Canadian Journal of Cardiology 28 (2012) 375382

Clinical Research

Factors Associated With Lack of Awareness and Uncontrolled High Blood Pressure Among Canadian Adults With Hypertension
Marianne E. Gee, MSc, PhD candidate,a,b Asako Bienek, MSc,a Finlay A. McAlister, MD, MSc,c Cynthia Robitaille, MSc,a Michel Joffres, MD, PhD,d Mark S. Tremblay, PhD,e Helen Johansen, PhD,f and Norm R.C. Campbell, MDg
a

Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario, Canada
b

Department of Community Health and Epidemiology, Queens University, Kingston, Ontario, Canada
c

Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada

d

Simon Fraser University, Vancouver, British Columbia, Canada

f

Childrens Hospital of Eastern Ontario Research Institute and Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada Statistics Canada, Ottawa, Ontario, Canada Departments of Medicine, Community Health Sciences, and of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada

ABSTRACT
Background: Approximately 17% of Canadians with high blood pressure were unaware of their condition, and of Canadians aware of having the condition, approximately 1 in 5 have uncontrolled high blood pressure despite high rates of pharmacotherapy. The objectives of the current study are to estimate the prevalence of resistant hypertension and examine factors associated with (1) lack of awareness and (2) uncontrolled hypertension despite pharmacotherapy. Methods: Using the 2007-2009 Canadian Health Measures Survey (N 3473, aged 20-79 years) and logistic regression, we quantied relationships between characteristics and (1) presence of hypertension, (2) lack of awareness (among those with hypertension), and (3) uncontrolled high blood pressure (among those treated for hypertension). Results: Older age, lowest income, and less than high school education were associated with presence of hypertension. Men (odds ratio [OR], 1.6; 95% condence interval [CI], 1.1-2.2) and adults 60 years (OR, 1.7; 95% CI, 1.1-2.6) were more likely than others to be

RSUM
Introduction : Approximativement 17 % des Canadiens ayant une pression artrielle leve ignorent leur tat, et parmi les Canadiens qui connaissent leur tat, approximativement 1 sur 5 a une pression artrielle leve non contrle en dpit des taux levs de pharmacothrapie. Les objectifs de ltude actuelle sont destimer la prvalence de lhypertension rsistante et dexaminer les facteurs associs : (1) lignorance; (2) lhypertension non contrle en dpit de la pharmacothrapie. Mthodes : En utilisant lEnqute canadienne sur les mesures de la sant 2007-2009 (N 3473, gs de 20 79 ans) et la rgression logistique, nous avons quanti les relations entre les caractristiques et : (1) la prsence dhypertension; (2) la mconnaissance (parmi ceux ayant de lhypertension); et (3) la pression artrielle leve non contrle (parmi ceux traits pour lhypertension). Rsultats : Lge plus avanc, le revenu le plus faible et les tudes secondaires non termines taient associs la prsence

Hypertension is a leading global risk factor for cardiovascular disease and stroke,1 making its control an international health priority.2,3 In order to meet this priority, Canadian governmental and nongovernmental organizations have partnered in
Received for publication November 23, 2011. Accepted December 27, 2011. Corresponding author: Dr Norm Campbell, 3280 Hospital Drive, NW, Calgary, Alberta T2N 4Z6, Canada. E-mail: ncampbel@ucalgary.ca See page 381 for disclosure information.

a national effort toward hypertension prevention and control.4 Part of this effort included the formation of the Canadian Hypertension Education Program (CHEP), which has 3 components: (1) development of annual scientic recommendations on managing hypertension; (2) translation of these recommendations into resources for health care professionals and the public; and (3) evaluation of CHEPs impact on hypertension prevention and control and identication of clinical care gaps, in order for new educational interventions and resources to be developed.5

0828-282X/$ see front matter 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.cjca.2011.12.012

376 unaware. Among those aged 60 years, women were more likely than men to have uncontrolled high blood pressure (OR, 2.4; 95% CI, 1.15.2) despite treatment. Elevated systolic blood pressure was the issue in over 90% of women and 80% of men with uncontrolled hypertension. Depending on the denition employed, 4.4% (95% CI, 2.4-6.4) to 7.8% (95% CI, 6.0-9.6) of the population with hypertension had resistant hypertension. Conclusions: Messaging or interventions encouraging screening may be helpful for all younger Canadian adults and men; programs encouraging blood pressure control may help older women.

Canadian Journal of Cardiology Volume 28 2012 dhypertension. Les hommes (ratio dincidence approch [RIA], 1,6; intervalle de conance [IC] de 95 %, 1,1-2,2) et les adultes 60 ans (RIA, 1,7; IC de 95 %, 1,1-2,6) taient plus susceptibles que les autres dignorer leur tat. Parmi ceux gs de plus de 60 ans, les femmes taient plus susceptibles que les hommes davoir une pression artrielle leve non contrle (RIA 2,4; IC de 95 %, 1,1-5,2) en dpit du traitement. La pression artrielle systolique leve tait la consquence dune hypertension non contrle chez plus de 90 % des femmes et chez plus de 80 % des hommes. Selon la dnition employe, 4,4 % (IC de 95 %, 2,4-6,4) 7,8 % (IC de 95 %, 6,0-9,6) de la population ayant de lhypertension avaient une hypertension rsistante. Conclusions : De linformation ou des interventions encourageant le dpistage peuvent tre utiles aux jeunes adultes canadiens et aux hommes; les programmes encourageant la matrise de la pression artrielle peuvent aider les femmes plus ges.

Data from a national health survey (2007-2009 Canadian Health Measures Survey [CHMS]) showed marked improvements in the control of hypertension during the past 2 decades.6,7 Nevertheless, substantive care gaps were also identied: approximately 17% of Canadians with high blood pressure were unaware of their condition, and of Canadians treated for hypertension (95% of those who were aware), approximately 1 in 5 had uncontrolled high blood pressure.7 In order to further improve blood pressure control, it is critical to understand the characteristics of those who have inadequate control so that new initiatives and resources can be targeted and tailored to the needs of high-risk groups. Although other studies have examined relationships between sociodemographic factors and lack of blood pressure control,8-12 rapid changes in diagnosis, treatment, and control in Canada suggest the need to reevaluate these factors in Canadas current context. Furthermore, only 1 study from the United States has examined the prevalence of and factors associated with resistant hypertension at a population level, and it is unknown whether that data is generalizable to Canada.13 The CHMS includes the most recent and comprehensive set of physical measures ever collected in Canada from a population-based sample and provides a unique opportunity to estimate the prevalence of resistant hypertension and explore factors associated with lack of blood pressure awareness and control in the Canadian context.

dent participation rate (88%), and the proportion of respondents who attended the mobile clinic (85%).17 On an appointed date after the in-person interview, physical measurements, including blood pressure, heart rate, height, and weight were obtained at a mobile examination centre. Blood pressure was measured with the BpTRU BP-300 device (BpTRU Medical Devices, Coquitlam, BC). Measures of systolic blood pressure and diastolic blood pressure were calculated by taking the average of the rst set of valid blood pressure measurements (last 5 of 6 measurements taken 1 minute apart).14 Blood pressure measures were available for 3515 adults aged 20 to 79 years (nmissing 2). In order to exclude cases of pregnancy-induced high blood pressure, pregnant women (n 29) were excluded from analysis. Individuals who answered do not know, refused, or did not state an answer to the question In the past month have you taken any medicine for high blood pressure (n 3) or to the question Do you have high blood pressure (n 10) were excluded, leaving 3473 adults remaining for analysis. Coverage of the CHMS excludes full-time members of the Canadian Forces and individuals living on First Nations reserves or Crown lands, in institutions, and in certain remote regions.17 Key measures Hypertension was dened as either a measured mean systolic blood pressure of 140 mm Hg or higher, a measured mean diastolic blood pressure of 90 mm Hg or higher, or the respondents report of blood pressure medication use in the past month. For individuals with diabetes or chronic kidney disease, hypertension was dened on the basis of a 130/80 mm Hg cut point.18 Individuals with measured elevated blood pressure were considered unaware of hypertension if they did not report having high blood pressure or did not report taking medication for high blood pressure in the preceding month. Individuals were considered as treated but uncontrolled if they reported taking medication for high blood pressure in the preceding month and had either a systolic blood pressure 140 mm Hg or a diastolic blood pressure 90 mm Hg (systolic blood pressure 130 mm Hg or diastolic blood pressure 80 mm Hg for individuals with self-reported diabetes or chronic kidney disease). Self-reported medication use had high

Methods Data source and study population Data from the 2007-2009 CHMS were analyzed; information on the study design, response rate, and blood pressure collection methods have been described previously.7,14-16 In brief, the CHMS uses in-person household interviews and a multistage cluster sampling design, with stratication by age and sex, to collect self-reported information on sociodemographics, medical history including current medication use, current health status, and health behaviours. A representative sample of Canadians aged 6 to 79 years was selected; representativeness was ensured by the application of weights that account for nonresponse and the demographic distribution of the 2006 census population.17 The overall response rate was 52%, reecting the household participation rate (70%), the respon-

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377

agreement with the medication inventory (sensitivity 96%, specicity 92%). Because of the lack of a generally accepted denition of resistant hypertension,19 3 denitions were considered: (1) uncontrolled blood pressure in spite of concurrent use of 3 antihypertensive medications,19 (2) uncontrolled blood pressure in spite of concurrent use of 3 antihypertensive medications including a diuretic,19 and (3) uncontrolled blood pressure in spite of concurrent use of antihypertensive medications from 3 different drug classes or controlled blood pressure and use of 4 antihypertensive drug classes.13 Specically, the latter denition is used in this study to allow comparison with the only other population-based study of resistant hypertension.13 Number and class of antihypertensive medications were derived on the basis of Anatomical Therapeutic Chemical (ATC) Classication System codes of up to 15 prescription medications that respondents reported at the time of the inperson household interview and up to 5 newly prescribed medications reported at the time of the clinic examination.17 Classes of antihypertensive medications were dened by ATC codes C02 (miscellaneous antihypertensive drugs, excluding C02KX01), C03 (diuretics, excluding C03BA08 and C03CA01), C07A (-blockers, excluding C07AA07, C07AA12, and C07AG02), C08 (calcium channel antagonists), C09A (angiotensin-converting enzyme [ACE] inhibitors), C09C (angiotensin receptor blockers), C09-X (renin inhibitors), and 2-class combinations (C07C -blockers diuretic; C09BA ACE inhibitor diuretic; C09BB ACE inhibitor calcium channel antagonist; C09D angiotensin receptor blocker diuretic). Sociodemographic descriptors Presence of hypertension, lack of awareness (among individuals with hypertension), and presence of uncontrolled blood pressure (among individuals reporting treatment with antihypertensive medications) were examined according to the following factors: gender, age (20-59, 60-79 years), the interaction between age and gender, education (less than high school, high school graduate, some postsecondary or postsecondary graduate), total household income ( $30,000, $30,000-$49,999, $50,000-$79,999, $80,000 [CAD$]), and marital status (married, including common-law, or unmarried [single, widowed, divorced, or separated]), and being a visible minority (yes, no). Health behaviours Uncontrolled blood pressure was also described by measured body mass index ( 25 kg/m2, 25-29 kg/m2, 30 kg/m2), minutes of moderate- to vigorous-intensity physical activity per week (obtained from accelerometry; 0-29 min/ wk, 30-119 min/wk, 120 min/wk), smoking status (never, former, current), and alcohol consumption (0-1 drink/d vs 2 drinks/d). Cut points were established on the basis of current recommendations for the treatment of hypertension.20 The analysis also considered use of nonsteroidal anti-inammatory drugs, dened as ATC codes M01A,B (anti-inammatory and antirheumatic products) derived from lists of up to 20 prescription and/or over-the-counter medications reported by the respondent.

Analysis Data were analyzed with SAS Enterprise Guide version 4 (SAS, Cary, NC). Associations between variables and (1) having hypertension, (2) being unaware of having hypertension (among those with hypertension), and (3) having uncontrolled high blood pressure (among those reporting treatment with pharmacotherapy) were evaluated by estimating crude and agegenderadjusted odds ratios (ORs) from logistic regression models. Point estimates and ORs were weighted to reect the 2006 Canadian census population. To account for stratication and clustering in the CHMS design, 95% condence intervals (CIs) around point estimates and ORs were calculated with the use of exact standard errors generated through bootstrap resampling methods.21 Signicance of interactions between age and gender was estimated with the use of normalized weights.22 In a sensitivity analysis, BpTRU measurements were adjusted to reect sphygmomanometer readings, according to these validated equations:
adjusted systolic blood pressure 11.4 (0.93 BpTRU systolic blood pressure), and adjusted diastolic blood pressure 15.6 (0.83 BpTRU diastolic blood pressure).23

Results Table 1 outlines characteristics of the study population. Overall, 1 in 5 (19.9%; 95% CI, 18.4%-21.3%) Canadians had hypertension. Of these, 38.5% (95% CI, 33.9%-43.1%) had uncontrolled high blood pressure: 17.5% (95% CI, 13.7%-21.3%) were unaware, 3.6% (95% CI, 1.8%-5.5%) were aware but untreated, and 17.4% (95% CI, 12.8%21.9%) were treated but uncontrolled. Depending on the definition employed, resistant hypertension was present in 4.4% (95% CI, 2.4%-6.4%) to 7.8% (95% CI, 6.0%-9.6%) of the population with hypertension. Of those who were treated but had uncontrolled hypertension, approximately 22.3% (95% CI, 14.7%-29.9%) to 29.0% (95% CI, 20.8%-37.3%) had resistant hypertension. Table 2 shows associations between sociodemographic characteristics and (1) having hypertension and (2) being unaware of having hypertension. Although men and women were equally likely to have hypertension, men were more likely than women to be unaware of having the condition (OR, 1.6; 95% CI, 1.1-2.2). Adults aged 60 years or older were 5 times more likely to have hypertension than were individuals aged younger than 60 years (54.1% vs 10.8%) but less likely to be unaware (14.2% vs 21.8%). Factors associated with presence of hypertension and lack of awareness remained unchanged when blood pressures were adjusted to estimate values obtained by the auscultatory blood pressure technique (see Supplemental Appendix S1). Table 3 illustrates the associations between sociodemographic characteristics, health behaviours, and uncontrolled high blood pressure among those subjects taking antihypertensive medications. A signicant interaction between age and gender was observed (Pinteraction 0.01). Among individuals aged 60 years and older, women were more likely to have uncontrolled blood pressure than were men (OR, 2.4; 95% CI, 1.1-5.2); this relationship remained unchanged after we controlled for age (OR, 2.4; 95% CI, 1.1-5.3). The same relationship was not observed among individuals aged 20 to 59 years (ORcrude, 0.7; 95% CI, 0.2-3.0; ORadjusted for age, 0.7; 95% CI,

378 Table 1. Characteristics of Canadian adults aged 20 to 79 years, Canadian Health Measures Survey 2007-2009 (n 3473) n Sociodemographic characteristics Gender Female Male Age (years) 20-39 40-59 60 Education Less than secondary Secondary school graduate Some postsecondary or postsecondary graduate Household income (CAD$) $0-$29,999 $30,000-$49,999 $50,000-$79,999 $80,000 Marital status Married, including common-law Widowed, separated, or divorced Single Visible minority No Yes Outcomes Has hypertension Among those with hypertension (n 878) Uncontrolled high BP Unaware Untreated Treated but uncontrolled high BP Resistant hypertension Denition 1 Denition 2 Denition 3 Among those treated for hypertension (n 677) Treated but uncontrolled high BP Resistant hypertension Denition 1 Denition 2 Denition 3 878 363 172 29 162 42 37 82 162 42 37 82 19.9 (18.4-21.3) 38.5 (33.9-43.1) 17.5 (13.7-21.3) 3.6 (1.8-5.5) 17.4 (12.8-21.9) 4.4 (2.4-6.4) 3.9 (2.1-5.6) 7.8 (6.0-9.6) 22.0 (16.7-27.3) 5.6 (3.1-8.1) 4.9 (2.8-7.0) 9.9 (7.7-12.0) 1832 1641 1154 846 1091 466 574 2395 616 701 811 1159 2203 622 646 2952 516 50.1 (49.8-50.4) 49.9 (49.6-50.2) 37.6 (37.2-38.0) 41.5 (41.1-41.8) 20.9 (20.8-21.1) 12.1 (9.3-14.8) 18.2 (13.8-22.5) 68.0 (61.2-74.7) 15.0 (11.6-18.5) 18.9 (17.2-20.6) 25.8 (23.0-28.6) 40.3 (35.7-44.8) 68.1 (63.3-73.2) 11.4 (9.6-13.2) 20.4 (16.0-24.9) 82.3 (74.3-90.3) 17.7 (9.7-25.7) %* (95% CI)

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trolled had mean blood pressures of 152 1.4 mm Hg (systolic) and 79 1.3 mm Hg (diastolic); among men, systolic and diastolic blood pressures were 146 1.4 mm Hg and 89 2.2 mm Hg, respectively. The 6/10 mm Hg difference between men and women was statistically signicant (P 0.007 and P 0.001, respectively). Among those with diabetes or renal disease, women who were treated but remained uncontrolled had mean blood pressures of 150 5.1 mm Hg (systolic) and 76 3.3 mm Hg (diastolic); among men, systolic and diastolic blood pressures were 134 2.5 mm Hg and 79 2.1 mm Hg, respectively. The 16 mm Hg difference in systolic blood pressure between men and women was statistically signicant (P 0.01), whereas the difference in diastolic blood pressures was not (P 0.4). Differences between mens and womens average blood pressures remained unchanged after continuous age was controlled for in linear regression models (no diabetes or chronic kidney disease: 6/7 mm Hg, P 0.03 and P 0.005; diabetes or chronic kidney disease: 15/2 mm Hg, P 0.01 and P 0.6). In the population with treated but uncontrolled high blood pressure, elevated systolic blood pressure was the main driver in both sexes and was more common among women (97.1%; 95% CI, 93.4%-100% for women; 82.5%; 95% CI, 67.4%97.6% for men; Pdifference 0.06). More men than women had elevated diastolic blood pressure (20.0%; 95% CI, 9.7%30.3% for women compared with 65.0%; 95% CI, 48.3%81.7% for men; Pdifference 0.0001). Discussion Hypertension control rates reported in Canada may be higher than in other countries. In Canada, approximately 61% of people with hypertension had their blood pressure controlled, compared with approximately 28% and 50% of people with hypertension in the United Kingdom24 and the United States.25 Better hypertension control in Canada may be related to the development of educational interventions targeted to address previously identied care gaps.5 This study provides an updated platform for developing new Canadian hypertension interventions through characterization of those who have hypertension, those who are unaware of their hypertension, and those who have uncontrolled high blood pressure despite treatment. We found that socioeconomically disadvantaged people were more likely to have hypertension and exhibited a strong trend toward greater risk of remaining uncontrolled despite treatment. Although likely explained in part by age and gender, the 2-fold higher prevalence of hypertension and higher rate of uncontrolled blood pressure in people with the lowest levels of education and income may justify hypertension prevention and control programs aimed at these populations. For example, population initiatives targeting environmental inuences on health and wellness, such as the recent Canadian population health strategy for reduction of dietary salt,26 may be needed in order to increase the accessibility of nutritious foods, increase physical activity levels, and reduce obesity among socioeconomically disadvantaged groups. Second, we found that men and younger Canadians were less likely to be aware of having hypertension and thus may benet from targeted initiatives encouraging blood pressure assessment. Although there has been a large improvement in

BP, blood pressure; CI, condence interval. * Proportions are weighted to reect Canadian household population. Unaware, aware but untreated, or treated but uncontrolled. Uncontrolled BP in spite of concurrent use of 3 or more antihypertensive medications. Uncontrolled BP in spite of concurrent use of 3 antihypertensive medications including a diuretic. Uncontrolled BP in spite of use of antihypertensive medications from 3 different drug classes or use of 4 antihypertensive drug classes regardless of BP. Interpret with caution (coefcient of variation, 16.6%-33.3%).

0.1-3.1). Results remained unchanged when blood pressures were adjusted to estimate values obtained by the auscultatory blood pressure technique (see Supplemental Appendix S1). Among individuals who were treated but had uncontrolled high blood pressure, mean blood pressures were 150 0.9 mm Hg/83 1.7 mm Hg for those without diabetes or renal disease and 142 3.8 mm Hg/78 1.5 mm Hg for those with diabetes or renal disease. Among those without diabetes or renal disease, women who were treated but remained uncon-

Gee et al. Associations With Uncontrolled Blood Pressure Table 2. Associations between sociodemographic characteristics and (1) hypertension and (2) lack of awareness of hypertension, among Canadian adults aged 20-79 years, Canadian Health Measures Survey 2007-2009 (n 3473) Has hypertension n Gender Female Male Age 20-59 years 60-79 years Education Some postsecondary or postsecondary graduate High school graduate Less than high school Household income ($CAD) $80,000 $50,000-$79,999 $30,000-$49,999 $0-$29,999 Married No Yes Visible minority No Yes % Crude OR (95% CI) Referent 1.0 (0.9-1.2) Referent 9.7 (7.0-13.4)* Referent 1.2 (0.9-1.6) 3.5 (2.6-4.8)* Referent 1.3 (0.8-1.9) 2.4 (1.8-3.3)* 2.3 (1.5-3.4)* Referent 1.3 (1.0-1.7)* Referent 0.8 (0.5-1.2) Age- gender-adjusted OR (95% CI)

379

Unaware (among those with hypertension, n 878) n % Crude OR (95% CI) Referent 1.6 (1.1-2.2)* Referent 0.6 (0.4-0.9)* Referent 0.9 (0.5-1.7) 0.6 (0.3-1.1) Referent 0.7 (0.4-1.2) 0.9 (0.6-1.4) 0.5 (0.3-0.8)* Referent 0.9 (0.5-1.6) Referent 0.6 (0.3-1.4) Age- gender-adjusted OR (95% CI)

427 451 275 603 495 154 213 194 181 225 209 319 558 772 105

19.5 20.2 10.8 54.1 16.1 18.6 40.2 13.8 16.9 27.8 26.8 16.9 21.1 20.5 17.1

69 103 73 99 96 36 33 36 37 45 35 71 101 154 17

14.2 20.8 21.8 14.2 19.1 18.3 12.1 20.8 15.1 19.1 11.5 19.1 17.0 18.2 12.7

Referent 1.1 (0.8-1.5) 1.6 (1.1-2.5)* 1.2 (0.8-1.8) 1.7 (1.2-2.5)* 1.5 (0.9-2.4) Referent 1.0 (0.8-1.3) Referent 1.5 (0.9-2.6)

1.1 (0.6-2.0) 0.7 (0.3-1.4) 0.8 (0.4-1.4) 1.1 (0.6-1.9) 0.6 (0.4-1.1) 0.8 (0.4-1.4) 0.5 (0.2-1.1)

CI, condence interval; OR, odds ratio. * P 0.05. Adjusted for age (continuous) and gender. Interpret with caution (coefcient of variation, 16.6%-33.3%).

awareness of hypertension among Canadian men since the initiation of CHEP (from 47% unaware in 1986-199212 to 21% unaware in 2007-2009), men remain more likely than women to be unaware of their condition (21% vs 14%). This nding is consistent with recent ndings from the United States9,27 and previous ndings in Canada.12 Lack of awareness of hypertension in men has been attributed to fewer interactions with the health care system compared with women; thus the development of community- or work-based health programs focused on screening for hypertension in men may hold promise.28 Such resources may also benet younger Canadians, who in the current study were also less likely to be aware of having the condition. Third, among those taking antihypertensive medication, older women were less likely to have their blood pressure controlled; this group may require resources and educational messages promoting systolic blood pressure control. This nding is supported by similar results in the US household population,27,29-31 in Canada,12 in primary care,32,33 and internationally.34 Although CHEP has emphasized improving systolic blood pressure control in the past, the resources and educational messages have not been directed specically to women. Lower rates of control in older women may be due to the types or combinations of antihypertensive medications prescribed, the effectiveness of antihypertensive medications in this group, adherence to pharmacotherapy and health behaviour changes, or the underlying pathophysiology of hypertension; further research is needed to understand the reasons for observed agegender differences. In the interim, messages or communitybased programs targeted to older women may improve blood pressure control. Some existing programs, such as the Cardiovascular Health Awareness Program, have been shown to be

effective in improving hypertension control in older people.35 Similarly, a physician and pharmacist collaborative model in community-based medical ofces has been shown to improve blood pressure control.36 Because the CHMS samples the Canadian population continuously and provides data on a biennial schedule, the impact of initiatives implemented to address these clinical care gaps may be evaluated in the future. The estimated prevalence of resistant hypertension in Canada in 2007-2009 was comparable to recent estimates from the 2003-2008 cycles of the National Health and Nutrition Examination Survey in the United States:13 10% of Canadians treated with antihypertensive medication, compared with 13% of Americans, were estimated to have resistant hypertension, dened as uncontrolled blood pressure despite concurrent use of antihypertensive medications from 3 different drug classes or 4 drug classes regardless of blood pressure level. As seen in the National Health and Nutrition Examination Survey,13 approximately one-quarter of individuals with treated but uncontrolled blood pressure were estimated to have resistant hypertension. The current analysis was underpowered to examine factors associated with resistant hypertension separately from uncontrolled blood pressure. In the household population of the United States,13 individuals with resistant hypertension were more likely to be older, to be non-Hispanic black, to have higher body mass index, to have lower glomerular ltration rate, and to have other comorbidity (coronary heart disease, heart failure, stroke, and diabetes). It will be important to consider correlates of resistant hypertension separately from other cases of uncontrolled blood pressure in the Canadian context with future cycles of the CHMS. The small sample size of the CHMS limits the ability to make denitive inferences about many of the sociodemo-

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Table 3. Associations between sociodemographics, health behaviours and medication use, and uncontrolled high blood pressure, among Canadian adults treated for hypertension aged 20-79 years; Canadian Health Measures Survey 2007-2009 (n 677) Uncontrolled n Among those aged 60-79 years Male Female Among those age 20-59 years Male Female Education Some postsecondary or postsecondary graduate High school graduate Less than high school Household income ($CAD) $80,000 $50,000-$79,999 $30,000-$49,999 $0-$29,999 Married Yes No Visible minority No Yes Measured body mass index (kg/m2) 25 25-29 30 Moderate-to-vigorous physical activity 120 min/wk 30-119 min/wk 0-29 min/wk Smoking status Never Former Current Average daily alcohol consumption 0-1 drink/day 2 drinks/day Antihypertensive medications 1 2 3 NSAID use No Yes 52 83 14 13 88 23 50 25 21 48 55 93 69 136 26 36 65 60 34 25 81 71 63 28 101 17 68 48 42 118 44 % 18.1 34.2

Crude OR (95% CI) Referent 2.4 (1.1-5.2)* Referent 0.6 (0.2-3.0) Referent 1.0 (0.5-2.1) 1.5 (0.9-2.4) Referent 0.7 (0.3-1.4) 1.5 (0.6-3.5) 2.2 (1.1-4.3)* Referent 1.8 (1.2-2.7)* Referent 1.8 (0.6-5.2) Referent 0.6 (0.2-1.9) 0.5 (0.2-1.6) Referent 0.3 (0.1-0.8)* 1.0 (0.5-2.0) Referent 0.8 (0.6-1.0) 1.5 (0.7-3.4) Referent 0.7 (0.2-1.8) Referent 0.8 (0.5-1.2) 1.8 (1.1-2.8)* Referent 1.1 (0.6-2.0)

Age- gender-adjusted OR (95% CI) Referent 0.9 (0.4-1.9) 1.2 (0.7-2.0) Referent 0.6 (0.3-1.1) 1.2 (0.5-2.7) 1.6 (0.8-3.0) Referent 1.3 (0.8-2.2) Referent 2.6 (0.9-7.6) Referent 0.6 (0.2-1.9) 0.6 (0.2-1.8) Referent 0.3 (0.1-0.7)* 0.6 (0.3-1.3) Referent 0.8 (0.5-1.1) 1.9 (0.9-4.2) Referent 0.8 (0.3-2.0) Referent 0.7 (0.5-1.1) 1.4 (0.9-2.3) Referent 1.1 (0.6-2.2)

12.5 20.5 20.7 28.0 17.7 12.8 24.4 31.6 19.3 29.8 20.3 31.2 30.4 21.6 18.2 26.0 10.8 25.6 23.0 18.5 31.4 20.7

21.7 17.6 32.8 21.7 22.9

CI, condence interval; NSAID, nonsteroidal anti-inammatory drug; OR, odds ratio. * P 0.05. Adjusted for continuous age, gender, and cross-product (interaction) term for age and gender. Interpret with caution (coefcient of variation 16.6% to 33.3%). Too unreliable to be reported (coefcient of variation greater than 33.3%).

graphic characteristics under study. In addition, the sample size allowed characterization of hypertension prevalence, awareness, and control by only a dichotomous visible minority status and not according to specic ethnicities. A recent populationbased study from Ontario, which is Canadas most populous province, oversampled ethnic minorities and found a much higher prevalence of hypertension in blacks and South Asians, as well as ethnic differences in treatment and control of hypertension.37 Our ndings, although underpowered to detect signicance, are consistent with the Ontario ndings. Conrmation of the ndings on a national level would require pooling of additional cycles of the CHMS and/or the addition of a sampling strategy to oversample vulnerable minority populations. Estimates from the CHMS may be conservative since partici-

pants in surveys are often healthier than the general population. For example, the prevalence of hypertension in the CHMS (19.9%) was slightly lower than that estimated from Canadian hospitalization and physician billing data (22.7%).38 It does not appear that presentation to a clinic imposed a further selection pressure; individuals who did and did not attend the clinic were similar in terms of self-reported body mass index, health utility index scores, access to a regular medical doctor, and use of medications.17 The small sample size and design of the CHMS also precluded more-complex multivariate analyses that would identify independent correlates of hypertension, lack of awareness, or lack of control. For example, the observed complex relationship between physical activity and hypertension may be due to

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other confounding factors that remained unaccounted for or, alternatively, to reverse causality. In the latter case, it is possible that, in response to their uncontrolled blood pressure, individuals increased their physical activity levels. The current study estimates uncontrolled high blood pressure at 39% for the Canadian population. This estimate is slightly higher than that previously reported for the same data source (34%)7 because of the inclusion of the lower 130/80 mm Hg blood pressure denition threshold for respondents reporting diabetes or kidney disease. Concern has been expressed previously that the methods used to assess blood pressure in the CHMS may have inated the rates of hypertension awareness and control compared with other countries;39 to address this concern, we performed a sensitivity analysis whereby we adjusted BPTru blood pressures to reect manual mercury sphygmomanometry according to the validated equation proposed by Myers et al.,23 and estimates of resistant hypertension were largely unchanged. Furthermore, the main objective of the study was to identify factors associated with increased likelihood of being unaware of having hypertension and of having uncontrolled hypertension despite treatment. We would expect any measurement error of blood pressure to be nondifferential between comparison groups, resulting in effect estimates biased toward the null. In other words, we expect true associations to be stronger than those observed. As demonstrated by the sensitivity analysis, relationships were not altered when blood pressure was adjusted to reect sphygmomanometry. The current descriptive study characterized Canadians who were unaware of their hypertension or whose hypertension was uncontrolled despite treatment with antihypertensive medications. Findings suggest that hypertension awareness and control may differ based on easily identiable sociodemographic characteristics. Targeted interventions that are based on these characteristics may be effective in improving blood pressure control in the Canadian population. Acknowledgements The Canadian Health Measures Survey was conducted by Statistics Canada in partnership with Health Canada and the Public Health Agency of Canada, with funding from the Canadian government. We thank Dr Christina Bancej, Dr Howard Morrison, and Dr Louise Pelletier from the Public Health Agency of Canada for comments on this manuscript. Funding Sources M.E.G. is supported by a doctoral award from the Canadian Institutes of Health Research. N.R.C.C. holds the Canada Chair in Hypertension Prevention and Control, funded by the Canadian Institutes of Health Research, the Canadian Hypertension Society, and Sano-aventis. F.A.M. is supported by an Alberta Innovates Health Solutions Senior Health Scholar Award. Disclosures In the past 2 years, N.R.C.C. has received travel support from Boehringer Ingelhiem; has presented talks sponsored by Sano-aventis, Bayer, Biovail, and Bristol-Myers Squibb; and was a member of the medical advisory board of Bristol-Myers

Squibb-Sano. None of the other authors has any conicts of interest to declare.

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Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca, and at doi: 10.1016/j.cjca.2011.12.012.