115 Hypertension awareness, treatment, and control in hypertensive CHD patients 5 and medication adherence were positively associated with hypertension control. Physician-level barriers, such as the difficulties to modify treatment strategies even with uncontrolled BP levels (29), were beyond the scope of this paper but should be further explored. The EUROASPIRE V survey was conducted in 27 countries, with different health system organization, financing, service delivery and policies (33) affecting availability and access to services, rehabilitation programs, prescription coverage, and reimbursements (34). These system-level factors could contribute to the wide differences that we observe in hypertension awareness, treatment, and control between countries and specifically between HICs and MICs. Implications Our results show that hypertension control remains low among hypertensive patients with CHD. Although most patients are using antihypertensive medication to lower blood pressure and report to adhere to medication, awareness of hypertension and health behaviors can be improved. Further research is needed on the role on awareness on health behaviors and the use and adherence of multiple medications to device strategies that are most effective in improving BP levels in the context of secondary prevention. Strategies to improve risk factor awareness, including provision of information, educational programs, promotion of self-assessment controls (29), should be adapted and communicated to make them more effective in patients with lower educational level. Strengths and limitations The EUROASPIRE V survey investigating CHD patients from 27 countries, provides a wide picture of hypertension in the context of secondary prevention of CHD. The methodology of the study was robust, with data collection by trained staff following standardized methods. The extensive questionnaire allowed the investigation of hypertension awareness, treatment, and control in depth. The current analysis is the first to report the prevalence of hypertension based on a definition applicable to CHD patients in an international analysis. Our results show poor hypertension control and high medication use in line with previous study waves, but it is the first to report these estimates among hypertensive patients, and to investigate awareness of hypertension and its determinants in detail. Limitations of the current study relate to the cross-sectional design of the survey that does not allow for the study of casual associations between patient characteristics and hypertension control. Additionally, the centers included in this study were in many instances large centers located in urban areas that may provide specialized cardiology services and staff. Therefore, our results might overestimate the level of hypertension awareness, treatment, and control, compared to a more global picture including smaller centers and community settings. CONCLUSION Less than half of the hypertensive CHD patients in the EUROASPIRE V survey have controlled hypertension, and controlled patients are generally younger and have a healthier risk
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