the population impact of arterial hypertension ( aht ) consists in its high prevalence and in the strength of its risk ratio with cardiovascular pathologic conditions .
more than a quarter of the world adult population is already hypertensive and this number is projected to increase to 1,56 billion people by 2025 .
this estimation relies especially on a steep increase of aht in the developing countries [ 1 , 2 ] .  
a large number of clinical trials have shown that the cardiovascular risk could be considerably diminished by a tight reduction of the blood pressure ( bp ) values . despite their encouraging data ,
the real rates of arterial hypertension awareness , and control are continuing to remain unsatisfactory in many areas of the world [ 3 , 4 ] .  
romania is an east european developing country , with a high mortality in cardiovascular disease , as was reconfirmed in the last european cardiovascular disease statistics report   and it is supposed that uncontrolled aht is an important contributor to this result . in order to find out the prevalence , the awareness , and the control of blood pressure in romania , we have carried on a cross - sectional survey , named sephar : study for the evaluation of prevalence of hypertension and cardiovascular risk in adult population in romania .
this study is the first assessment of blood pressure and major correlated cardiovascular risk factors accomplished on a representative sample for the entire adult population in romania .
the design of the sephar study was similar with that of the natpol plus study , conducted earlier in poland [ 6 , 7 ] .
the procedures applied in the sephar study were in accordance with the declaration of helsinki of 1975 , revised in 1983 .
romania 's area was divided into ten regions , recommended by the national commission of statistics .
the locations of interviewing were selected at random , on a basis of a computerized system elaborated and applied by a company specialized in research .
the structure of the population aged 18 , according to sex , in each location , was obtained from the central bureau of statistics , having as a source document the census made in 2002 .
the addresses of interviewing were selected from the database of the general direction of computerized evidence of the population .
consequently , we were able to find out that in a specific location there is a person , male or female , aged of certain years .
it is worth noticing that , using this procedure , we did not reach a person with a precise identity ; we found out a subject with certain demographic characteristics , with respect to the law no .
677/2001 on protection of persons regarding the processing of personal data and their free circulation in romania .    on the whole , 2131 subjects agreed to participate in the study , to have the blood pressure measured , and to fill in the medical history questionnaires . among these , 2017 have accepted also the collection of blood samples .  
specially trained nurses obtained data for the respondents at the patients ' home . during the visit ,
the nurse had to obtain the informed consent for the participation in the study , to complete the questionnaire , and to measure the arterial blood pressure , weight , height , and waist circumference .
the bp was measured at each arm with fully automatic devices ( oscillometric pressameters omron m5-i ) , adapted for the arm circumference .
the highest value between the two arms was that of reference . if at the initial visit the bp was elevated and the subject was not known with arterial hypertension , two more visits for bp measurement were mandated to confirm the abnormal values , at one - to - three day interval .
three measurements of bp had to be done at each visit with at least three minutes pause between the consecutive readings , ignoring the first one and calculating the average between the last two of them .
the arterial ht was defined as values 140  mmhg for the sbp or 90  mmhg for the dbp , according to the european society of hypertension guidelines applicable in 2005   and reconfirmed by the guidelines issued in 2007 .
new diagnosed cases of arterial hypertension were those who have denied a previous diagnosis of hypertension and were found at the initial and at the confirmation visits with high bp .
the prevalence of arterial hypertension resulted from the addition of known to the new diagnosed cases .
the general control of hypertension was calculated from the ratio of subjects with blood pressure below 140/90  mmhg to the number of hypertensive persons on a whole ( known and newly diagnosed ) .
the control of treated hypertension was deduced from the ratio of subjects with blood pressure below 140/90  mmhg to the total number of treated hypertensive persons .
data about the prevalence , awareness , rate of treatment , and control of hypertension were obtained for the whole sample and by comparing specific categories of population splitted by gender , age groups , and area of residence with the  test . on the analysis of the results ,
the statistical significance was tested with an interval of confidence of 95% , for which the maximum error was of 2,18% for 2017 respondents .
the age and gender structure , the repartition of subjects depending on the area of residence , and the mean values of blood pressure are represented in table 1 .
we have to mention that bucharest , the capital , which was analyzed separately from the other nine regions of the country , was included in the urban area , conducting to a higher number of subjects in this category of residence .
the mean systolic bp was 137.63  23.43  mmhg , with an important rise for every age group in each gender .
the values have continuously increased from 119.99  13.70  mmhg in the youngest age group to 152.76  24.17  mmhg in the age group 65 years old .
the mean diastolic bp was 83.13  13.12  mmhg , higher with every age group until the age of 5564 years , but starting to decline in the oldest age group ( 65 years ) .
for both systolic and diastolic bp , the mean level was higher in men than in women for adult subjects , the gender difference diminishing by the sixth decade .
the total prevalence of the arterial hypertension was 44,92% , significantly higher in men ( 50,17% ) than in women ( 41,11% ) ( p < .0001 ) , but with the gender difference beginning to diminish in the age group of 5564 years .
the frequency of arterial hypertension was augmenting with age , reaching a rate above 70% after 65 years .
a greater prevalence of arterial hypertension was observed in the rural area ( 49,47% ) as compared to the urban area ( 41,58% ) , which attended statistical significance ( p < .02 ) table 2 .
the general rate of awareness was 44,26% , increasing with age , higher in women ( 52,8% ) than in men ( 34,58% ) ( p
< .0006 ) , with the gender difference being noticed for every age group after 45 years old .
the rate of treated hypertension was again in favor of women ( 46,56% ) in comparison with men ( 30,11% ) ( p < .003 ) table 4 .
the number of the total hypertensive subjects who were on the target values of bp was 7,72% .
the analysis of data regarding the treatment control has revealed a general rate of 19,88% , with no differences between gender or area of residence table 4 .
sephar was the first study addressed to the prevalence , awareness , and control of hypertension on a representative sample for the entire population of romania .
even if the selection of the subjects was based on the method of stratified proportional sampling , the results must be cautiously interpreted due to the limited number of subjects included , in comparison with the adult inhabitants as a whole . when referring the data to the literature , we have to notice the heterogeneity of different studies with regard to the sampling method ( stratified sampling or selection during clinical visits ) , age of subjects enrolled , number of visits for the measurements of blood pressure , adaptation of cuff size for the arm circumference , or the period of time when the survey has been done .
therefore , a special attention will be focused on the comparison with the results of natpol plus , a study that has been realized with the same methodology in poland .  
our data are indicating a 44,92% prevalence of the aht in romania , higher than in poland , where was estimated at 29% [ 6 , 7 ] . in general , the rates of aht are greater in europe than in the united states ( 28% ) , canada ( 27% ) , or asian countries including china ( 20% ) or korea ( 22,9% ) [ 4 , 1012 ] .
the prevalence of aht in romania can be integrated between lower values in europe like those in greece ( 31,1 ) , sweden ( 38% ) , italy ( 38% ) , united kingdom ( 42% ) , czech republic ( 42% ) , or portugal ( 42,1% ) and higher values such as those from spain ( 47% ) or germany ( 55% ) [ 4 , 1315 ] . for each gender
the ratio of aht frequency between the two genders is varying from one study to another and in poland was greater in women .
there are not many studies analyzing the results in regard to the area of residence .
in contrast to other observations and the assertion that aht is more often encountered in the urban areas , we have found a bigger prevalence of high blood pressure in the rural areas .
we are not able to comment , at this moment , if these results could be explained by some deleterious habits in lifestyle such as the excessive salt or alcohol consumption or by concomitant predominance of obesity in the rural zones .
less than half of the hypertensive subjects were aware of their condition . in the polish study ,
. in europe , the hypertension awareness is varying from 46% in portugal   to 60% in greece   or even 70% in czech republic . in countries with national health programs effectuated for cardiovascular risk reduction ,
the level of aht awareness has much improved , rising to 66% in united kingdom   or 76% in united states   and attesting the success of a coordinated policy for high bp detection .  
the rate of treatment control in our sample ( 19,88% ) was similar with poland and comparable with the results of other studies [ 4 , 14 , 17 ] .
the good survey has found that in the atlantic european mainland more patients had uncontrolled bp ( 80% ) compared with northwest , mediterranean , and central europe ( 70% ) .
recent data from bp - care study , conducted in central and east european countries ( including romania ) with subjects selected from clinical visits to general practitioners or specialists , are showing that bp control was achieved in only 27,1% of treated hypertensive persons .   as a whole , in comparison with the results of the natpol plus
study in poland , the prevalence of aht was higher , the awareness was worse , and the bp control was similar .
these data should be interpreted , in the future , taking into account the differences between the genetic background , the lifestyle habitudes , and the health policies in each country .
 east european countries have reported high prevalence of arterial hypertension ( aht ) . in order to investigate the data for romania 
 , we firstly performed a national survey  the study for the evaluation of prevalence of hypertension and cardiovascular risk in adult population in romania ( sephar ) . 
 a representative population was selected using stratified proportional sampling , including 2017 adult subjects , 18 years old . 
 the general prevalence of   aht was 44,92% , higher in men ( 50,17% ) than in women ( 41,11% ) ( p < .0001 ) and predominant in rural areas ( 49,47% ) in comparison to the urban ones ( 41,58% ) ( p < .02 ) . 
 aht awareness attended 44,26% , rising with age , significantly lower in men ( 34,58% ) than in women ( 52,8% ) ( p < .0006 ) . 
 we have found a 38,85%   proportion of treated hypertensive persons , worse for men ( 30,11% ) then for women ( 46,56% ) ( p < .003 ) . 
 the rate of aht control was 19,88% , with no significant differences between gender . in conclusion , we estimated for romania a high prevalence of aht , a level of awareness and treatment lower than in many european countries and a rate of treatment control at the inferior limit of the european average . 
 males , characterized by a higher prevalence of aht , were also less aware and less treated than women . 
1. Introduction
2. Method
3. Statistical Analysis
4. Results
5. Discussion