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THE guideline for hypertension management has been updated by the National Heart Foundation, but the Royal Australian College of General Practitioners (RACGP) is worried they will lead to confusion in general practice.
In a statement to MJA InSight, the RACGP said that the guideline was a helpful reference for Australian health professionals.
“However, there is some inconsistency with the current National Vascular Disease Prevention Alliance (NVDPA) absolute risk guidelines.”
“This could be seen as a move away from, or weaken the focus on absolute cardiovascular disease risk as a trigger for treatment initiation.”
Summarised in the MJA this week, the guideline is designed to equip health professionals, especially those in primary care and community services, with the latest evidence to prevent, detect and manage hypertension.
These changes reflect the latest research on hypertension, including a 2015 meta-analysis of patients with uncomplicated mild hypertension, which demonstrated that blood pressure (BP)-lowering therapy is beneficial in reducing stroke, cardiovascular death and all-cause mortality.
- Related: MJA — Guideline for the diagnosis and management of hypertension in adults — 2016
- Related: MJA — Relieving the pressure: new Australian hypertension guideline
- Related: MJA — Lost in translation: the gap between what we know and what we do about cardiovascular disease
- Related: MJA — Absolute risk of cardiovascular disease events, and blood pressure- and lipid-lowering therapy in Australia
One of the main changes to management as a result of the update is the recommendation that ambulatory and/or home BP monitoring should be offered if clinic BP is greater than 140/90 mmHg, as out-of-clinic BP is a stronger predictor of outcome.
The updated guideline also recommended that in high cardiovascular risk populations, aiming for a target of less than 120 mmHg systolic can improve cardiovascular outcomes. If targeting less than 120 mmHg, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury.
The RACGP disagreed with the guideline’s recommendation that anti-hypertensive therapy should be initiated in patients with moderate risk and persistent BP over 140/90.
“The NVDPA guidelines do not recommend this,” they said.
The NVDPA instead recommends treating if BP is over 160/100 and there is a family history of premature CVD in in people of South Asian, Middle Eastern, Maori, Pacific Islander ethnicity.
“It is unfortunate that the Heart Foundation guideline is not consistent with the NVDPA absolute risk guidelines,” the RACGP said.
In an accompanying MJA editorial, Professor Garry Jennings, CEO of the National Heart Foundation, said that the guideline had been excellently adapted to reflect Australia conditions.
He wrote that “the holes in the evidence base and shifting ground as new evidence comes forward are not helpful to the individual clinician who wants advice on what to do for a particular patient on a particular day”.
“In future, we need to move the emphasis from large tomes written by expert groups to providing decision support individualised to the patient.”
Professor Jennings concluded that in the meantime, the new guideline would guide the management of hypertension in Australia for the immediate future.
Dr Clara Chow, acting director of the cardiovascular division at Westmead Hospital in Sydney, told MJA InSight that it was important for health professionals to remember that guidelines are meant to be just that – guidance.
She said that one of the biggest challenges for hypertension management was “around the cut-off points and when you should or shouldn’t treat”.
“It’s a spectrum. We all know that high blood pressure isn’t good, but as to when we start to actively measure and treat is where the uncertainty and controversy has been.
“For people with a history of heart disease or loads of lifestyle risk factors, it’s clear. Then the question becomes how low their blood pressure should go – and these guidelines say less than 120.”
Lead author of the guideline summary and senior staff specialist at SA Health, Dr Genevieve Gabb, said there were indeed ongoing issues around blood pressure measures and measurement of vascular risk.
“There are different techniques for blood pressure measurement which have developed over time, including clinic, 24-hour ambulatory and home blood pressure. It is important clinicians are aware of the differences between these methods, and which technique has been used when interpreting results and making treatment decisions,” she told MJA InSight.
“What is clear is that blood pressure is a strong risk factor for vascular events, but it can be treated effectively,” Dr Gabb said.
Dr Chow said that all patients should receive advice about lowering their lifestyle risk factor.
“We all know that we can start a patient on medication, but if they keeping drinking alcohol and not managing their weight, they aren’t going to lower their blood pressure.
“Clinicians should give specific advice about diet, alcohol consumption, physical activity and weight reduction,” she said.
Dr Gabb said there was a huge amount of information on hypertension building up, but the challenge would be implementing evidence into practice. The key to improving the effectiveness of this implementation was patient engagement.
“This is about having a mechanism for shared decision making to help patients make an informed choice about risks and benefits.”
Dr Gabb said that as technology advances and treatments improve, Australia also runs the risk of becoming complacent about hypertension.
“There’s been a move to take a more global overview of blood pressure and cholesterol as vascular risk. But the thing with blood pressure is that it has its own important aspects to it.
“I’ve seen people get slack with their blood pressure, and then end up with severe hypertension and become very unwell,” Dr Gabb said.
“The consequences of stopping statins is different to stopping blood pressure treatment.”
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Guidlelines are helpful but with blood pressure measurement and treatment there is a real problem. We know that a single episodic reading in the artificial and overtly or sublminally stressful envoronment of the doctor’s office is unlikely to reflect the day to day reality for most patients. At best, our measurements give us a rough idea or where the BP is sitting… it can vary greatly between two measurements at the one visit and between sitting and standing.
I have been bemused by the fact that the government via PBS is happy to fork out many hundreds of dollars per year, year after year, on medications that may not in fact be needed but are not willing to subsidise or pay for a machine that can be used by patients for home monitoring to determine if medication is in fact warranted, or whether a lower dose would suffice. Equally, home monitoring may reveal the targeted need for more medication but the long term benefits there would outweigh the cost of the BP measuring device.
Ambulatoroy monitoring is helpful but is not practical for ongoing assessment.
Guidlines need to simple and realistic. Unless there are other factors, less than 140/90 should suffice as a target for most patients over 40. Those with renal issues, diabetes, high lipids or previous CV events may warrant more intense therapy as tolerated. Home monitoring with a good quality machine and technique is the way to go in my view. There should be a government subsidy of up to $150 per patient every five years to pay for a quality home BP measuring device.