Background: Uncontrolled hypertension results in hypertension crisis, and it is an important public health concern around the world. The incidence of complicating hospitalizations with hypertension continues to grow and is associated with increased mortality and adverse discharge. Hypertension crisis and stroke are caused by numerous factors; however, there is a paucity of studies to identify determinants of hypertension crisis and stroke in Ethiopia, particularly the study area.

Objective: To identify determinants of hypertension crisis and stroke among hypertensive patients in South Wollo zone and Oromia special zone public hospitals, 2022.

Methods:  An institution based cross-sectional study was conducted among 416 participants in South Wollo and Oromia special zones public hospitals. Systematic random sampling technique was used to select study participants. Data were entered into Epidata version 3.1 and analyzed using Statistical package for social sciences version 23. Variables having P<0.25 in binary logistic regression was retained in the multivariable analysis to control the effect of confounding. Finally, determinants were identified based on adjusted odds ratio along with 95% confidence level at p-value less than 0.05. Model fitness was checked using Hosmer-Lemshow test.

Results: In this study, the magnitude of hypertensive crisis was 35.6%(95%CI:31.1,40.4). Age(41-60years)(AOR=0.76,95%CI:0.42,0.98), Social support(AOR=0.82,95%CI:0.41,0.93), living in urban(AOR=0.56,95%CI:0.24,0.86) and good medication adherence(AOR=0.48,95%CI:0.29,0.83) were determinants of hypertensive crisis. Another, the magnitude of stroke was 5.0%(95%CI:3.1,7.8). Rural residence (AOR=3.4,95%CI:1.23,9.44), Systolic blood pressure (AOR=9.6,95%CI:2.71,34.06), family history of stroke (AOR=0.26,95%CI:0.07,0.79) were determinants of stroke.

Conclusion and recommendation: The magnitude of hypertensive crisis was high, whereas the magnitude of stroke was relatively low. Age 41-60 years, urban residence, having social support and good medication adherence were determinants of hypertensive crisis, while rural residence, systolic blood pressure and family history of stroke were determinants of stroke. Thus, health care providers should screen aged patients and patients with family history of stoke.

Keywords: determinants, Ethiopia, hypertension crisis, stroke, blood pressure

HE, hypertension emergency; HU, hypertension urgency; AOR, adjusted odds ratio; COR, crude odds ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; SPSS, statistical package for social sciences; WHO, world health organizations

Hypertension crisis is a sudden and severe increase in blood pressure. It is classified into two categories: hypertensive urgency and hypertension emergency. Hypertensive urgency is blood pressure reading ≥ 180/120mm Hg without target organ damage while Hypertensive emergency is Blood Pressure(BP)≥180/120mmHg with organ damage.¹ According to the World Health Organization (WHO), stroke is defined as rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24hours or longer or leading to death which may be either ischemic or hemorrhagic disturbances of the cerebral blood circulation.² The two major types of stroke are ischemic and hemorrhagic stroke. Ischemic stroke is the most common type that results in reduced blood supply to the brain tissues, whereas hemorrhagic stroke occurs due to the rupture of blood vessels within the brain.³

In developed countries, ischemic stroke is high whereas hemorrhagic stroke is high in sub-Saharan Africa countries, as such in Kenya (15%),⁴ Ethiopia (41%).⁵ The high prevalence of hypertension among Africans maybe attributed to decreased production and increased degradation of nitric oxide resulting in endothelial dysfunction.⁶ WHO points out that cardiovascular diseases account for approximately 17million deaths per year, and complications from hypertension accounts for 9.4 million of these deaths, hypertensive crisis is one of the major acute complications of hypertension, resulting in an emergency admission to hospitals.^2,7

Africa is particularly worst hit, owing to population growth, unchecked industrialization and increased consumption of western diets, leading to a rise in many modifiable vascular disease risk factors including smoking, excessive use of alcohol, physical inactivity and unhealthy diets, and invariably resulting in increased prevalence of hypertension, diabetes and obesity.^8,9 Even with this increasing burden, the public health response, accesses to health services and treatment options in many African countries have been poor. This facilitates the fatality rates of hypertension crisis.¹⁰

Currently in Ethiopia, stroke is one of the greatest public health problems, accounts for 7% of total deaths.¹¹ As studies showed that stroke was the third most common cause of medical intensive care unit admissions (15.2%) and the first cause of death, which accounts for 17% of all deaths in the medical intensive care unit.¹² Similarly, hypertension is responsible for 66.2% of all stroke admission and 38% of all strokes were on anti-hypertensive treatment.¹³

Uncontrolled hypertension results in a hypertension crisis and it is an important public health concern in the world. The incidence of complicating hospitalizations with hypertension continues to grow and is associated with increased mortality and adverse discharge. Hypertension crisis and stroke are caused by numerous factors. However, there is a paucity of studies to identify determinants of hypertension crisis and stroke in Ethiopia, particularly in the study area. Thus, this study was aimed at identifying determinants of hypertension crisis and stroke among hypertension patients in south Wollo and Oromia special zone public hospitals.

Study design and Study area description 

The study was conducted in South Wollo and Oromia special zone public hospitals. There are 13 public hospitals in the South Wollo zone and 2 hospitals in the Oromia special zones. From a total of 15 public hospitals, 5 hospitals were selected randomly.

Study design and period

A five year retrospective institution-based cross-sectional study design was implemented from 21 January 2017 to 20 January 2022.

Study participants             

The study populations were all hypertensive patients who had visited selected public hospitals found in South Wollo and Oromia special zones from January 20, 2017 to January 21, 2022.

Eligible criteria

Hypertensive patients aged equal or greater than 18years were included in the study, whereas patient charts with incomplete data were excluded from the study.

Sample size determination 

The sample size was calculated using a single population proportion formula by considering the following assumptions: 95% CI (1.96), 5% margin of error, and estimated proportion of hypertension crisis (50%) due to lack of prior research.

$n=\frac{{\left(za/2\right)}^{2}p\left(1-q\right)}{d^2}$

Where, n=is sample size

z=the value of the standard normal curve score corresponding to the given confidence interval=1.96

p=estimated proportion of hypertension crisis (50%) as there is no previous study in Ethiopia as our knowledge.

d=the permissible margin of error (the required precision)=5%

$n=\frac{\left({1.96}^2\right)(0.5\left(1-0.5\right)=384}{{0.05}^2}$

After adding 10 % non-response rate, the final sample size was 422.

Sampling technique and procedure

Out of 15 hospitals found in South Wollo and Oromia special zones, 5 hospitals were selected by a simple random sampling technique (the lottery method). A proportional allocation of sample size was done for each selected hospital based on the number of patient flows. A systematically random sampling technique was used to select the records of the study subjects. The records of the study subjects were selected based on constant interval K, where K was calculated from total hypertension cases attended in public hospitals from January 21, 2017 to January 20, 2022 in chronological order divided by the sample size of the study (422). The first patient's medical record was selected by a lottery method and all patients’ charts in the K interval were included in the study until the calculated sample size was obtained.

Study variables  

1. Outcome variable

Magnitude of hypertension crisis

Magnitude of stoke

2. Independent variables

1. Scio-demographic (age, sex, marital status, occupation, residence, educational status, and monthly income).
2. Behavioral factors (Physical exercise, Smoking, alcohol consumption, excessive salt in diet, fatty food use, medication adherence).
3. Physical exercise

1. Physically active - if patients make regular physical activities ≥ 30minutes
2. for 5 days and above per week
3. Physically inactive - if patient is made physical exercise less than 30minutes per week or less than 5 days per week.

4. Medication adherence was assessed using Morisky medication adherence score to anti-hypertensive medications having eight questions with Yes =1 and No=0
1. Good adherence - if participants score mean and above the mean.
2. Poor adherence- if participants score less than the mean value.

5. Alcohol drinker: a person who drinks 10.5 units of alcohol and above per week.
6. Physical measurements and clinical factors: Fasting blood glucose (FBG), cholesterollevel, blood pressure control, body mass index (BMI) and comorbidities, normal FBG <126 mg/dl, raised FBG > =126 mg/dl.
7. Cholesterol level: normal if less than 200 and high cholesterol level 200 and above
8. BMI: Underweight (<18.5), normal (18.5–24.9), overweight (25–29.9) and obese (≥30).
9. Systolic blood pressure: controlled (<140mm Hg) and uncontrolled (≥140mmHg),
10. diastolic blood pressure: controlled (<90mmHg) and uncontrolled (≥ 90mmHg).

Operational definitions

1. Stroke: It is clinically defined as per WHO criteria, as rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24hours or longer or leading to death, with no apparent cause other than vascular origin.¹⁴
2. Ischemic Stroke: It is the evidence of a recent infarct in the clinically relevant area of the brain/confirmed cerebral infarction.¹⁵
3. Hemorrhagic stroke: It occurs due to the weakening of blood vessels which would rupture and bleed into the surrounding brain tissues.¹⁶

Data collection tools and procedure          

The data source for the study was hospital medical record review (history & summary of patient card). Data was collected by using a data collection format prepared to include all the necessary variables on the patient card. First, all hypertension patient cases were counted from the log book. Then, by using these card numbers, charts of the patients were retrieved from the card room. Five data collectors and five supervisors from each hospital were recruited.

Data quality assurance

Training was given for data collectors and supervisors for one day on the objective of the study and the contents of the questionnaire. Continuous supervision was held by supervisors and principal investigators, and communication by phone was done on a daily basis. Prior to actual data collection, the questionnaire was pretested on 5% at Woldia hospital. After reviewing the results of the pretest, modification of the questionnaire was performed for applicability of the questionnaire.

Data processing and analysis

The collected data was numerically coded, checked, cleaned, and entered into Epidata version 3.1 and then exported to SPSS version 23.0 for analysis. Descriptive statistics were calculated. Bivariable and multivariable logistic regression were used to see the associations between dependent and independent variables. Variables with a p-value ≤0.25 in bivariable analysis were candidates for multivariable analysis to control the possible effect of confounding. The AOR and 95% confidence intervals were used to determine the presence and strength of the association, and p< 0.05 was declared statistically significant. Model fitness was checked by the Hosmer-Lemeshow test.

Sociodemographic characteristics of participants

More than half (60.6%) of patients were females, 51.2% of patients were categorized as aged 40–60 years, and most (42.8%) of these patients could not read and write (Table 1).

Clinical and anthropometric measurements

Most (96.2%) of patients had normal cholesterol levels, but 78.1% of patients had uncontrolled blood glucose levels. More than one-third (37.3%) of patients had comorbidities, and peripheral neuropathy accounted for 36.7% of the total comorbidities (Table 2).

Anti-hypertension medication adherence

The mean (±SD) of antihypertensive adherence was 12.76(±1.83). This mean was used to classify participants into two categories. Thus, 228(54.8%, 95%CI: 50.0-58.9) patients had good adherence and 188(45.2%, 95%CI: 41.1-50.0) had poor adherence (Table 3).

Adherence to dietary modifications

Dietary modification for hypertension patients is crucial to control different complications. In this study, more than three-fourths (78.4%) of patients rarely ate fruits and vegetables (Table 4).

 Adherence to exercise      

As non-pharmacological management, exercise is recommended for hypertension patient. In this finding, one –fourths (25.2%) patients perform exercise. (Table 5)

Cessation of smoking

Cigarette smoking is a risk factor for hypertension patients. For hypertension patients, stopping cigarette smoking is recommended. As shown from the table, 11.8% of patients were smokers. (Table 6) 

Alcohol consumption

Moderate alcohol consumption is good for hypertension patients to control further complications. In the current study, majority (92.1%) of hypertension patients had never drank alcohol. (Table 7)

Magnitude of hypertension crisis

In this study, 34.1% of patients had greater than 140 mmHg (uncontrolled hypertension) and 30% of patients had greater than 90 mmHg. The magnitude of the hypertensive crisis was 35.6 %( 95% CI: 31.1, 40.4).

Determinants of hypertensive crisis

From bivariable analysis, age, marital status, occupation, blood glucose level, type of comorbidity, type of antihypertensive drugs, attending hypertensive education, having social support, and good adherence were significantly associated with hypertensive crisis. From multivariable analysis; age (41-60years), residence, having social support, and good adherence were determinants of hypertensive crisis.

Accordingly, participants aged 41–60years were 24% less likely to develop hypertensive crises as compared to participants aged >60 years (AOR=0.76, 95%CI: 0.42, 0.98). Those participants living in urban areas were 44% less likely to develop hypertensive crises as compared to rural residents (AOR=0.56, 95%CI: 0.24, 0.86). Participants who received social support were 18% less likely than their counterparts to develop hypertensive crises (AOR= 0.82, 95% CI: 0.41, 0.93). Lastly, participants who had good adherence were 52% less likely to develop hypertensive crisis as compared to their counterparts (AOR=0.48, 95%CI: 0.29, 0.83) (Table 8).

Magnitude of stroke

Out of 416 patients, 21 patients had stroke. Thus, the magnitude of stroke was 5.0% ( 95%CI: 3.1-7.8).

 Determinants of stroke

From bivariable analysis, sex, age, residence, systolic blood pressure (SBP), diastolic blood pressure, and family history of stroke were significantly associated with the magnitude of stroke. From multivariable analysis, residence, SBP, and having a family history of stroke were determinants of stroke.

Accordingly, rural participants were 3.4 times more likely to develop a stroke as compared to urban residents (AOR=3.4, 95%CI: 1.23, 9.44). Participants with uncontrolled systolic blood pressure were 9.6 times more likely to develop stroke as compared to control SBP (AOR=9.6, 95%CI: 2.71, 34.06). Participants without a family history of stroke were 74% less likely to develop a stroke as compared to their counterparts (AOR=0.26, 0.07, 0.79).(Table 9)

Ethiopian morbidity and mortality rates rise from time to time as a result of hypertension crises. In this study, the magnitude of hypertensive crisis was 35.6%( 95% CI: 31.1, 40.4). This finding is higher than a study conducted in Ayder comprehensive specialized hospital and Debre Markos, Ethiopia.^17,18 However, this finding is lower than a study conducted in Karachi, Pakista(56.3%)¹⁹ and Gondar(59.2%),Ethiopia.²⁰

Being old was a risk factor for a hypertension crisis. Accordingly, participants aged 41–60years were 24% less likely to develop hypertensive crises as compared to participants aged >60years (AOR=0.76, 95%CI: 0.42, 0.98). This is supported by studies in Shashemene, Ethiopia²¹ and Luanda, Angola.²²

The living environment was a factor in hypertensive crisis. Those participants living in urban areas were 44% less likely to develop hypertensive crises as compared to rural residents (AOR= 0.56, 95%CI: 0.24, 0.86). This finding is supported by other studies; Kenya,⁴ Bahirdar, Ethiopia,⁵ and Nigeria.²³

Another found that having social support was significantly associated with a hypertension crisis. Participants who received social support were 18% less likely to develop hypertensive crisis than their counterparts(AOR=0.82, 95%CI: 0.41, 0.93).This is congruent with different studies.^8,24

The determinant of the hypertension crisis was drug adherence. Participants who had good adherence were 52% less likely to develop hypertensive crises as compared to their counterparts. This finding was supported by other studies: Nigeria,²⁵ Ethiopia¹⁷ and India.¹⁵

In the present study, the magnitude of stroke was 5.0%( 95: CI: 3.1-7.8). This is in line with a study conducted in Debre Markos,7.7%³ and JUMC,²⁶ Felege Hiwot hospital,²⁷ Ethiopia. However, this finding is lower studies conducted in Addis Ababa, Ethiopia,²⁸ India,¹⁵ and Nigeria.²⁹

Concerning determinants of stroke, rural residence, uncontrolled systolic blood pressure, and having a family history of stroke were determinants of stroke. Accordingly, rural participants were 3.4 times more likely to develop a stroke as compared to urban residents (AOR= 3.4, 95%CI: 1.23, 9.44). This result is congruent with studies conducted in different settings: Debre Markos,³ Ethiopia, USA,³⁰ and Kenya.⁴

Participants with uncontrolled systolic blood pressure were 9.6 times more likely to develop stroke as compared to controlled systolic blood pressure (AOR=9.6, 95%CI: 2.71, 34.06). This is supported by previous studies.^6,29,31

Having family history of stroke was significantly associated with stroke. Participants without family history of stroke were 74% less likely to develop stroke as compared to their counter parts (AOR=0.26, 0.07, 0.79). This is similar with previous studies.^{5,24,27,32,33}

The magnitude of the hypertensive crisis was high, whereas the magnitude of the stroke was relatively low. Age (41–60years), urban residence, having social support and good medication adherence were determinants of hypertensive crisis, while rural residence, uncontrolled systolic blood pressure and family history of stroke were determinants of stroke. Thus, healthcare providers should screen aged patients and patients with a family history of stroke, and the minister of health should prepare guidelines on how to manage hypertensive patients and increase imaging facilities for early screening of stroke.

First and foremost, we would like say thank you Wollo University for financial support. Next to this, we would like to give special thanks and appreciation for study participants and data collectors.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

None.

Not applicable. No individual personal details, images or videos are being used in this study

The authors declare that they have no competing interests.

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted, and agree to be accountable for all aspects of the work.

An ethical letter was obtained from the institutional review board (IRB) of Wollo University, and a letter of permission was obtained from the chief executive officers of the study hospitals. To ensure confidentiality, data were collected anonymously, and all data collection was done in accordance with the Helsinki Declaration.

1. Lopez–Jimenez F. Hypertensive crisis: What are the symptoms? Minnesota, USA: Mayo Clinic; 2022.
2. WHO MONICA Project Principal Investigators. The world health organization MONICA project (monitoring trends and determinantsin cardiovasculardisease): a major international collaboration. J Clin Epidemiol. 1988;41(2):105–114.
3. Mulugeta H, Yehuala A, Haile D, et al. Magnitude, risk factors and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia: a retrospective observational study. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2020;56(41):1–9.
4. Jowi JO, Mativo PM. Pathological sub–types, risk factors and outcome of CVA at the Nairobi Hospital, Kenya. East Afr Med J. 2008;85(12):572–581.
5. Erkabu SG, Agedie Y, Mihretu DD, et al. Ischemic and Hemorrhagic CVA in Bahir Dar, Ethiopia: A Retrospective Hospital–Based Study. J CVA Cerebrovasc Dis. 2018;27(6):1533­–1538.
6. Mensah GA, Roth GA, Sampson UK, et al. Causes of Death, Mortality from cardiovascular diseases in subSaharan Africa, 1990–2013: a systematic analysis of data from the Global Burden of Disease Study 2013. Cardiovasc J Afr. 2015;26(2 suppl 1):S6–10.
7. Wikipedia. CVA and its classification mechanisms. Wikipedia.
8. Connor MD, Walker R, Modi G, et al. Burden of CVA in black populations in sub–Saharan Africa. Lancet Neurol. 2007;6(3):269–278.
9. O’Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic CVA in 22 countries (the INTERCVA study): a case–control study. Lancet. 2010;376(9735):112–123.
10. Chin JH. CVA in Sub–Saharan Africa: An Urgent Call For Prevention. Neurology. 2012;78(13):1007–1008.
11. CDC, Centers for disease control and prevention(Fact sheet). Ethiopia: CDC–Ethiopia; 2016.
12. Gidey K, Hailu A, Bayray A. Pattern and Outcome of Medical Intensive Care Unit Admissions to Ayder Comprehensive Specialized Hospital In Tigray, Ethiopia. Ethiopian Medical Journal. 2017;56(1):31–36.
13. Gebremariam SA, Yang HS. Types, risk profiles, and outcomes of CVA patients in a tertiary teaching hospital in northern Ethiopia. eNeurologicalSci. 2016;3:41–47.
14. Ekeh B, Ogunniyi A, Isamade E, et al. CVA mortality and its predictors in a Nigerian teaching hospital. African Health Sciences. 2105;15(1):74–81.
15. Dash D, Bhashin A, Pandit AK, et al. Risk Factors and Etiologies of Ischemic CVAs in Young Patients: A Tertiary Hospital Study in North India. J stroke. 2014;16(3):173–177.
16. Kuriakose C, Shifafiya MN, Tharakan NS, et al. A prospective study of clinical profile of CVA in a tertiary care hospital. Asian Journal of Pharmaceutical and Clinical Research. 2016;9(3):1–4.
17. Hagos H, Birhanu MM, Mossie TB, et al. Factors associated with CVA among adult patients with hypertension in Ayder Comprehensive Specialized Hospital, Tigray , Ethiopia , 2018 : A case–control study. PLoS One. 2020;15(2):e0228650.
18. Owolabi MO, Agunloye AM. Journal of the Neurological Sciences Risk factors for CVA among patients with hypertension : A case – control study. J Neurol Sci. 2013;325(1–2):51–56.
19. Almas A, Ghouse A, Iftikhar AR, et al. Hypertensive crisis, burden, management, and outcome at a tertiary care center in karachi. Int J Chronic Dis. 2014:413071.
20. Gebresillassie BM, Debay YB. Characteristics, treatment, and outcome of patients with hypertensive crisis admitted to University of Gondar Specialized Hospital, northwest Ethiopia: A cross‐sectional study. J Clin Hypertens (Greenwich). 2020;22(12):2343–2353.
21. Temesgen TG, Teshome B, Njogu P. Treatment Outcomes and Associated Factors among Hospitalized CVA Patients at Shashemene Referral Hospital, Ethiopia. In: Ishrat T, editor. Stroke Res Treat. 2018:8079578.
22. García GM, Miúdo V, Lopes CdGAM, et al. Characterization of patients aged 45 or under admitted with hypertensive emergencies in the Hospital do Prenda. Rev Port Cardiol. 2014;33(1):19–25.
23. Oluyombo R, Akinwusi PO, Olamoyegun MA, et al. Clustering of cardiovascular risk factors in semiurban communities in south–western Nigeria. Cardiovasc J Afr. 2016; 27(5):322–327.
24. Adeloye D. An Estimate of the Incidence and Prevalence of CVA in Africa : A Systematic Review and Meta–Analysis. PLoS One. 2014;9(6):e100724.
25. Wahab KW. The burden of stroke in Nigeria. Int J Stroke. 2008;3(4):290–292.
26. Akinyemi RO, Owolabi MO, Ihara M, et al. Stroke, Cerebrovascular Diseases and Vascular Cognitive Impairment in Africa. Brain Res Bull . 2020;145:97–108.
27. Mulat B, Mohammed J, Yeseni M, et al. Magnitude of stroke and associated factors among patients who attended the medical ward of Felege Hiwot Referral Hospital, Bahir Dar town, Northwest Ethiopia. Ethiopian Journal of Health Development. 2016;30(3):129–134.
28. Lester FT. Neurological Disease in Addis Ababa, Ethiopia. Afr J Med Med Sci. 1979;8(1–2):7–11
29. Ezejimofor MC, Uthman OA, Maduka O, et al. Stroke survivors in Nigeria: A door–to–door prevalence survey from the Niger Deltaregion. J Neurol Sci . 2017;372:262–269.
30. Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic CVA: a guideline for health care professionals from the American Heart Association/American stroke Association. Stroke. 2013;44(3):870–94.
31. Bogiatzi C, Wannarong T, McLeod AI, et al. SPARKLE (Subtypes of Ischaemic CVA Classification System), incorporating measurement of carotid plaque burden: a new validated tool for the classification of ischemic CVA subtypes. Neuroepidemiology. 2014;42(4):243–251.
32. Zenebe G, Alemayeu M, Asmara J. Charactersitics and outcomes of CVA at Tikur Anbessa Teaching Hospital, Ethiopia. Ethiop Med J. 2005:43(4):251–259.
33. Baye M, Hintze A, Gordon–Murer C, et al. Stroke characteristics and outcomes of adult patients in Northwest Ethiopia. Front Neurol. 2020;11:428..