Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study

Background In Cuba, hypertension control in primary care has been prioritised as a cost-effective means of addressing premature death from cardiovascular disease (CVD). However, there is little large-scale evidence on the prevalence and management of hypertension in Cuba, and no direct evidence on the expected benefit of such efforts on CVD mortality. Methods Between Jan 1, 1996, and Nov 24, 2002, 146,556 men and women in Cuba were interviewed, measured and followed up for certified causes of death to Jan 1, 2017; 24,345 participants were resurveyed between Jul 14, 2006, and Oct 19, 2008. We calculated the prevalence of hypertension at recruitment (systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or receiving treatment for hypertension) and the proportion of hypertensives who were diagnosed, treated and controlled (systolic Findings After exclusion of those with incomplete data, there were 136 111 participants aged 35-79 at recruitment (mean age 54 [SD 12] and 75 947 [56%] women). Overall, one-third of these participants were hypertensive (34%). Of those with hypertension, two-thirds were diagnosed (67%); of those diagnosed, three-quarters were treated (76%); and, of those treated, about one-third had controlled blood pressure (36%). During 1.7 million person-years of follow-up, there were 5707 CVD deaths. Uncontrolled hypertension at baseline was associated with RRs of 2.15 (95%CI 1.88-2.46), 1.86 (1.69-2.05) and 1.41 (1.32-1.52) at ages 35-59, 60-69 and 70-79, respectively, and accounted for ~20% of premature CVD deaths. Interpretation In this Cuban population, one-third had hypertension. The proportion of hypertensives that were diagnosed and treated was high, and commensurate with some high-income countries. However, the proportion of treated hypertensives with controlled blood pressure was low. In addition to measures to reduce hypertension prevalence, public health programs should address the need for improved blood pressure control among treated hypertensives in Cuba.</p

Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study

Background In Cuba, hypertension control in primary care has been prioritised as a cost-effective means of addressing premature death from cardiovascular disease (CVD). However, there is little large-scale evidence on the prevalence and management of hypertension in Cuba, and no direct evidence on the expected benefit of such efforts on CVD mortality. Methods Between Jan 1, 1996, and Nov 24, 2002, 146,556 men and women in Cuba were interviewed, measured and followed up for certified causes of death to Jan 1, 2017; 24,345 participants were resurveyed between Jul 14, 2006, and Oct 19, 2008. We calculated the prevalence of hypertension at recruitment (systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or receiving treatment for hypertension) and the proportion of hypertensives who were diagnosed, treated and controlled (systolic &lt;140 mmHg and diastolic &lt;90 mmHg). Cox regressions relate CVD mortality rate ratios (RRs) at ages 35-79 among participants with, versus those without, uncontrolled hypertension. RRs were used to estimate the fraction of CVD deaths attributable to hypertension. Findings After exclusion of those with incomplete data, there were 136 111 participants aged 35-79 at recruitment (mean age 54 [SD 12] and 75 947 [56%] women). Overall, one-third of these participants were hypertensive (34%). Of those with hypertension, two-thirds were diagnosed (67%); of those diagnosed, three-quarters were treated (76%); and, of those treated, about one-third had controlled blood pressure (36%). During 1.7 million person-years of follow-up, there were 5707 CVD deaths. Uncontrolled hypertension at baseline was associated with RRs of 2.15 (95%CI 1.88-2.46), 1.86 (1.69-2.05) and 1.41 (1.32-1.52) at ages 35-59, 60-69 and 70-79, respectively, and accounted for ~20% of premature CVD deaths. Interpretation In this Cuban population, one-third had hypertension. The proportion of hypertensives that were diagnosed and treated was high, and commensurate with some high-income countries. However, the proportion of treated hypertensives with controlled blood pressure was low. In addition to measures to reduce hypertension prevalence, public health programs should address the need for improved blood pressure control among treated hypertensives in Cuba.</p

Educational inequalities and premature mortality: the Cuba Prospective Study

Background Although socioeconomic status is a major determinant of premature mortality in many populations, the impact of social inequalities on premature mortality in Cuba, a country with universal education and health care, remains unclear. We aimed to assess the association between educational level and premature adult mortality in Cuba. Methods The Cuba Prospective Study (a cohort study) enrolled 146 556 adults aged 30 years and older from the general population in five provinces from Jan 1, 1996, to Nov 24, 2002. Participants were followed up until Jan 1, 2017, for cause-specific mortality. Deaths were identified through linkage to the Cuban Public Health Ministry's national mortality records. Cox regression models yielded rate ratios (RRs) for the effect of educational level (a commonly used measure for social status) on mortality at ages 35–74 years, with assessment for the mediating effects of smoking, alcohol consumption, and BMI. Findings A total of 127 273 participants aged 35–74 years were included in the analyses. There was a strong inverse association between educational level and premature mortality. Compared with a university education, men who did not complete primary education had an approximately 60% higher risk of premature mortality (RR 1·55, 95% CI 1·40–1·72), while the risk was approximately doubled in women (1·96, 1·81–2·13). Overall, 28% of premature deaths could be attributed to lower education levels. Excess mortality in women was primarily due to vascular disease, while vascular disease and cancer were equally important in men. 31% of the association with education in men and 18% in women could be explained by common modifiable risk factors, with smoking having the largest effect. Interpretation This study highlights the value of understanding the determinants of health inequalities in different populations. Although many major determinants lie outside the health system in Cuba, this study has identified the diseases and risk factors that require targeted public health interventions, particularly smoking. Funding UK Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen)

Alcohol consumption and cause-specific mortality in Cuba: prospective study of 120 623 adults

Background The associations of cause-specific mortality with alcohol consumption have been studied mainly in higher-income countries. We relate alcohol consumption to mortality in Cuba. Methods In 1996-2002, 146 556 adults were recruited into a prospective study from the general population in five areas of Cuba. Participants were interviewed, measured and followed up by electronic linkage to national death registries until January 1, 2017. After excluding all with missing data or chronic disease at recruitment, Cox regression (adjusted for age, sex, province, education, and smoking) was used to relate mortality rate ratios (RRs) at ages 35–79 years to alcohol consumption. RRs were corrected for long-term variability in alcohol consumption using repeat measures among 20 593 participants resurveyed in 2006-08. Findings After exclusions, there were 120 623 participants aged 35-79 years (mean age 52 [SD 12]; 67 694 [56%] women). At recruitment, 22 670 (43%) men and 9490 (14%) women were current alcohol drinkers, with 15 433 (29%) men and 3054 (5%) women drinking at least weekly; most alcohol consumption was from rum. All-cause mortality was positively and continuously associated with weekly alcohol consumption: each additional 35cl bottle of rum per week (110g of pure alcohol) was associated with ∼10% higher risk of all-cause mortality (RR 1.08 [95%CI 1.05-1.11]). The major causes of excess mortality in weekly drinkers were cancer, vascular disease, and external causes. Non-drinkers had ∼10% higher risk (RR 1.11 [1.09-1.14]) of all-cause mortality than those in the lowest category of weekly alcohol consumption (<1 bottle/week), but this association was almost completely attenuated on exclusion of early follow-up. Interpretation In this large prospective study in Cuba, weekly alcohol consumption was continuously related to premature mortality. Reverse causality is likely to account for much of the apparent excess risk among non-drinkers. The findings support limits to alcohol consumption that are lower than present recommendations in Cuba. Funding Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen)