ORIGINAL ARTICLE

Characterization, Risk Stratification and the Hypertension

Control Rate at Hospital-based Clinics: A Survey of 25,336
Hypertensives in Beijing, Shanghai and Guangzhou
Hui Sui 1, Wen Wang 1, Huai-yong Cheng 2, Yun-fang Cheng 3,
Li-sheng Liu 1,4 and Weiguo Zhange 5

Abstract
Objective To characterize hypertensive patients living in metropolitan cities in China.
Methods This was a cross-sectional survey conducted in Beijing, Shanghai and Guangzhou. The eligibility
criteria included outpatients 35-85 years of age with a systolic blood pressure (SBP) of !140 mmHg or a diastolic blood pressure (DBP) of !90 mmHg or both and/or patients receiving antihypertensive medications.
The patients demographic characteristics, medical history and findings of physical examinations, laboratory
tests and cardiovascular imaging (i.e., ultrasonic cardiogram) were included in the survey. Risk stratification
and the rate of hypertension control were evaluated.
Results A total of 25,336 individuals were surveyed, of which 79.1% were from cardiology clinics and
51.8% were male hypertensives. The average SBP/DBP was 139.318.6/82.312.0 mmHg. The mean age
was 63.611.5 years. The mean BMI was 25.13.8 kg/m2. Among the men, 55.9% had a waist circumference
of >90 cm. Among the women, 50.9% had a waist circumference of >85 cm. The percentages of patients
with diabetes mellitus, heart disease and cerebral vascular disease were 20.3%, 39.2% and 10.4%, respectively. The smoking rate was 17.6%. Overall, 60.9% of the patients were in the very high risk group. While
97.7% of the patients were receiving antihypertensive drug therapy, only 40.2% had controlled SBP/DBP
(i.e., under 140/90 mmHg). The control rate was statistically higher in Beijing and Shanghai than in Guangzhou and among older patients than among younger patients (43% among the patients >75 years of age vs.
28.1% among the patients 35-45 years of age).
Conclusion In Beijing, Shanghai and Guangzhou, most hypertensive patients have various cardiovascular
risk factors and cardiovascular diseases. High blood pressure is not under appropriate control in all cases, especially among young hypertensives and patients living in Guangzhou city. Approaches designed to target
multiple risk factors and concomitant cardiovascular diseases and boost the hypertension control rate are warranted.
Key words: blood pressure, hypertension, cardiovascular disease, risk factors, antihypertensive treatment,
control rate
(Intern Med 52: 1863-1867, 2013)
(DOI: 10.2169/internalmedicine.52.9582)

Introduction
Approximately 26.4% of the adult population worldwide

had hypertension in 2000, a rate that is projected to reach

29.2% by 2025 (1). According to the 2002 National Nutrition and Health Survey in China, the prevalence of hypertension among adults was 18.8% (2), which included 200

National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China,
Department of Medicine, University of Virginia, USA, Chinese Physician Association, China, Chinese Hypertension League & Beijing Hypertension Institute, China and Cardiovascular and Neurological Institute, USA
Received for publication December 26, 2012; Accepted for publication April 19, 2013
Correspondence to Dr. Wen Wang, wangwen5588@vip.sina.com

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DOI: 10.2169/internalmedicine.52.9582

Table1.Risk Factors Surveyed in the Study

CV risk factors

Target organ

Diabetes mellitus

Concomitant CV diseases

damage
Systolic and diastolic BP level

LVH: ECG;

Fasting plasma glucose

Cerebrovascular diseases: ischemic

Age (M>55 years, W>65 years)

UCG

 mmol/L (126mg/dL)

stroke; cerebral haemorrhage; transient

Smoking

Postprandial plasma

ischaemic attack

Dyslipidaemia

glucose 10 mmol/L

Heart disease: myocardial infarction;

(200mg/dL)

angina; coronary revascularization;

7&Pmol/L(220mg/dL) or
LDL-&6 mmol/L(140mg/dL) or

heart failure

HDL-& mmol/L(40mg/dL)

Peripheral artery disease

Obesity
Abdominal: WC M85cm, WFm)
General: BMI28kg/m2
CV: cardiovascular, LVH: left ventricular hypertrophy, TC: total cholesterol, LDL: low density lipoprotein, HDL: high density
lipoprotein, WC: waist circumference, M: male, F: female, BMI: body mass index, ECG: electrocardiogram, UCG: ultrasonic
cardiogram

Table2.Stratification of CV Risk to Hypertensive Patients

Other risk factors, OD or
disease

Grade 1 HTN
SBP140-159 or DBP 9099
low risk
moderate risk
high risk

Blood pressure (mmHg)

Grade 2 HTN
SBP160-179 or DBP
100-109
moderate risk
moderate risk
high risk

Grade 3 HTN
6%380 or '%310

No other risk factors

high risk
1-2 risk factors
very high risk
3 or more risk factors,
very high risk
MS, OD or Diabetes
Established CV diseases very high risk
very high risk
very high risk
HTN: hypertension, MS: metabolic syndrome, CV: cardiovascular, OD: subclinical organ damage

million hypertensive patients at that time.

Hypertension accounts for approximately two-thirds of all
strokes and one-half of all heart attacks and causes 1.5 million premature deaths per year (3). Therefore, hypertension
is a major risk factor for cardiovascular morbidity and mortality and requires effective management (4, 5). However,
both the rates of treatment and control of hypertension remain low. For example, a previous survey of 4,510 patients
treated at hospital-clinics in 1999 showed that the treatment
rate was 69%, while the control rate was only 33%, and less
than half of hypertensive patients regularly took antihypertensive medications in China (6).
The reasons for the poor treatment and control rates of
hypertension in China are multifactorial; however, one reason may be that hypertensive patients living in mainland
China have not been characterized systematically, so that
physicians and health care providers have insufficient
knowledge regarding the hypertensive population.
The purpose of the present study was therefore to assess
the general characteristics, risk factors for hypertension, concomitant factors for cardiovascular disease (CVD), treatment
rate and blood pressure control rate among patients with
clinical hypertension. To this end, a cross-sectional survey
was conducted in clinics in hospital settings in Beijing,
Shanghai and Guangzhou, which represent the first-tier met-

ropolitan cities in mainland China and serve as examples of

industrialization and urbanization for other areas.

Materials and Methods

This was a cross-sectional survey conducted by both the
Chinese Hypertension League and the Chinese Physician
Association between August and November in 2006. More
than 500 physicians from 100 (out of approximately 136 eligible) hospitals in Beijing, Shanghai and Guangzhou received pre-survey training from May to July 2006, during
which each physician was trained to be familiar with the
survey protocol (e.g., blood pressure measurement, the inclusion and exclusion criteria and survey form filling). The
selection of the hospitals and physicians was based on their
(1) eligibility, (2) willingness to participate and (3) previous
experience with surveys and clinical trials. For quality assurance and standardization, the 100 hospitals received certificates from the National Center of Clinical Laboratories. The
study protocol was approved by the institutional ethics committee. Written informed consent was obtained from all participants.
Subject recruitment criteria: Patients were recruited if they
were: (1) male and female outpatients between 35 and 85
years of age who visited hospital-based clinics in three cities

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Table3.Baseline Characteristics of the Patients

Beijing
(n=12,291)
53.4
62.411.6
139.312.5
82.412.5
25.63.7

Shanghai
(n=9,536)
51.7
65.411.3
138.218.0
81.811.1
25.13.5

Guangzhou
(n=3,509)
46.4
62.911.1
145.019.7
83.612.3
24.64.4

Total
(n=25,336)
51.8
63.611.5
139.318.6
82.312.0
25.13.8

Gender (male, %)
Age (years)
SBP (mmHg)
DBP (mmHg)
BMI (kg/m2)
WC (cm)
Male
92.712.4
89.910.3
85.510.3
91.111.5
Female
86.711.7
85.611.1
83.510.3
85.611.3
Classification of WC (%)
Male
FP
78.4
70.7
68.0
74.1
FP
62.0
51.4
45.6
55.9
FemalH80 cm
76.7
70.6
68.6
73.1
FP
55.5
45.2
45.8
50.9
Rate of smoking (%)
20.2
12.8
13.4
17.6
Rate of medical history (%)
Heart disease
39.3
41.0
34.0
39.2
Cerebral vascular disease
9.5
12.8
7.1
10.4
Diabetes mellitus
21.4
19.6
19.3
20.3
19.6*
26.6
19.7
LVH
17.8*
Antihypertensive drugs (%)
97.2
98.4
97.2
97.7
Values are expressed as Mean SD. WC: waist circumference, LVH: left ventricular
hypertrophy. * p <0.005 vs. Guangzhou, p <0.005 vs. Shanghai

(Beijing, Shanghai and Guangzhou); (2) individuals with

primary hypertension with either a systolic blood pressure
(SBP) of !
140 mmHg or a diastolic blood pressure (DBP)
of !
90 mmHg; (3) patients receiving antihypertensive drug
therapy. Hypertension was considered to be controlled if
both the SBP was <140 mmHg and the DBP was <90
mmHg based on the 2005 Chinese guidelines for the management of hypertension (7).
Survey form and procedures: The survey was conducted
using a standardized form including the patients name, gender, age, current cigarette smoking status, CVD history,
physical examination findings (blood pressure, weight,
height, waist circumference and BMI), medications and
laboratory test results (the fasting blood glucose level, blood
lipids), as well as electrocardiogram (ECG), ultrasonic cardiogram (UCG) and X-ray findings within the last three
months. The survey was conducted immediately on-site
when the subject met the recruitment criteria and signed the
consensus form. The survey forms were filled out by the
participating physicians in the clinics and delivered to the
Chinese Physician Association for the data entry and analysis.
Analysis and statistics: Stratification of the total cardiovascular risk was performed according to the 2005 Chinese
guidelines for the management of hypertension (7). The total
cardiovascular risk stratification was based on the blood
pressure level, risk factors, subclinical organ damage and
concomitant CVD. The selected parameters evaluated in this
study are listed in Table 1, and the risk stratification is defined in Table 2. The data are presented as the mean standard deviation (SD). One way analyses of variance
(ANOVA) were used to compare continuous variables. The
chi-square test was used to compare frequencies or proportions of categorical variables. The standardized hypertension

Table4.Cardiovascular Risk Stratification

Risk stratification (%)
Low
Moderate
High
Very high

Beijing
5.6
22.1
11.3
61.0*

Shanghai
6.3
20.6
9.9
63.2*

Guangzhou
7.7
23.6
14.7
54.0

Total
6.2
21.7
11.2
60.9

* p <0.005 vs. Guangzhou, p <0.005 vs. Shanghai

control rate in each city was adjusted according to the age

and sex composition of the total surveyed population. The
SAS 8.2 software package was used for all data analyses.

Results
In total, 25,336 survey forms were collected, representing
a response rate of 88.9%. A total of 12,291 forms were collected from Beijing, 9,536 forms were collected from
Shanghai and 3,509 forms were collected from Guangzhou.
The survey forms were collected from cardiology, internal
medicine, hypertension and gerontology clinics (79.1%,
11.0%, 5.0% and 4.9%, respectively).
The general characteristics of the patients are listed in Table 3. The patients were middle-aged and older. While most
of the parameters exhibited only marginal differences among
the three cities, general obesity, as expressed by the body
mass index (BMI), and abdominal obesity, as expressed by
the waist circumference (WC), were highest in Beijing, as
was the smoking rate. However, the rate of left ventricular
hypertrophy (LVH) was greater in Guangzhou (p<0.05 vs.
Beijing and Shanghai).
With respect to risk stratification, 19,852 forms were eligible and 5,484 forms were excluded due to missing lipid
profiles, ECG and ultrasound findings, blood glucose test results, data regarding the smoking status and/or miscalcula-

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Table5.Control Rate (%) of Hypertension (SBP<140 and

DBP <90) by Sex and Age
Beijing
Shanghai
Overall
Crude
40.7*
42.7*
Adjusted by age and sex 41.1*
42.2*
Gender
Men
39.9
41.9
Women
41.6
43.4
Age (years)
3528.1
31.1
4535.4
40.1
5541.9
43.1
6544.4
43.6
7544.3
44.5
* p <0.005 vs. Guangzhou, p <0.05 vs. women,
p <0.0001 vs.75-year old group

Guangzhou

Total

31.6
31.6

40.2

30.8
32.3

39.5
40.8

24.0
35.6
31.6
31.3
31.9

28.1
37.0
40.0
42.2
43.0

tion of the BMI. The results are shown in Table 4. The proportion of hypertensive patients in the very high group of
cardiovascular risk was highest in Shanghai (>Beijing>
Guangzhou, p<0.05).
The hypertensive control rates are shown in Table 5. The
overall control rate in Guangzhou was the lowest among the
cities, and this result remained unchanged following age and
sex adjustment. The control rate increased in association
with age, being 28.1% in the 35- to 45-year-old group versus 43% among the patients over 75 years of age.

Discussion
This study was a large scale survey of cardiovascular risk
stratification and hypertension control rates in hospital-based
clinics in three cities in China. The sample size in the current study was five times greater than that used in our previous study (6); therefore, the data should be more representative and more applicable to hospital-based clinics in large
cities in China. Our new major finding is that hypertensive
patients treated at hospital-based clinics in three big cities
often had multiple cardiovascular risk factors and concomitant cardiovascular diseases, which confirms our previous
findings in a Chinese population. In a cohort of 26,655 hypertensive patients (18-98 years of age) treated at 282 hospitals across the nation (8), 21.1% and 53.3% were classified
as belonging to the high and very high risk groups, with
higher rates of diabetes, obesity and smoking.
The rate of diabetes mellitus was 20.3% in our survey of
hypertensive patients and was 9.7% in the general adult Chinese population (9). As a noncommunicable disease, the incidence of diabetes has increased substantially in China over
the last few decades. The higher rate of diabetes warrants
that the blood glucose level of each individual with hypertension be examined. Among various cardiovascular risk factors, elevated levels of blood pressure and blood glucose are
the greatest risk factors for incident stroke (10).
Obesity is an important CVD risk factor (11) and is significantly related to poor BP control (12). Abdominal obesity is more closely related to CVD than overall obe-

sity (13, 14). The rate of abdominal obesity is higher in men

than in women (15). Measuring the waist circumference is a
simple and reliable method for assessing the abdominal fat
mass. In our study, 55.9% of men and 50.9% of women had
abdominal obesity, according to the new criteria defined in
the 2010 Chinese Hypertension Guidelines (i.e., a WC of
>90 cm for adult men and >85 cm for adult women) (16).
Lifestyle modification plays a major role in the nonpharmacological management of hypertension and should be
undertaken by those who are overweight or obese.
Cigarette smoking is another independent risk factor of
CVD (17) that results in endothelial dysfunction and stroke,
particularly ischemic stroke (18, 19). In China, cigarette
smoking is the second most important risk factor of CVD
after hypertension (20). The risk of CVD is twice as high
among smokers than non-smokers. The smoking rate among
Chinese men and women 15 years of age or over was
66.0% and 3.1%, respectively, in 2002 (21). The absolute
number of smokers was approximately 350 million in
China. The smoking rate decreased slightly to 59.7% in men
in a survey conducted from 2005 to 2007 (22). A previous
study showed that a high smoking rate is associated with a
poor education and low income. The educational and income levels in Beijing, Shanghai and Guangzhou are indeed
the highest in the nation. Therefore, the overall smoking rate
in the present study was lower than the national average.
In line with the findings of previous studies, the present
study demonstrated that hypertensive patients often exhibit
multiple risk factors, including diabetes mellitus, smoking
and obesity. CVD treatment and prevention should target all
modifiable risk factors in individual patients (23, 24).
The present study is the first to report the hypertension
control rate among outpatients in metropolitan hospital clinics at a large scale in China. The hypertension control rate
was 40.2% in the present study, which represents a progressive improvement, as the control rate in treated hypertensives was 25.0% in 2002 national survey (2, 6).
There are regional differences in hypertension control.
Among the three cities, the hypertensives in Guangzhou had
the highest systolic blood pressure values and the lowest
control rate, which may largely explain why the rate of cardiac hypertrophy was also highest among the Guangzhou
patients. However, more hypertensives in Shanghai and Beijing exhibited other risk factors. The factors underlying the
poor control rate observed in Guangzhou were unknown;
however, the low rate may be partially explained by (1) the
relatively lower prevalence of hypertension compared with
that observed in northern regions, such as Shandong, Liaoning and Beijing (25), indicating that hypertension and its
consequences are not prioritized; (2) the poor awareness
rate; and (3) a preference for alternatives to pharmacologic
regimens in the region. There are also age differences in hypertension control. The control rates in the younger hypertensives were much lower than those observed in the older
hypertensives. This fact and its consequences should be particularly emphasized.

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In conclusion, the majority of hypertensive patients

treated at hospital-based clinics in three big cities in China
had multiple cardiovascular risk factors and co-existing
CVD, therefore belonging to the very high CVD risk group
categorically. Although most of the patients were receiving
antihypertensive treatment, a significant proportion of the
population had poorly controlled blood pressure, especially
the younger patients and those living in Guangzhou city.
Therapeutic regimens should target all risk factors and concomitant cardiovascular diseases and boost the hypertension
control rate.
The authors state that they have no Conflict of Interest (COI).
Author Contributions
Wang W and Liu LS designed the study, Wang W and Cheng
YF were responsible for the data collection, Sui H, Cheng HY,
Wang W, Liu LS and Zhang W performed the analysis and
drafted the manuscript and Sui H, Wang W and Zhang W revised and finalized the manuscript.

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