Translation of Hypertension Guidelines into Practice

Abstract

Hypertension is a major and modifiable risk factor for cardiovascular and cerebrovascular disease, yet its prevalence in the community remains high and, despite the promulgation of hypertension-specific treatment guidelines, levels of hypertension diagnosis, treatment and control remain low. Prevalence rates of arterial hypertension in western Europe derived from studies published in the 1990s range from 38% to 55%. More recent data indicate at least one quarter to one third of the adult population in Europe and the United States has hypertension. The proportion of treated patients with hypertension who achieve the currently recommended level of blood pressure (BP) control, i.e. 140/90 mmHg or less, remains surprisingly low. In Portugal, a country distinguished by its high-salt diet, the prevalence of hypertension is particularly high, with over 40% of adults receiving a diagnosis of hypertension and only 29% of treated patients achieving BP control. Various organizations including the European Society of Cardiology (ESC)/European Society of Hypertension (ESH) have produced hypertension treatment guidelines that aim to translate evidence from clinical trials into everyday clinical practice. Whereas most patients with hypertension are managed by their general practitioner, a variety of studies has found hypertension guideline recommendations to be poorly implemented in general practice. A survey of general practitioners throughout Portugal was conducted to assess their awareness of and adherence to the 2007 ESC/ESH hypertension treatment guidelines. In addition to collecting demographic information, the survey included 19, five-answer multiple choice questions on topics including cardiovascular risk stratification, BP targets and hypertension treatment in routine and special situations. For 14 questions there was only one ‘correct’ answer that conformed to the 2007 ESC/ESH guidelines; the remaining 5 questions were properly highlighted and could have had more than one ‘correct’ answer. Of 120 randomly selected general practitioners invited to participate, 98 completed the online questionnaire. The survey results showed some significant gaps in their knowledge and adherence to the guidelines. The correct answer was identified by more than 50% of respondents in only three of the 19 clinical questions, and overall only 16.3% of participants provided the correct answer to more than half of the survey questions. The rate of correct responses was significantly lower in older compared with younger participants. These findings are consistent with other surveys of general practitioners that have found low levels of guideline awareness and implementation. A variety of factors may act as barriers to the implementation of treatment guidelines, including the large volume of information and time needed to stay informed, lack of agreement with specific guidelines and patient preferences. Primary care represents a key site in the prevention of cardiovascular disease through proper management of hypertension. More efforts are needed to ensure general practitioners are well informed about current treatment guidelines and are motivated to implement their recommendations.