Current European guidelines for management of arterial hypertension: Are they adequate for use in...
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Current European guidelines for Current European guidelines for management of arterial hypertension: management of arterial hypertension:
Are they adequate for Are they adequate for use in primary care?use in primary care?
Halfdan PeturssonLinn Getz
Johann Agust SigurdssonIrene Hetlevik
Objectives
• To model the implications of recent European guidelines for the management of arterial hypertension
A. Prevalence of individuals “at risk” for CVD
B. Clinical workload associated with recommended measures
• Number of follow-up visits/year
• Number of physicians needed (general practitioners?)
• Treatment recommendations are based on combined risk estimate
• “A new” risk factor: – High pulse pressure* in the elderly
• No further definition in the guidelines!
• ≥ 60 mmHg in individuals > 55 years of age
* Pulse pressure = Systolic BP – diastolic BP
Treatment recommendations
0022
3-43-4
3-43-4
HUNT 2
• Every adult invited• Participation > 2/3
– 76% of women
– 67% of men
• 65,028 individuals 20-89 years old
• 51,066 (79%) eligible for our model
Exclusion criteria
• Excluded if:– blood pressure <120/80 mmHg
– no information available about any of the other risk factors
The risk factors
HUNT 21. Age2. Smoking3. Dyslipidemia (total- and HDL cholesterol)4. Waist circumference5. 1° relatives with CVD6. Pulse pressure of the elderly
Guidelines but not HUNT 2• Fasting blood values: triglycerids, glucose, LDL• Left ventricular hypertrophy indicated on echo/EKG• Renal disease, microalbuminuria
Age standardised prevalence
Total: 100% = 100 000 adults after standardisationData from those included only (51 066)
Age standardised prevalence
Age standardised prevalence
Averagerisk 6.6%
Do 75% or more haverisk above average?
+ Low risk? <21%
The excluded group
= <25%
Average risk?6,6%
99% of all 50-64 y.o. should attend regular
follow-up visits or receive drug treatment for high bp!
How many physicians are needed?
Follow-up visits / 100,000 adults / year = 296,624
Number of GP positions = 296,624 / 3,000 consultations / year = 99
• 99 physicians needed for bp control only per 100,000 adults
• Current status in Nord-Trøndelag: – 87 GPs / 100,000 adults
Conclusions
• Clinical practice guidelines overestimate the risk
• Fail to define a manageable number of people “at risk”
• Fundamental problem regarding the theoretical framework
• Only ethically justifiable if – practical feasibility,– sustainability, and– social determinants of health are considered
Funding
• Funding:– The Icelandic Family Physicians Research Fund
• HUNT 2– HUNT Research Center, Faculty of Medicine NTNU– Norwegian Institute of Public Health– Nord-Trøndelag County Council– Levanger Hospital, Nord-Trøndelag
Treatment recommendations
0022
3-43-4
3-43-4
WHO Health for all database, Aug 2008
Mortality from CVD per 100.000 1970-2006
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