risk. 1 Similarly if the HTN remains undiagnosed or untreated, it can lead to uncontrolled BP and may result in poor health outcomes. 2 For these reasons, the American diabetes association (ADA) recommends regular monitoring of BP levels among diabetics and treating them to the targets of <140/90 mmHg. 3 The prevalence of HTN is higher in diabetic patients than of non-diabetic individuals. 4 All-cause mortality and cardiovascular disease related mortality rates are higher in hypertensive diabetics than of nonhypertensive diabetics. 5 Unfortunately, the prevalence of HTN 26.34% 6 and DM 13.7% 7 are on rise among adult population of Pakistan. However, the studies reporting

Original Article
Risk factors of previously undiagnosed and known untreated hypertension among patients with Type-2 diabetes mellitus the undiagnosed and/or untreated HTN and their risk factors in diabetic patients are still lacking. Therefore, the present study aimed to assess the risk factors of previously undiagnosed and known untreated HTN among patients with T2DM.

METHODS
The single-center cross-sectional analytical study was conducted at Diabetes Clinic of Sir Ganga Ram Hospital Lahore during Oct-Dec 2021. Sample size was calculated using 7.0 % previously undiagnosed HTN in Type-2 diabetics 8 , 95.0% confidence level, 5.0% absolute precision and 80.0% anticipated response rate. Total 180 patients were asked to participate in the study. Inclusion criteria were known T2DM patients, with and without HTN, age ≥18 years and any gender. With a response rate of 85.0%, 153 cases enrolled using convenience sampling. Patients (n=24) with ischemic heart disease (IHD), hepatitis C and missing information were excluded. Consequently, data from 129 diabetics with and without HTN were analyzed.

RESULTS
The sociodemographic and clinical characteristics of study participants are shown in Table- Step-1 and the prediction rate increased to 82.2% at Step-5, Table-IV. Angiotensin-converting enzyme inhibitors (ACEIs) 32.14% was the most frequently prescribed drug as monotherapy, followed by 19.64% calcium channel blockers (CCBs), 10.71% β blockers (BBs), and 7.14% Angiotensin II receptor blockers (ARBs). As combined therapy, CCBs with ARBs were prescribed to 10.71% patients.

DISCUSSION
HTN, if remains undiagnosed or untreated, can lead to uncontrolled BP and results in poor health outcomes. 2 Therefore, the study aimed to assess the factors associated with previously undiagnosed and known untreated HTN in patients with T2DM. In the present study, overall rate of HTN 58.1% exhibit that HTN was a common comorbid condition of T2DM in the settings. Although, it was equivalent to 59.5% HTN observed in Ethiopian diabetics 9 , but was markedly lower than of 70.5% 10 and 74.0% 11 in Pakistani diabetics, 72.4% in Jordanian diabetics 8 , 79.4% in Spanish diabetics 12 , and 83.4% in Emirati diabetics. 13 The previously undiagnosed HTN 25.3% suggesting that every 4 th diabetic remain with undiagnosed HTN in the settings was lower than 37.4% undiagnosed HTN in Spanish diabetics 12 , but three times higher than 7.0% in Jordanian diabetics. 8 The known untreated HTN 19.6% suggesting that every 5 th diabetic was non-compliant to antidiabetic treatment in the settings was higher than 11.7% untreated HTN in Spanish diabetics. 12 In addition, the present study Risk factors of hypertension among patients with T2DM   Classification Table a Step In the present study, 73.3% diabetics could not achieve their BP levels within target limits, which was notably higher than 50.4% uncontrolled HTN in Jordanian diabetics. 8 Isolated diastolic hypertension (IDH) is a less common type of HTN and accounts for <20.0% of HTN cases. 22 It is an independent risk factor for stroke and heart disease. 23 Surprisingly, a higher rate of IDH 24.0% observed in the study. Adherence rate to anti-HTN medications was 80.4%; and ACEI (32.14%) was the most frequently prescribed monotherapy, followed by CCB (19.64%) and BB (10.71%). Differently, Menendez et al. reported a little higher adherence rate 88.3%; and ACEI (39.0%) as the most frequently prescribed monotherapy, followed by ARB (19.9%) and diuretics (19.5%). 12 Kanj et al. reported that ACEI+ARB (26.0%) was the most frequently prescribed drug, followed by BB (15.0%) and diuretics (10.0%). 14 Limitations: The single-center observational study included small sample size, convenience enrollment of cases and higher participation rate of poor class with poorly controlled diabetes.

CONCLUSIONS
Large numbers of T2DM patients remain with previously undiagnosed and known untreated HTN in our population. The modifiable factors such as no education, sedentary lifestyle and unhealthy diet are also contributing to the risk of undiagnosed and untreated HTN. Thus, strict compliance to diabetes care guidelines by both the physicians and the patients is much needed to minimize the risk of undiagnosed and untreated HTN.

Funding: None.
Risk factors of hypertension among patients with T2DM