Our study was conducted to determine the magnitude, clinical presentations, treatment adherence, undiagnosed hypertension, and outcome of stroke among admitted patients in tertiary hospitals in Addis Ababa, Ethiopia. The prevalence of undiagnosed hypertension was 79 (15.1%). Nearly half, 271(51.2%) had a hypertension history with 33.6% of them having poor adherence to their medication and 24.4% didn’t start anti-hypertensive medication. In-hospital mortality in this study was 90 (17.2%). Being male was found independently associated with undiagnosed hypertension among stroke patients.
In the current study, more than two-thirds, (65.8%) of the patients had an ischemic stroke, and (29.8%) had intracerebral hemorrhage. This is consistent to the study conducted in Shashemenie(65.8%) [12],Bahirdar (59.4%) [13], and Ayder compressive hospital(55.6%) [14]. On the contrary, hemorrhagic stroke was the most common cause of stroke accounting for 57% of all patients according to the study conducted in Black Lion Hospital. This difference in the type of stroke might be related to the study setting.Black Lion Hospital is the country referral center where neurosurgical procedures are commonly conducted. So, most critical patients with hemorrhagic stroke might be referred to this hospital.
The standard treatment for ischemic stroke is the administration of thrombolysis within 4.5 hours of the occurrence of stroke. However, in our study, only 27.3% of the patients presented to the hospital within this time frame. Similarly, only 3.6% of patients arrived at the hospital within 3 hours of the onset of clinical symptoms in a study conducted in Bahardare [13]. Despite this, drugs are not available in many public hospitals of the country and even if it’s available in a few centers, the delayed presentation of stroke patients hinders its use.
In our study, among the known hypertensive patients, 33.6% of patients had poor treatment adherence and 24.4% were not started on antihypertensive. This is similar to the study conducted in Black Lion Hospital where 38.3% of patients had poor adherence and 28.9% had not started antihypertensive [15]. Another retrospective study in Felege-Hiwot Referral Hospital in Bahir Dar showed that 56% of the known hypertensive patients had discontinued antihypertensive medications [16].
Undiagnosed hypertension was 15.5% among all the stroke patients in our study. This is consistent with the study conducted in Bangladesh study (15.8%) [16]and India King George's Medical University Hospital indicated that 24.39%[17]. On the other hand, our study is less than the study conducted in China ( 55.6%) and another study in Mexico where about one-third of the patients had undetected hypertension [18].
Lastly, in our study, male stroke patients had a significantly higher risk of undiagnosed hypertension. In a community-based cross-sectional, undiagnosed hypertension was significantly higher among males in Mizan-Aman Town, Bench Sheko Zone, Southwest Ethiopia[19] in another study Among Adults in Hawela Tula Sub-City, Hawassa, Southern Ethiopia [20].The higher number of undiagnosed hypertension in the community increases the incidence of stroke related to diagnosed hypertension in health institutions.
In our study, 17.2% of stroke patients died in the hospital. The study conducted in different parts of the country revealed different findings. The study conducted in Bahirdare revealed an 11% in-hospital mortality rate[21], 12.0% in-hospital mortality in Ayder a comprehensive tertiary referral Hospital [22], and 14.7% in-hospital stroke mortality in Hawassa[23] showed a lower mortality rate compared to our finding. On the other hand, a significantly higher (44.5%) in-hospital mortality rate was reported in Tikur Anbessa tertiary referral Hospital[24]. This variation across the studies might be related to the patient profile, the study setting, and the care provided to the patients.
The study had the following limitations: We cannot directly assess the influence of undiagnosed or inadequately managed hypertension on the incidence of stroke. There is incomplete data due to the retrospective nature of the study. The study is single-centred which challenges generalizing the findings to the other institutions. The time frame of stroke presentation in our study indicated only from the disease presentation to the hospital visit. However, this time frame should include the time for imaging which is important for management decisions.The study used a relatively large sample size. It tried to assess the most important but not well-investigated problem. The study included compressive data including clinical presentation, the most important risk factors, and patient outcomes.