Current European guidelines for management of arterial hypertension:
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Current European guidelines for management of arterial hypertension: Are they adequate for use in primary care?. Halfdan Petursson Linn Getz Johann Agust Sigurdsson Irene Hetlevik. Objectives.

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Halfdan Petursson Linn Getz Johann Agust Sigurdsson Irene Hetlevik

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Halfdan petursson linn getz johann agust sigurdsson irene hetlevik

Current European guidelines for management of arterial hypertension: Are they adequate for use in primary care?

Halfdan Petursson

Linn Getz

Johann Agust Sigurdsson

Irene Hetlevik


Objectives

Objectives

  • To model the implications of recent European guidelines for the management of arterial hypertension

    • Prevalence of individuals “at risk” for CVD

    • Clinical workload associated with recommended measures

      • Number of follow-up visits/year

      • Number of physicians needed (general practitioners?)


Halfdan petursson linn getz johann agust sigurdsson irene hetlevik

  • 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

Treatment recommendations

0

2

3-4

3-4


Hunt 2

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

Exclusion criteria

  • Excluded if:

    • blood pressure <120/80 mmHg

    • no information available about any of the other risk factors


The risk factors

HUNT 2

Age

Smoking

Dyslipidemia (total- and HDL cholesterol)

Waist circumference

1° relatives with CVD

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

The risk factors


Age standardised prevalence

Age standardised prevalence

Total: 100% = 100 000 adults after standardisationData from those included only (51 066)


Age standardised prevalence1

Age standardised prevalence


Age standardised prevalence2

Age standardised prevalence

The excluded group

Averagerisk

6.6%

+

Low risk?

<21%

= <25%

Do 75% or more haverisk above average?


Halfdan petursson linn getz johann agust sigurdsson irene hetlevik

99% of all 50-64 y.o. should attend regular follow-up visits or receive drug treatment for high bp!

Average risk?6,6%


How many physicians are needed

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

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

  • 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 recommendations1

Treatment recommendations

0

2

3-4

3-4


Halfdan petursson linn getz johann agust sigurdsson irene hetlevik

Mortality from CVD per 100.0001970-2006

WHO Health for all database, Aug 2008


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