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

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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

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WHO Health for all database, Aug 2008

Mortality from CVD per 100.000 1970-2006

         

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