DR. SOBROTO KUMAR ROY
FCPS (INTERNAL MEDICINE PART- ll)
JULY 2014
MOBILE NO- 01755463597

DEPARTMENT OF MEDICINE
RANGPUR MEDICAL COLLEGE HOSPITAL
RANGPUR

THIS DISSERTATION IS SUBMITTED IN THE PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR FCPS (MEDICINE) PART-II EXAMINATION OF THE BANGLADESH COLLEGE OF PHYSICIANS AND SURGEONS, DHAKA, BANGLADESH. THIS RESEARCH WORK WAS DONE DURING 1st JULY 2012 TO 30th DECEMBER 2012 IN HYPERTENSION AND RESEARCH CENTRE, RANGPUR. NO PORTION OF THE WORK REFERED TO IN THIS DISSERTATION HAS BEEN SUBMITTED IN SUPPORT OF AN APPLICATION FOR ANOTHER DEGREE OR QUALIFICATION OF THIS OR ANY OTHER INSTITUTION OF LEARNING.

Certified that Dr. Sobroto Kumar Roy has worked on this research work titled “Association of ABO & Rh Blood group with Hypertension in patients of Hypertension & Research Centre, Rangpur” under my guidance and supervision. I have gone through the dissertation. This is up to my satisfaction.

PROF. DR. MD. ZAKIR HOSSAIN
FCPS (Medicine), MD (Medicine), FACP (USA)
Professor & Head of the Department of Medicine
Rangpur Medical College & Hospital
Rangpur.

Dedicated to
My favourite teacher
Professore Dr. Md. Zakir Hossain
Whose inspiration will always be with me.

ABSTRACT

Background:
Hypertension is one of the foremost causes of morbidity, mortality and a socioeconomic challenge, more so in Bangladesh where health support system including the rehabilitation system is not within the reach of ordinary people. It is clear that, this long term sufferings not only affect the patients but also it generates an enormous economic and social burden for families and communities.
Nation wide survey on NCD conducted in Bangladesh in 2010 indicated that the prevalence of hypertension is 17.9%. 5 Twelve million people suffers from hypertension in Bangladesh.6
Population based study on association of hypertension with ABO and Rh blood group lacking in our country.
In most cases the cause of hypertension is unknown, there may be some genetic influence though yet not established. ABO and Rh blood group in each individual is also genetically determined. So this association might helps in the identification of hypertension, its early prevention, treatment and prevention of target organ damage.

Objectives:
This study was conducted at hypertension and research centre, Rangpur. The principle aim is to find out the association of Hypertension with ABO and Rh blood groups and to see socio-demographic characteristics of hypertensive patient in different ABO and Rh blood groups.

Research design and method:

Study type: Descriptive and cross sectional study.

Sample size: 1128.
Sampling method: Purposeful consecutive sampling.

Procedure/data collection:

During the study period a total 1128 hypertensive patients were studied. Staging of hypertension was done according to The Seventh Report of the Joint National Committee on Prevention, detection, Evaluation and treatment of High Blood Pressure. ABO and Rh blood group of all hypertensive patients are determined by agglutination method. Several other investigations were done to see the target organ involvement. Lastly association of ABO and Rh blood group with hypertension was assessed.

Results:
The patients are in between 18 to 85 years of age and majority are 40 to 60 years of age 655 (58.1%) that is majority are young and middle aged. out of 1128 hypertensive patients 733 (63.7%) are male and 410 (36.3%) are female. In this study 733 (65%) patients were from rural areas and the rest 395 (35%) was from urban areas. Among the 1128 hypertensive patients majority patients comprised of service holder 548 (48.6%), businessman 152 (13.5%), farmer 138 (12.2%) and others occupation includes 290 (25.7%) like retired person, student etc.
Out of 1128 patients, majority 992 (87.9%) is non-smoker, and 136 (12.1%) are smoker. Among the study population majority 459 (40.7%) are poor with monthly income 15000 taka. In this study hypertension is controlled (BP <140/90 mm o Hg) in 503 (44.60%) patient and uncontrolled (BP 140/90 or >140/90 mm of Hg) in 625 (55.40%) patients despite getting treatment. In this study maximum observed systolic blood pressure (SBP) is 170 mm of Hg; minimum SBP is 110 mm of Hg and mean SBP is 136.42 mm of Hg with standard deviation 18.538. Maximum diastolic blood pressure (DBP) is 120 mm of Hg; minimum DBP is 60 mm of Hg and mean DBP 86.65 mm of Hg with standard deviation 11.602. Out of 1128 hypertensive patients’ 236 (21%) patients have normal BMI, 751 (66.7%) patients are overweight or mild obese, 100 (8.8%) patients are moderately obese and 41 (3.5%) patients are under weight. Majority of the study patients have positive family history of hypertension 851(75.4%) and 277 (24.6%) of patient have no family history of hypertension.
In this study among the 1128 subjects 465 (41.2%) belongs to ABO blood group B, 362 (32.1%) blood group A, 159(14.1%) blood group O and 142(12.6%) subjects belongs to blood group AB respectively in comparison with another study in our country where ABO blood group A – 22.40%. B – 35.54%, AB – 9.49% and O – 32.57% are found in nonhypertensive individuals. It shows that prevalence of hypertension is more in B (41.2%) and A (32.1%) respectively and lowest in O (14.1%) and AB (12.60%) group which is significant.
In this study majority 1045 (92.6%) belongs to Rhesus positive and only 83 (7.4%) are Rhesus negative. In a study it has been found that Rh D-negativity is most common in Caucasians (15%), less common in Blacks (8%), and rare in Asians (1%). That is prevalence of hypertension found more or less equal both in Rh negative (7.4%) and in Rh-positive blood group (92.6%) In this study the frequency of HTN is 401 (35.54%) in B positive, 361(32%) in A positive, 142 (12.58%) in AB positive, 141 (12.5%) in O positive, 64 (5.7%) in B negative, 18 (1.6%) in O negative and only 1 (.1%) in A negative blood group. In comparison with a study where Rh positive group A-21.58%, B- 34.58%, AB- 8.85%, O- 30.70% and Rh negative group A- 0.82%, B- 0.96%, AB- 0.64%, O- 1.87% respectively.
In this study out of 361 A positive group 44 (12.18%) subjects, among 401 B positive 36 (8.97subjects and among 142 AB positive 56 (39.43%) and none of O positive group subjects have showed predominantly raised systolic blood pressure (>140mm of hg). In this study among the 83 Rh negative group none of them shows predominantly raised systolic blood pressure. Among the 361 A positive ABO blood group 30 (8.31%) subjects, among 401 B positive 01 (0.24%) subjects, out of 142 AB positive 63 (44.36%) and among 141 O positive majority 116 (82.26%) subjects shows predominantly raised diastolic blood pressure (>90mm of hg). In this study among the 83 Rh-negative study subjects 64 subjects are B negative and all of them (100%) shows predominantly raised diastolic blood pressure. Among 361 A positive ABO blood group majority 205 (56.78%) subjects, among 401 B positive 24 (5.98%) subjects, among 142 AB positive 01 (0.70%) subjects and among 141 O positive blood group 25 (17.73%) subjects have showed predominantly raised both systolic and diastolic blood pressure (>140mm of Hg) and diastolic blood pressure (>90mm of Hg). In this study only 01 is A negative 01 (100%) found to have predominantly raised both systolic and diastolic blood pressure.

In this study among 1128 hypertensive patients 119 (10.5%) patients shows renal impairment, 58 (5.1%) ischaemic heart disease, 49 (4.3%) stroke and 21 (1.9%) patients show retinopathy.

Conclusion:
The significant association is found between hypertension and ABO blood group is the incidence of hypertension is significantly less in blood group O than other ABO blood group. The prevalence of hypertension is more or less equal both in Rh positives and Rh-negative blood group. High systolic blood pressure (>140mm of hg) is more common in AB positive blood group. High diastolic blood pressure (>90mm of hg) is associated with O positive and AB positive blood group respectively. High diastolic blood pressure (>90mm of hg) is also associated with B negative blood group. High blood pressure both systolic and diastolic is associated with A positive ABO blood group (systolic >140mm of Hg and diastolic >90mm of Hg).
In a developing country like ours the best policy for combating hypertension is the primary prevention. Implementation of screening programme doing blood grouping in community to identify population at risk and educate people about primary prevention. This way, we can reduce morbidity and mortality among hypertensive patients and alleviate the burden of hypertension.

TABLE OF CONTENTS

TITLE OF THE CONTENTS PAGE NO.
CHAPTERONE: INTRODUCTION…………………………. 1
1.1 Background 2
1.2 Rationale of the study 4
1.3 Aims and Objectives 5
1.4 Literature review 6
1.4.1 Epidemiology of Hypertension 6
1.4.2 Mechanism of essential Hypertension 7
1.4.3 Measurement of Blood pressure 8
1.4.4 Classification of Hypertension 9
1.4.5 Clinical features of Hypertension 10
1.4.6 Epidemiology of ABO & Rh Blood group 11
1.4.7 Target organ involvement 12
CHAPTER TWO: MATERIALS AND METHODS………….. 16
2.1 Study design 17
2.2 Place of study 17
2.3 Period of study 17
2.4 Study population 17
2.5 Sample size 17
2.6 Method of sample size estimation 17
2.7 Selection criteria 18
2.8 Operational definitions 18
2.9 Ethical measure 20
2.10 Data collection & sampling technique 21
2.11 Methods of data processing & statistical analysis 21

CHAPTER THREE: RESULTS 22
CHAPTER FOUR: DISCISSION 45
CONCLUSION: 54
RECOMMENDATION 55
LIMITATION OF THE STUDY 55
REFERENCES CITED 56
APPENDICES Xlll

LIST OF TABLES:
Table no. Title of the tables Page No.
Table-I Age distribution of the patients 23
Table -II Sex distribution of the patients 24
Table -IIl Residence of the patients 25
Table -IV Education Level of Respondents 26
Table -V Occupation of the respondents 27
Table -VI Socio-economic status of the patients 28
Table -VII Smoking status of the study subjects 29
Table -VlII Complications 30
Table- lX State of hypertension (controlled and uncontrolled) 31
Of the study subjects with medication
Table -X Systolic and diastolic blood pressure at 32
Presentation of the study subjects
Table -Xl BMI evaluation of the study subjects 33
Table -Xll Family history diseases of the of the 34
Study subjects
Table -Xlll F/H of HTN of the study subjects 35
Table -XlVl ABO blood group distribution of the study subjects 36
Table -XV Rh blood group distribution of the study subjects 37
Table -XVl Association of hypertension in ABO and 38
Rh blood group
Table -XVll Association of systolic blood pressure (SBP) 39
in ABO and Rh positive blood group
Table -XVlll Association of systolic blood pressure (SBP) 40
in ABO and Rh negative blood group
Table -XlX Association of diastolic blood pressure (DBP) 41
in ABO and Rh positive blood group
Table -XX Association of diastolic blood pressure (DBP) in 42
ABO and Rh negative blood group
Table -XXl Association of raised both systolic and diastolic 43
blood pressure (SBP & DBP) in ABO and Rh
positive blood group
Table -XXll Association of raised both systolic and diastolic 44
Blood pressure (SBP & DBP) in ABO and
Rh negative blood group
ACKNOWLEDGEMENT

I take pleasure to express my deep gratitude, respect and profound indebtedness to Professor Dr. Md. Zakir Hossain, FCPS (Medicine), MD(Medicine), FACP(USA), Professor and Head of the Department of Medicine, Rangpur Medical College and Hospital, for his enormous encouragement and continuous guidance and many suggestion which made this work possible.
I also express my gratitude to Dr. Md. Ashraful Haque, FCPS (Medicine), Assistant Prof. Department of Medicine and Dr. Md. Mahfuzur Rahman, MD (Internal Medicine), Assistant Prof. Department of Medicine, Rangpur Medical College for their valuable suggestions and assisting in carrying out this work.
I also express my gratitude to Dr. Sukumar Majumdar, FCPS (Medicine), MD (Neuromedicine) Registrar, Department of Medicine, Rangpur Medical College and Hospital for his appropriate supervision, constructive criticism with correction on every aspect of this study, which helped me for the successful accomplishment of the task.
I offer thanks to all the staffs working in Hypertension & Research Centre Rangpur for their sincere help in my case collection and for taking excellent care of the patient.

Date: Dr. Sobroto Kumar Roy

CHAPTER: ONE
INTRODUCTION

1.1 Background
Hypertension has proven to be a silent killer contributing to many deaths and considerably increasing morbidity worldwide.1 Worldwide prevalence estimates for hypertension may be as much as 1 billion individuals, and approximately 7.1 million deaths per year may be attributable to hypertension.2 Hypertension is rapidly emerging as a major public health problem in developing countries.3 25%of world adult population is already hypertensive. Almost three quarters of the hypertensive population are in developing countries.4

Nation wide survey on NCD conducted in Bangladesh in 2010 indicated that the prevalence of hypertension is 17.9%.5 Twelve million people suffers from hypertension in Bangladesh.6 Large prospective epidemiologic studies show a strong, direct relation between high blood pressure and mortality due to cardiovascular disease.7 Developing countries contribute nearly twice to the global cardiovascular disease burden than the developed countries.8

The ABO blood group system was discovered by Austrian scientist, Karl Landsteiner, who found three different blood types (A, B and O) in 1900 from serological differences in blood called the Landsteiner Law.9 In 1902, DesCasterllo and Sturli discovered the fourth type, AB.10 The ABO blood group is most important among the 29 blood group system and consists of four antigens (A, B, O and AB). 11, 12The genes of ABO blood group have been determined at chromosome locus 9. 13-16The blood group of a person depends upon the presence or absence of two genes, A and B.

The majority of ABO determinants are expressed on the ends of long polylactosamine chains.17 No diseases are known to result from the lack of expression of ABO blood group antigens, but the susceptibility to a number of diseases has been interrelated to a person’s ABO phenotype. 18 It has been speculated that an interaction of environmental factors acting on particular genotypes is responsible for familial (essential) hypertension, the genetic component is poorly defined and the mode of inheritance has not been determined.19 Essential hypertension generally is regarded as a polygenic disorder. 20 In some study of different parts of the world it has been shown that there are some correlation between ABO and Rh blood group with hypertension.
Karar and colleagues have estimated a > 3000% increase in Cardiovascular and cerebrovascular disease deaths in Bangladesh from 1986 to 2006.21 There is also evidence that Bangladeshi migrants to the West have high rates of Cardiovascular disease, as well as poor blood pressure control.22-24

A study conducted in Belgium reported an association between the ABO blood group and blood pressure among 42, 000 Belgian men.They found that those with blood type AB had the highest values of SBP and DBP, whereas no significant differences in blood pressure were noted according to Rh D+ and D− phenotypes.25 Another study in Israel of 621 male found 29 patients having positive association with the ABO blood group A and elevated SBP and DBP but no significant findings for the Rh system. 26

An investigation suggested significant associations between SBP and the ABO B antigen of European descent (n= 573) from Bogalusa.27 Though data are not available on a large scale about ABO and Rh blood grouping on overall population in our country but there are some study showed prevalence of ABO and Rh blood group which are A – 22.40%. B – 35.54%, AB – 9.49%, O – 32.57% and Rh positive-21.58%, 34.58%, 8.85%, 30.70% and Rh negative- 0.82%, 0.96%, 0.64%, 1.87% respectively.28

In conclusion, Hypertension is one of the main etiological factors for cerebrovascular and cardiovascular death in Bangladesh like other countries of the world. Its prevention and treatment are important public health issue.

1.2 Rationale of the study

Essential Hypertension cannot be cured, but it can be controlled through lifestyle changes and prescriptive medication. Hypertension affects multiple organs causing cardiovascular diseases, including coronary heart disease, congestive heart failure, ischaemic and haemorrhagic stroke, renal failure, and peripheral arterial disease.1 Cardiovascular diseases are the leading cause of death worldwide. The mortality rates in Bangladesh for ischaemic heart disease and cerebrovascular disease are high and increasing more rapidly than those seen in the West and in other Asian countries.29

There are some study which showed association of hypertension with ABO and Rh blood group.
A study was conducted of 5777 members of 1068 Brazilian families and investigators have reported higher diastolic pressures in subjects with blood group O than in their siblings with other ABO blood types.30 A study on African population showed significant association between the ABO blood group and DBP; Blood group B and O have high DBP than those of type A and AB. Additionally, in this population, Rh positive group was associated with elevated DBP. 31-34

In Bangladesh, data is lacking on association between Blood groups and Hypertension, our study will be therefore conducted to identify association of blood group with Hypertension.
So that by knowing the blood group we can detect the highest percentage of hypertension in specific blood group and its complications earlier as it is an asymptomatic disease.

In Bangladesh, there is no such study regarding association between blood groups and hypertension. Our study will be conducted to look at such association which will be helpful in epidemiological perspective of hypertension and its complication, co-morbidity and will also increase awareness among the general population about the management of hypertension.

1.3 Aims and objectives

General objective:

To evaluate the relationship of hypertension with the ABO and Rh blood groups.

Specific objective:

1. To find out the socio-demographic characteristics of hypertensive patient in
different ABO and Rh blood groups.
2. To find out the association of Hypertension with ABO and Rh blood groups.
3. To find out the frequency of complications of hypertensive patient in various
ABO and Rh blood group.
4. To find out the frequency of co-morbidity with hypertension in various ABO and Rh blood group.

LITERATURE REVIEW

1.4.1 Epidemiology of hypertension

The National Health and Nutritional survey (NHANES), which has been studying the health of representative samples of Americans since 1960; have reported data on the changing prevalence of hypertension and its control. According to this, the prevalence of hypertension decreased somewhat between 1960 and 1991 35. But the latest published analysis by the centre for disease control and prevention (CDC) 36, based on data obtained I the period 1991to2002, reported that the prevalence had increased by 3.6 percent, and that 28.6 percent of participants had hypertension.

Surveys in Europe show much higher rates of hypertension37. A comparison of seven European countries data found the highest rate in Germany (55 percent), and the lowest in Italy (38 percent) with France, England, Spain and Sweden II showing a prevalence between these two extremes. The prevalence in Canada is very similar to that n the United States (27 percent) 37. The reasons for these wide differences are unknown, but do not appear to be because of differences in measurements or sampling rates. In Egypt the rate is also approximately 25% whereas in China, the rate is lower (14 percent), but is increasing rapidly38.

In the United States, hypertension is significantly more prevalent in African Americans than in whites. In the more recent NHANES survey39, the prevalence in African American men was 38.6 percent whereas I white men it was 29.6 percent; in women the prevalence was 44 percent for African Americans and 29.6 percents for whites. The big issue here is whether the higher prevalence is genetic or environmental. Although the prevalence is higher than the other countries , for example , Brazil40, there is a large literature showing that the rate as of hypertension in Africans living in traditional rural societies are relatively low, but increase markedly when they move to the cities41.

There are also differences in the prevalence of hypertension in other ethnic groups. Hypertension tends to be relatively uncommon in Japanese Americans, while Philippines have rates approaching those of American Americans42. In American Indians the prevalence of hypertension is similar to that of American whites, despite a higher prevalence of obesity43.

The incidence of hypertension in India is 5- 15% in the adult population against 10- 12% in the west44. In Bangladesh overall prevalence of systolic and diastolic hypertension in a study were 14.4 & 9.1 percent respectively45. In other study overall prevalence of hypertension is11.3%46. Nation wide survey on NCD conducted In Bangladesh in 2010 indicated that the prevalence of hypertension is 17.9% 5.

1.4.3 Mechanism of Essential Hypertension1

Cardiac output and peripheral vascular resistance are the two determinants of arterial pressure. Cardiac output is determined by stroke volume and heart rate; stroke volume is related to myocardial contractility and to the size of the vascular compartment. Peripheral resistance is determined functional and anatomic changes in small arteries and arterioles.

Intravascular volume: Vascular volume is a primary determinant of arterial pressure over the long term. Sodium is predominantly an extracellular ion and is a primary determinant of the extracellular fluid volume. When Nacl intake exceeds the capacity of the kidney to excrete sodium, vascular volume initially expands and cardiac output increase. The initial elevation of blood pressure in response to vascular volume expansion is related to an increase of cardiac output reverts to normal. The effect of sodium on blood pressure is related to the provision of sodium with chloride; non-chloride salts of sodium have little or no effect on blood pressure.

Autonomic nervous system: The autonomic nervous system maintains cardiovascular homeostasis via pressure, volume and chemoreceptor signals. Adrenergic reflexes modulate blood pressure over the short term, and adrenergic function, in concert with hormonal and volume-related factors, contributes to the long-term regulation of arterial pressure. The three endogenous catecholamine are epinephrine, nor-epinephrine and dopamine. All three play important roles in tonic and phasic cardiovascular regulation.

Renin-angiotensin-aldosterone system: The renin-angiotensin-aldosterone system contributes to the regulation of arterial pressure primarily via the vasoconstrictor properties of angiotensin II and sodium retaining properties of aldosterone. There are three primary stimuli for renin secretion: 1. Decreased Nacl transport to the thick ascending limb of loop of H (macula densa mechanism). 2. Decreased pressure or stretch within the real afferent areteriol (baroreceptor mechanism), and 3. Sympathetic nervous system stimulation of renin-secreting cells via β1adrenoceptors. Once released into the circulation , active renin cleaves a substrate, angiotensinogen, to form angiotensin I. A converting enzyme located primarily but not exclusively in the pulmonary circulation, converts angiotensin I to the active angiotensin II, Acting primarily through angiotensin II type I receptors located on cell membranes, angiotensin II is a potent pressor substance, the primary trophic factor for the secretion of aldosterone by the adrenal zona glomerulosa and a potent mitogen stimulating vascular smooth-muscle cell and myocyte gro

1.4.4 Measurement of blood pressure52

Blood pressure should be measured with a well-calibrated sphygmomanometer. The bladder width within the cuff should encircle at least 80% of the arm circumference. Reading should be taken after the patient has been resting comfortably, back supported in the sitting or supine position, for at least 5 minutes and at least 30 minutes after smoking or coffee ingestion. Hypertension is diagnosed when systolic blood pressure is consistently elevated above 140 mm of Hg, or diastolic blood pressure is above 90 mm of Hg; a single elevated blood pressure reading is not sufficient to establish the diagnosis of hypertension. The major exceptions to this rule are hypertensive presentations with unequivocal evidence of life threatening end-organ damage, as seen in hypertensive emergency, or in hypertensive urgency where blood pressure is 220/125 mm of Hg but life threatening end-organ damage is absent. In less severe cases, the diagnosis of hypertension depends on a series of measurements of blood pressure, since readings can very and tend to regress toward the mean with time. Patients whose initial blood pressure is in the hypertensive range exhibit the greatest fall toward the normal range between the first and second encounters. Although blood pressure readings may still show variability after the third visit, these later changes are mostly random. However, the concern for diagnostic precision needs to be balanced by an appreciation of the importance of establishing the diagnosis of hypertension as quickly as possible, since a 3-month delay in treatment of hypertension in high risk patients is associated with a twofold increase in cardiovascular morbidity and mortality.

1.4.5 Classification of Hypertension 2

Table 1 provides a classification of blood pressure for adults aged 18 years or older. The classification based on the mean of 2 or more properly measured seated blood pressure readings on each of 2 or more office visits. This classification is provided in JNC 7 report.
Patients with prehypertension are at increased risk for progression to hypertension; those in the 130/80 to 139/89 mm of Hg BP range are at twice the risk to develop hypertension as those with lower values.

TABLE 1. Classification of blood pressure for adults aged 18 years or older
Class Systolic blood pressure Diastolic blood pressure
(mm of Hg) (mm of Hg)

Normal 120 80

Prehypertension 120-139 80-89

Stage 1 hypertension 140-159 90-99

Stage 2 hypertension ≥160 ≥100

1.4.6 Clinical Features of Hypertension53

Most patients with hypertension are asymptomatic, the high blood pressure usually having been noted during an incidental clinical examination. A proportion of patients present with a major complication of hypertension such as stroke or myocardial infarction, but only a small number present with symptoms directly attributable to hypertension such as breathlessness or headache.

Signs suggestive of secondary hypertension:
• Features of endocrine abnormalities, particularly cushing’s syndrome
• Multiple neurofibroma present in 5 percent of patients with pheochromocytoma
• Inappropriate tachycardia, suggesting catecholamine excess
• Abdominal or loin bruits, suggesting renal artery stenosis
• Renal enlargement, suggestive of polycystic kidney disease
• Radio femoral delay, due to coarctation of aorta

Signs suggestive of target organ damage:

• A forcible and displaced apex beat due to left ventricular hypertrophy.
• Accentuation of aortic component of the second heart sound
• Added heart sounds: A fourth heart sound may be audible, reflecting decreased ventricular compliance. As failure develops a third sound may occur.
• Fundal examination to detect hypertensive retinopathy.

Investigations: Routine investigation of all hypertensive patients should include

• Urinanalysis: Proteinuria,hyaline and granular cast may be found where there is renal disease or malignant hypertension. There is little or no protein in the urine if patients with benign essential hypertension.
• Blood urea: A raised level of urea suggests renal failure
• ECG: This is usually normal in patients with mild hypertension but may show evidence of left ventricular hypertrophy.
• Lipids: Although not directly related to blood pressure, an increased level of cholesterol is a risk factor for cardiovascular events.
• Blood sugar: To see associated diabetes mellitus.

1.4.2 Epidemiology of ABO & Rh Blood group

The reltive frequency of O, A, B and AB blood group in Western Europe are 46%, 42%, 9% and 3% respectively.47
In the United States, the frequency of O, A, B and AB blood group is 45%, 41%, 10% and 4%. 48 Some of the Eastern European show higher percentage of blood group B. Pure American Indians belong almost exclusively to group O.49 The frequency of Group B is highest in Central Asia. Rh D-negativity is most common in Caucasians (15%), less common in Blacks (8%), and rare in Asians (1%). 50
Though data are not available on a large scale about ABO and Rh blood grouping on overall population in our country but there are some study showed prevalence of ABO and Rh blood group, which are A – 22.40%. B – 35.54%, AB – 9.49%, O – 32.57% and Rh positive-21.58%, 34.58%, 8.85%, 30.70% and Rh negative- 0.82%, 0.96%, 0.64%, 1.87% respectively.28

1.4.9 Target organ involvement

Hypertension leads to adverse events in the brain, heart and kidneys through two related mechanisms, both of which involve the effects of increased pressure on the arteries. The first is the effects on the structure and function of the heart and arteries, and the second is the acceleration of the development of atherosclerosis. The former is directly the result of blood pressure, where as the latter requires an interaction with other risk factors for the cardiovascular disease, most importantly cholesterol. Thus strokes are closely related to the direct effects of blood pressure, whereas ischaemic heart disease is related to atherosclerosis, and the relationship between blood pressure and events is steeper for stroke than for ischaemic heart disease events. In countries where cholesterol levels are low, such as Japan, strokes are common, but ischaemic heart disease events are not54.

Heart:

Ischaemic heart disease: The prospective studies 55 Collaboration of 61 studies found strong log-liner relationships between systolic and diastolic pressure and the risk of ischaemic heart disease events in fives declines of age, ranging from 40-49 to 80-89, such that for each 20 mm increase of systolic pressure there was a twofold increase of risk over a range from 115 to 180. For diastolic pressure, the risk doubled with a 10 mm of Hg increase over a range of 75 to 100 mm of Hg. There is an interactive effect between the various risk factors; thus the relationship between systolic pressure and ischaemic heart disease risk is much steeper in patients whose cholesterols high than in patients whom it is normal 56. This relationship has been reported in several countries, although the slop of the line relating blood pressure and risk is shallower in countries where the overall risk of ischaemic heart disease is low, such as Japan57. Although it is well recognized that blood pressure is one of the three major risk factors for the development of ischaemic heart disease( the other two being high cholesterol and smoking ), it has been claimed that ischaemic heart disease often occur in patients who lack all of those risk factors. An analysis of three large prospective studies found that for both fatal and nonfatal myocardial infarctions, at least one of the big three was present in more than 90 percent of cases 58.

Heart failure:

Heart failure is now the leading cause of hospjtalization for people age 65 years and older in the United States, and unlike other complications of hypertension, its prevalence has been increasing over the past 30 years 59. For a 40 yrs old man or woman, the “remaining lifetime risk” of developing heart failure is approximately 20 percent, a surprisingly high number, if subjects with known ischaemic heart disease are excluded; the risk is 11 percent in men and 15 percent in woman 60. Blood pressure is a major contributor to this : The risk is twice as high in hypertensive men as in normotensives, and three times as high in hypertensive women; 90 percent of new cases of heart failure in the Framingham Heart Study had a history of previous hypertension61.This risk is much more strongly related to systolic than diastolic pressure 62. Treatment of hypertension in older people reduces the incidence of heart failure by approximately 50 percent 63. The good news is that the incidence of heart failure is now decreasing in women (not in men), while survival has improved in both sexes 64.
Brain:

Cerebrovascular disease: Stroke is the third most common cause of death throughout the world after ischaemic heart disease and cancer. Approximately 80 percent of strokes are ischaemic, 15 percents are hemorrhagic, and 5 percent are caused by subarachnoid hemorrhage 65. As with coronary events, there is a strong long linear relationship between both systolic and diastolic pressure and stroke, although the relationship is steeper for strokes than ischaemic heart disease events, and much stronger for systolic than diastolic pressure 66. Approximately 60 percent of patients who present with strokes have a past history of hypertension and in those who are hypertensive, approximately 78 percent have not had their blood pressure adequately controlled 67.

Kidney:

Chronic kidney disease: A Japanese study of nearly 100,000 men and women found a progressive relationship between the height of the blood pressure and the risk of developing end-stage renal disease during a 17 year follow-up period, such that there was an increased risk even in patients with high normal blood pressure, in comparison with those whose pressure was optimal (less than 120/80 mm of Hg) 68. Hypertensive patients whose blood pressure is not well controlled are more likely to show a deterioration of renal function 69, a prospective analysis of the MRFIT study also found that blood pressure was closely related to the likelihood of developing end-stage renal disease 70. Hypertensive patients with mildly impaired renal function (estimated GFR

Peripheral Vascular Disease:
Hypertension is a major risk factor for peripheral vascular disease. This is important for two reasons: first, it causes debilitating symptoms, and second, it is a marker of high risk for cardiovascular events.72 It is strongly associated with the risk factors of atherosclerotic disease-blood pressure, smoking, cholesterol, diabetes and most importantly, age.

Retina:
The optic fundi reveal a gradation of changes linked to the severity of hypertension; fundoscopy can, therefore, provide an indication of the arteriolar damage elsewhere. Cotton wool exudates are associated with retinal ischaemia or infarction, and fade in a few weeks. Hypertension is also associated with central retinal vein thrombosis. 73

CHAPTER: TWO
MATERIALS AND METHOD

2.1 Study design: Descriptive type of cross sectional study.

2.2 Place of study: Hypertension & Research Centre, Rangpur.

2.3 Period of study: July, 2012 to December, 2012.

2.4 Study population:
Hypertensive patient attending at Hypertension & Research Centre, Rangpur– A Hypertension care and Research centre.

2.5 Sample size: 1128

2.6 Method of estimation of sample size:

Sample size calculation:

Sample size is selected using the following statistical formula: n=z2pq/d2
Here,
n=sample size,
P=prevalence of adult onset hypertension in Bangladesh is 17.9%=0.179,
q=1-p=1-0.179=0.821
Z=1.96 (at 95% confidence level),
d= acceptable error or precision in the estimate of “p” it is 0.05 (5%),
Calculation: n= Z2pq/d2
= (1.96)2×0.179×0.821/(0.05)2
= 3.84×0.179×0.821/0.0025
= 0.564/0.0025
= 225.728
I will take 1128 number of hypertensive patient which is about five (5) times of minimum (225.728) sample size according to above mentioned statistical formula.
2.7 Selection Criteria

Inclusion criteria:
1. Diagnosed hypertensive patient
2. Age ≥18 years
3. Patient who gives informed consent for the study

Exclusion criteria:

1. Secondary hypertension.
2. Patients below 18 years of age.
3. Patients unwilling to take part to the study.

2.8 Operational definitions

Hypertension: Hypertension is defined as a systemic systolic blood pressure of 140 mmHg or greater and/or a diastolic blood pressure of 90 mmHg or greater, on at least 2 separate occasions.74
According to JNC-7 75: Classification of blood pressure for adults aged 18 years or older:

class Systolic blood pressure
(mmHg) Diastolic blood pressure
(mmHg)
Normal 120 and 80
Prehypertens-ion 120-139 or 80-89
Stage-1 hypertension 140-159 or 90-99
Stage-2 hypertension ≥160 or ≥100

Hypertension (controlled):

Patients whose blood pressure is bellow 140/90 mm of Hg with medication irrespective of diabetes mellitus; ischaemic heart diseases, chronic kidney diseases and stroke etc. is considered to be controlled.

Hypertension (uncontrolled):

Patients whose blood pressure is 140/90 or above 140/90 mm of Hg with medication irrespective of diabetes mellitus, ischaemic heart diseases, chronic kidney diseases and stroke etc. are considered to be uncontrolled.

Essential Hypertension:

Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors.53 In 95% of cases no causes for hypertension can be identified. The term essential (primary) hypertension is applied to this cases.53

ABO Blood Group System 76:

On the basis of the presence of A and B agglutinogens or antigens on the RBC membrane, individuals are divided into four major blood types:

BLOOD GROUP A:

Blood containing A antigen on RBC membrane and anti-B antibody in plasma is known as blood group A.

BLOOD GROUP B:

Blood containing B antigen on RBC membrane and anti-A antibody in plasma is known as blood group B.
BLOOD GROUP AB:

Blood containing A and B antigen on RBC membrane and neither antibody in plasma is known as blood group AB.

BLOOD GROUP O:

Blood containing neither antigen on RBC membrane and plasma contains both anti-A &anti-B antibody is known as blood group O.

The Rh Blood Group 76:

On the basis of the presence of D antigen o the red cell membrane, individuals are divided into two blood types:

Rh positive blood group:
Individual having antigen D on the red cell membrane is known as Rh positive blood.

Rh negative blood group:
Individual having no antigen D on the red cell membrane known as Rh negative blood.

2.9 Ethical measure

All patients were given an explanation of the study. An Written, informed and voluntary consent was taken and confidentiality assurance was provided. The study did not involve any additional investigation procedures and significant risk as well as economic burden to the patients.

2.10 Data collection and sampling technique

Data was collected using a structured data collection format containing the variables of interest. Purposive sampling method was followed as per inclusion and exclusion criteria. Evaluation of patient was based on history, physical examinations and relevant investigations.

2.11 Methods of data processing & statistical analysis:
All the data will be appropriately recorded in a computer in tabulated form. After final scrutiny data will be processed and analyzed statistically using computer software SPSS (Statistical Package for Social Sciences) windows version 17. The test statistics to be used for analysis of data are descriptive statistics, Chi-square Test. The level of significance is 0.05 and p value 60 18 1.6
Total 1128 100

The maximum number of patients 655(58.1%) in this study was in between 40-60 year followed by 455(40.3%) the 18-40 year age group. No patient was found in this study below the age of 18.

Table- lI: Sex distribution of the patients (n = 1128)
Sex Frequency Percent
Male 718 63.7
Female 410 36.3
Total 1128 100

In this study out of 1128 hypertensive patients 718 (63.7%) are male and 410 (36.3%) are female shows male preponderance with ratio of 1.75:1.

Table-Ill: Residence of the patients (n = 1128)
Residence Frequency Percent
Rural 395 35
Urban 733 65
Total 1128 100

In this study among 1128 patients 733 (65%) were from rural areas and the rest (35%) was from urban areas.

Table-IV: Education Level of Respondents (n=1128)
Educational qualification Frequency Percent
Primary 270 23.90
Secondary 262 23.20
Higher Secondary 105 9.3
Graduate 314 27.80
Post Graduate 177 15.7
Total 1128 100

In this study highest (27.8%) patients had graduate level of education followed by Primary (23.9%), secondary education (23.2%), postgraduate (15.7%) and higher Secondary (9.3%).

Table-V: Occupation of the respondents (n=1128)
Occopation Frequency Percent
Farmer 138 12.20
Service 548 48.60
Buisiness 152 13.50
Others 290 25.70
Total 1128 100.00

The above table shows that the majority patients comprised of service holder 548 (48.6%), businessman 152 (13.5%), farmer 138 (12.2%) and others occupation includes 290 (25.7%).

Table-Vl: Socio-economic status of the patients (n = 1128)
Monthly income Frequency Percent
15000 259 23.00
Total 1128 100.00

The above table shows that majority were poor 459 (40.7%) with monthly income 15000 taka.

Table-Vll: Smoking status of the study subjects (n = 1128)
Smoking status Frequency Percent
Smoker 136 12.10
Non-smoker 992 87.90
Total 1128 100.00

In the observed patients, majority (87.9%) of the patients was non smoker and 12.1%% was smoker.

Table-VllI: Complications (n=1128)
Complications Frequency Percent
None 881 78.10
Cerebral 49 4.30
Cardiac 58 5.10
Visual 21 1.90
Renal 119 10.50
Total 1128 100.00

In this study among 1128 hypertensive patients’ majority patients 881 (78.1%) showed no complication, 119 (10.5%) patients showed renal impairment, 58 (5.1%) cardiac, 49 (4.3%) cerebral and 21 (1.9%) patients showed visual complications.

Table-lX: State of hypertension (controlled and uncontrolled) of the study subjects with medication (n=1128)
State of hypertension Frequency Percent
Controlled 503 44.60
(BP<140/90mm of Hg) Uncontrolled 625 55.40 (BP>140/90mm of Hg)
Total 1128 100.00

In this study 503 (44.60%) patients are controlled and 625 (55.40%) are uncontrolled despite medication.

Table-X: Systolic and diastolic blood pressure at presentation of the study subjects
Blood Pressure Maximum Minim Mean Standard deviation

Systolic BP 170 110 136.42 18.534
Diastolic BP 120 60 86.65 11.602

In his study maximum systolic blood pressure (SBP) is 170 mm of Hg; minimum SBP is 110 mm of Hg and mean SBP is 136.42 mm of Hg with standard deviation 18.538. Maximum diastolic blood pressure (DBP) is 120 mm of Hg, minimum DBP is 60 mm of Hg and mean DBP 86.65 mm of Hg with standard deviation 11.602.

Table-Xl: BMI evaluation of the study subjects (n=1128)
BMI Frequency Percent Mximum Minimum Mean(sd)
Normal 236 21
Overweight 715 66.7
Moderate 100 8.8
obese 33 16 250.70(3.579)

Severe 00 00
obese
Under weight 48 3.5
Total 1128 100

Among 1128 hypertensive patients 236 (21%) patients have normal BMI, 751 (66.7%) patients are overweight or mild obese, 100 (8.8%) patients are moderately obese and 41 (3.5%) patients are under weight.

Table-Xll: Family history diseases of the of the study subjects (n=1128)
Family history of diseases Frequency Percent
DM 166 14.80
IHD 86 7.60
COPD 160 14.20
Hyperlipidaemia 15 1.30
Others 701 62.10
Total 1128 100.00

Among 1128 hypertensive patients 166 (14.2%) have family history of diabetes mellitus (DM), 86 (7.6%) have family history of ischaemic heart disease (IHD), 15 (1.3%) have family history of hyperlipidaemia and 701 (62.1%) patients have family history of other diseases.

Table-XIll: F/H of HTN of the study subjects (n=1128)
Family history of HTN Frequency Percent
Positive 851 75.4
Negative 277 24.6
Total 1128 100

The above table showed that majority of the study patients have positive family history of hypertension 851(75.4%) and 277 (24.6%) of patient have no family history of hypertension.

Table-XIV: ABO blood group distribution of the study subjects (n=1128)
Blood group Frequency Percent
A 362 32.1
B 465 41.2
AB 142 12.6
O 159 14.1
Total 1128 100.0

In this study among the 1128 subjects 465 (41.2%) belongs to ABO blood group B, 362 (32.1%) blood group A, 159(14.1%) blood group O and 142(12.6%) subjects belongs to blood group AB respectively.

Table-XV: Rh blood group distribution of the study subjects (n=1128)
Rh type Frequency Percent
Positive 1045 92.6
Negative 83 7.4
Total 1128 100.0

In this study among the 1128 subjects’ majority1045 (92.6%) belongs to Rh blood group positive and only 83 (7.4%) are Rh blood group negative.

Table-XVl: Association of hypertension in ABO and Rh blood group (n=1128)
ABO &Rh blood group Frequency Percent
A positive 361 32
A negative 01 0.1
B positive 401 35.54
B negative 64 5.7
AB positive 142 12.58
AB negative 00 00
O positive 141 12.5
O negative 18 1.6
Total 1128 100

In this study all the subjects were known hypertensive (HTN) and among the 1128 subjects majority 401(35.54%) are B positive, 361(32%) are A positive, 142 (12.58%) are AB positive, 141 (12.5%) are O positive, 64 (5.7%) are B negative, 18 (1.6%) are O negative, only 1 (.1%) are A negative and as well as hypertensive respectively and none of the study subjects are found to have blood group AB negative.

Table-XVlI: Association of systolic blood pressure (SBP) in ABO and Rh positive blood group (n=1128)
ABO group Rh group Frequency Frequency of SBP Percent
(>140/90mm of Hg)
A positive 361 44 12.18
B positive 401 36 8.97
AB positive 142 56 39.43
O positive 141 00 00
Total 1045

The table shown that out of total 1128 study subjects 1045 are Rh positive & among them 361 individuals belongs to A positive ABO blood group and among them only 44 (12.18%) subjects have showed predominantly raised systolic blood pressure (>140mm of hg). 401 subjects are B positive and among them 36 (8.97%) subjects and 142 subjects are AB positive and among them 56 (39.43%) subjects have showed predominantly raised systolic blood pressure.141 subjects belongs to O positive ABO blood group and none of them have showed predominantly raised systolic blood pressure.

Table-XVlll:Association of systolic blood pressure (SBP) in ABO and Rh negative blood group (n=1128)
ABO group Rh group Frequency Frequency of SBP Percent
(>140/90mm of Hg)
A Negative 01 00 00
B Negative 64 00 00
AB Negative 00 00 00
O Negative 18 00 00
Total 83

The table shown that out of total 1128 study subjects 83 are Rh negative & among them 01 individuals belongs to A negative ABO blood group, 64 subjects are B negative, 18 subjects are O negative and none of the study subjects belongs to AB negative ABO blood group and none of them have showed predominantly raised systolic blood pressure.

Table-XlX: Association of diastolic blood pressure (DBP) in ABO
and Rh positive blood group (n=1128)
ABO group Rh group Frequency Frequency of DBP Percent
(>90mm of Hg)
A Positive 361 30 8.31
B Positive 401 01 0.24
AB Positive 142 63 44.36
O Positive 141 116 82.28
Total 1045

The table shown that out of total 1128 study subjects 1045 are Rh positive and among them 361 individuals belongs to A positive ABO blood group and among them only 30 (8.31%) subjects have showed predominantly raised diastolic blood pressure (>90mm of hg). 401 subjects are B positive and among them 01 (0.24%) subjects and 142 subjects are AB positive and among them 63 (44.36%) subjects have showed predominantly raised diastolic blood pressure.141 subjects belongs to O positive ABO blood group and among them majority 116 (82.26%) subjects have showed predominantly raised diastolic blood pressure.

Table-XX: Association of diastolic blood pressure (DBP) in ABO
and Rh negative blood group (n=1128)
ABO group Rh group Frequency Frequency of DBP Percent
(>140/90mm of Hg)
A Negative 01 00 00
B Negative 64 64 00
AB Negative 00 00 00
O Negative 18 00 00
Total 83

The table shown that among the 83 Rh negative study subject 01 individuals belongs to A negative ABO blood group, 18 subjects are O negative and none of the study subjects belongs to AB negative ABO blood group and none of them have showed predominantly raised diastolic blood pressure. Only 64 subjects are B negative and all of them (100%) have showed predominantly raised diastolic blood pressure.

Table-XXl: Association of raised both systolic and diastolic blood pressure (SBP & DBP) in ABO and Rh positive blood group (n=11228)
ABO group Rh group Frequency Frequency of SBP&DBP Percent
(SBP>140& DBP>90
mm of Hg)
A Positive 361 205 56.78
B Positive 401 24 5.98
AB Positive 142 01 0.70
O Positive 141 25 17.73
Total 1045

The table shown that among the 1045 Rh positive study subject 361 individuals belongs to A positive ABO blood group and among them mjority205 (56.78%) subjects have showed predominantly raised both systolic (>140mm of Hg) and diastolic blood pressure (>90mm of Hg). 401 subjects are B positive and among them 24 (5.98%) subjects and 142 subjects are AB positive and among them 01 (0.70%) subjects have showed predominantly raised both systolic and diastolic blood pressure.141 subjects belongs to O positive ABO blood group and among them 25 (17.73%) subjects have showed predominantly raised both systolic and diastolic blood pressure.

Table-XXll: Association of raised both systolic and diastolic blood pressure (SBP & DBP) in ABO and Rh negative blood group (n=11228)
ABO group Rh group Frequency Frequency of SBP&DBP Percent
(SBP>140& DBP>90
mm of Hg)
A Negative 01 01 100
B Negative 64 00
AB Negative 00 00
O Negative 18 00
Total 83

The table shown that out of total 1128 study subjects 83 are Rh negative & among them 01 individuals belongs to A negative ABO blood group and 01 (100%) found to have predominantly raised both systolic and diastolic blood pressure. 64 subjects are B negative, 18 subjects are O negative and none of the study subjects belongs to AB negative ABO blood group and none of them have showed predominantly raised both systolic and diastolic blood pressure.

CHAPTER: FOUR
DISCUSSION

DISCUSSION
This is a cross-sectional retrospective study to observe the association of hypertension with ABO and Rh blood group in hypertension and research centre, rangpur. A total number of eleven hundred twenty eight five cases of hypertensive patients were selected from hypertension and research centre, rangpour during the period of July 2011 to July 2012. Patients diagnosed clinically as hypertension and ABO and Rh blood group was detected in every individual followed by other laboratory investigation that was done in all study subjects

Age frequency:

This study shows 1128 hypertensive patients who are between 18 to85 years of age. Among them majority are 40 to 60 years of age 655 (58.1%), that is majority are young and middle aged. When for the first time they are diagnosed as hypertensive 252 (22.3%) patients are in stage 1 HTN and 370 (32.8%) patients are in stage 2 HTN. In both stages majority of patients are in
between 40 to 60 years of age.
The result of a study shows that increased age is associated with a significant increase in the prevalence of hypertension and especially systolic hypertension after aged 50 years. Increased obesity between aged 30 to 50 years is associated with significant increased in diastolic blood pressure. 77

Another study shows the prevalence of hypertension among individual aged >60, is 65.4 percent 1. In this study, total 1128 hypertensive patients, most are in 40 to 60 years of age group. The discrepancy may be due to the increased awareness of hypertension in middle-aged people and aged people are neglected in our society because of low socio-economic condition.

Sex frequency:

In this study out of 1128 hypertensive patients 718 (63.7%) are male and 410 (36.3%) are female. male female ratio is 1.75:1. The percentage of male patients are higher than female both in stage l and ll hypertension.

Hypertension is more common in men than in women of same age. Sex difference in the prevalence of hypertension may be mainly attributed to the differences in dietary habit, life style choice, sodium and potassium intake, Physical activity level and some genetic polymorphism. 77

Smoking and hypertension:

In this study among 1128 hypertensive patients, majority (87.9%) of the patients was non-smoker and 12.1%% was smoker.

A prospective study shows that cigarette smoking is modestly associated with hypertension. 78, 79

Family history of hypertension:

In this study among 1128 hypertensive patients majority 851(75.4%) patients have family history of hypertension. So there is a strong association of hypertension with positive family history.

In a screening program, blood pressure measurements, family (parents) histories of hypertension and self evaluations of weight class are obtained for more than a half million people. Positive family history is associated with hypertension prevalence double that found in patients with negative history and is independent with weight. When over weight is also present, however hypertension prevalence is three to four times as high.80

BMI and hypertension:

Higher BMI is associated with a higher prevalence of hypertension in all ethnic groups.81
In this study among 1128 hypertensive patients’ 236 (21%) patients have normal BMI, 751 (66.7%) patients are overweight or mild obese, 100 (8.8%) patients are moderately obese and 41 (3.5%) patients are under weight that is BMI <18.5.

State of hypertension (controlled & uncontrolled) with medication:

In this study among 1128 hypertensive patients’ 503 (44.60%) patients are controlled (BP < 140/90 mm of Hg) and 625 (55.40%) are uncontrolled (BP 140/90 or > 140/90 mm of Hg) despite taking regular medication.
In a study involving patients with hypertension, who is followed up regularly at veterans’ affairs clinics, where free care and medications are provided. Only 25% of patients have well-controlled blood pressure and 40% have levels below 160/90 mm of hg after years follow up. 82
The disparity between these studies is probably due to single centre study.

ABO blood group and hypertension:

In this study among the 1128 subjects 465 (41.2%) belongs to ABO blood group B, 362 (32.1%) blood group A, 159(14.1%) blood group O and 142(12.6%) subjects belongs to blood group AB respectively.
The relative frequency of O, A, B and AB blood group in Western Europe are 46%, 42%, 9% and 3% respectively.47
In the United States, the frequency of O, A, B and AB blood group is 45%, 41%, 10% and 4%. 48
In a study of our country showed prevalence of ABO blood group are A – 22.40%. B – 35.54%, AB – 9.49%, O – 32.57%. 28
So it shows that prevalence of hypertension is more in B (41.2%) and A (32.1%) respectively and lowest in O (14.1%) and AB (12.60%) group that is significant.
In a study of Belgium reported an association between the ABO blood group and blood pressure among 42, 000 Belgian men. 25 They found that those with blood type AB had the highest values of SBP and DBP.
The discrepancy between Belgian study and this study probably due to small number of sample size.

Rh blood group and hypertension:
In this study majority 1045 (92.6%) belongs to Rhesus positive and only 83 (7.4%) are Rhesus negative.
In a study it has been found that Rh D-negativity is most common in Caucasians (15%), less common in Blacks (8%), and rare in Asians (1%)50.
That is prevalence of hypertension found more or less equal both in Rh negative (7.4%) (7.4% vs 1%) and in Rh positive blood group (92.6%).
A study conducted in Belgium among 42, 000 Belgian men reported no significant association between Rh D+ and D− phenotypes.25
Another study in Israel of 621 male found no significant findings for the Rh system. 26
The discrepancy between Belgian and Israelis study and this study probably due to small number of sample size and as well as absent of control group.

Systolic blood pressure and ABO and Rh positive blood group:

A study was conducted of 5777 members of 1068 Brazilian families and investigators have reported higher diastolic pressures in subjects with blood group O than in their siblings with other ABO blood types.30
In this study 142 subjects are AB positive and among them 56 (39.43%) subjects have showed predominantly raised systolic blood pressure than other ABO blood types.
The discrepancy probably due to small number of sample size.
Systolic blood pressure and ABO and Rh negative blood group:

In this study there is no relation of systolic hypertension with Rh positive ABO blood group.
The discrepancy is probably due to small number of sample size.

Diastolic blood pressure and ABO and Rh positive blood group:

A study on African population showed significant association between the ABO blood group and DBP; Blood group B and O have high DBP than those of type A and AB. Additionally, in this population, Rh + group was associated with elevated DBP31-34.
Among the 361 A positive ABO blood group 30 (8.31%) subjects, among 401 B positive 01 (0.24%) subjects, out of 142 AB positive 63 (44.36%) and among 141 O positive majority 116 (82.26%) subjects shows predominantly raised diastolic blood pressure (>90mm of hg).
These data are consistent with this study. In this study diastolic blood pressure is high in O positive blood group 116 (82.26%) and in AB positive group 63 (44.36%).

Diastolic blood pressure and ABO and Rh negative blood group:

In this study among the 83 Rh negative study subjects 64 subjects are B negative and all of them (100%) (100% vs 5.70%) shows predominantly raised diastolic blood pressure.
A study on African population showed, Rh + group was associated with elevated DBP. 31-34
The discrepancy probably due to small number of sample size.

Both systolic and diastolic blood pressure and ABO and Rh positive blood group:
In this study out of 1045 Rh positive subjects 361 individuals are A positive ABO blood group and among them majority 205 (56.78%) subjects, among 401 B positive 24 (5.98%) subjects, among 142 AB positive 01 (0.70%) subjects and among 141 O positive blood group 25 (17.73%) subjects have showed predominantly raised both systolic and diastolic blood pressure (>140mm of Hg) and diastolic blood pressure (>90mm of Hg).

In a study of Belgium reported an association between the ABO blood group and blood pressure among 42, 000 Belgian men25. They found that those with blood type AB had the highest values of SBP and DBP.
These findings are not consistent with other studies possibly due to small number of sample size and absent of control subjects.

Both systolic and diastolic blood pressure and ABO and Rh negative blood group:

In this study among the 83 Rh-negative study subject 01 individuals belongs to A negative ABO blood group and 01 (100%) found to have predominantly raised both systolic and diastolic blood pressure.
These findings are not consistent with other studies probably due to small sample size.

Target organ damage:

Hypertension and heart disease:

For adult aged 40 to 69 years each 20 mm of hg rise in usual systolic blood pressure or 10 mm rise in diastolic blood pressure doubles the risk of death from ischaemic heart disease. 83 The INTERHEART study shows that 20% of heart attacks in Western Europe are due to a history of high blood pressure and those with hypertension have almost twice the risk of a heart attack. 84 One study shows that, the percentage of IHD is higher in patients with hypertension and dyslipidaemia 85.

In this study, among 1128 hypertensive patients 58 (5.1%) patients have IHD. The discrepancy between INTERHEART study and this study probably the study was done in European population, not in Asian.

Hypertension and stroke:

Hypertension was the main cardiovascular ri9sk factor only for lacunar and atherothrombotic infarction that is ischaemic stroke associated with small and large artery disease. 86
Untreated hypertension is an important risk factor for haemorrhagic stroke. Study shows that among hypertensive subjects, approximately one fourth of haemorrhagic strokes would be prevented if all hypertensive subjects receive treatment. 87
In this study among 1128 hypertensive patients total 49 (4.3%) patients have stroke.

Kidney diseases and hypertension:
Chronic kidney disease (CKD) occurs commonly in patients with cardiovascular disease. In addition, CKD is a risk factor for the development and progression of cardiovascular disease. 88

Study shows, after adjusting for age, sex, smoking status, and baseline glomerular filtration rate (GFR), hypertensive patients without other metabolic risk factors have a double relative risk of CKD (Versus normotensive patients). 89
In this study, among 1128 hypertensive patients In this study among 1128 hypertensive patients 119 (10.5%) patients showed renal impairment.
Retinopathy and hypertension:

Both the presence 90 and development of new hypertensive retinopathy signs 91 are strongly related to elevated blood pressure.
In this study among 1128 hypertensive patients 21 (1.9%) patients have hypertensive retinopathy.

Peripheral arterial disease and hypertension:

In the SHEP study, it is shown that 2-5% hypertensive patients also experience signs and symptoms of peripheral arterial disease at presentation such as intermittent claudication, the prevalence increases with age. 92 Conversely, in PARTNARS study, 30 to 65 patients with peripheral arterial disease have elevated blood pressure at presentation.93

In this study, no patient is found with peripheral arterial disease.
In 1128 hypertensive patients cardiac, cerebral and renal involvement as target organ damage is not significant statistically. The cause may be, the patients have not got enough time for organ damages to be significant statistically.

CONCLUSION

Hypertension is one of the foremost causes of morbidity, mortality and a socioeconomic challenge, more so in Bangladesh where health support system including the rehabilitation system is not within the reach of ordinary people. It is clear that, this long term sufferings not only affect the patients but also it generates an enormous economic and social burden for families and communities.
This study shows significant association is found between hypertension and ABO blood group is the incidence of hypertension is significantly less in blood group O than other ABO blood group. The prevalence of hypertension is more or less equal both in Rh positives and Rh-negative blood group. High systolic blood pressure (>140mm of hg) is more common in AB positive blood group. High diastolic blood pressure (>90mm of hg) is associated with O positive and AB positive blood group respectively. High diastolic blood pressure (>90mm of hg) is also associated with B negative blood group. High blood pressure both systolic and diastolic is associated with A positive ABO blood group (systolic >140mm of Hg and diastolic >90mm of Hg).

In most cases the cause of hypertension is unknown, there may be some genetic influence though yet not established. ABO and Rh blood group in each individual is also genetically determined. So this association might helps in the identification of hypertension, its early prevention, treatment and prevention of target organ damage. In a developing country like ours the best policy for combating hypertension is the primary prevention.

RECOMMENDATION

For the primary prevention of hypertension and to reduce the morbidity of hypertension recommendations of this study are:

• As hypertension is related with some ABO and Rh blood group, to Increase awareness and education among people regarding hypertension in community blood grouping should be done in medical practice.
• For the effective control of hypertension and to prevent or minimize target organ damage it needs proper screening program of ABO and Rh blood grouping and early detection of hypertension.

LIMITATION OF THE STUDY:

• The study is conducted in one centre only.
• Small sample size and absent of control group.
• Reversible risk factors of hypertension are not considered.
• Unavailability and unaffordability of necessary investigations to rule out secondary hypertension.

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Appendix l

Data Collection Format
Hypertension & Research Centre, Rangpur.

Title: Association of ABO blood group with Hypertension in hypertensive patients of Hypertension & Research Centre, Rangpur.

ID NO………… Mobile No Date…………..

(A) Socio-demographic data:

1. Age 18-40 years-1, 40-60 years- 2, 60 years- 3
2. Sex Male- 1, Female- 2
3. Residence Rural – 1, Urban – 2
4. Educational Qualification No education- 1, Primary- 2, Secondary- 3, Higher secondary- 4, Graduate- 5, Post Graduate- 6, Madrasa education- 7
5. Occupation Farmer- 1, Service- 2, Businessman- 3, Others- 4
6. Socioeconomic status(monthly income) 5000- 1, 5001-10000- 2, 10001-15000- 3, 15000
7. Smoking status Yes – 1, No – 2, Number of stick/day…….. Duration in days……. Pack years…… No- 1, ≤10- 2, 11-20- 3, 21-30- 4, 30- 5
8. Other habit No- 1, Jarda, Gul, Other tobacco derived substances- 2, Alcohol- 3, Other addiction- 4
9. Dietary habit Vegetarian – 1, Non vegetarian – 2
10. Physical activity Yes- 1, No- 2

(B) Clinical data:

1. Hypertension Stage-(1) – 1
Stage-(2) – 2
2. BMI wt(kg) / height(m2)
Weight(kg)- Height(cm)- BMI-
3. Complications None – 1, Cerebral – 2, Cardiac – 3, Visual – 4, Renal– 5, Others (………………………) – 6
4. Associated diseases DM – 1, IHD – 2, COPD/Bronchial Asthma – 3, Migraine – 4, Hyperlipidaemia – 5, Others (…………………) – 5
5. Drugs OCP – 1, Steroids – 2, NSAIDs – 3, Sympathomymetic drugs – 4, Others (……………….) – 5
6. Pulse Rate: Normal – 1, Abnormal – 2,
Rhythm: Regular – 1, irregular – 2
7. Oedema Absent – 1, Present – 2
8. Neck vein Engorged – 1, Not engorged – 2
9. Drugs Treatment history Regular – 1, Irregular – 2

(C) Investigations:

1.
Urine-R/E:
Albumin: Absent(1), Present (2),  (3),  (4)
2. Blood sugar:
Fasting : Normal- 1, IGT- 2, DM- 3
2hours after 75 gm glucose intake : Normal- 1, IGT- 2, DM- 3

3. Serum creatinine: Normal- 1, Abnormal- 2
4. Lipid profile (mg/dl):
Total cholesterol: Desirable- 1, Borderline high- 2, high- 3
High-density lipoprotein (HDL) cholesterol: Low- 1, High- 2
LDL-cholesterol: Optimal- 1,Above optimal- 2,Borderline- 3,
High- 4, Very high- 5
Triglyceride (TG) : Normal- 1, Borderline high- 2, High- 3,
Very high- 4
5. ECG: Normal- 1, Abnormal- 2
6. X-ray chest P/A view: Normal-1, Cardiomegaly-2, Aortic unfolding- 3, Others- 4
7. Echocardiogram: LVH: Present- 1, Absent- 2

RWMA: Present- 1, Absent- 2

LVEF: ≥55%- 1,50-54%- 2, 40-49%- 3, 40%- 4
8. Blood Group: A – 1 , B – 2, AB – 3, O – 4,
Rh- Positive – 1, Rh-Negative – 2

Signature of Doctor

Appendix ll

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