Hypertension In Primary Care Research Articles

Duration of and fee for comprehensive assessment and care planning for patients with hypertension and/or diabetes in primary care

Duration of and fee for comprehensive assessment and care planning for patients with hypertension and/or diabetes in primary care

Alcohol screening and alcohol interventions among patients with hypertension in primary health care: an empirical survey of German general practitioners

Background: Alcohol is one of the least intervened risk factors in the management of hypertension at the primary care level. In order to improve alcohol interventions, a better understanding of knowledge, attitudes and clinical practice of lifestyle interventions in the management of hypertension is needed.Method: As a part of a European study (France, Germany, Italy, Spain, UK), 211 German general practitioners (GPs) were recruited in Bavaria and Hamburg and surveyed via an Internet-based questionnaire. Results were compared with the European sample (n = 2870).Results: One-third of the patients seen by German GPs had hypertension (36.2%, standard deviation (SD): 14.6) and among cases with hypertension, less than half were ever screened for alcohol (4.5 out of 10 patients). The foremost reasons for not screening for alcohol were that alcohol was not considered a major risk factor for hypertension plus the lack of knowledge of appropriate alcohol screening instruments. The majority of German GPs managed patients with hazardous drinking levels themselves or in their practice (71.3%, 95% confidence interval (CI): 64.6–77.2%), but only 42.0% (95% CI: 35.2–49.0%) managed alcohol dependent patients. German screening rates were slightly lower but interventions of screened positive patients higher than the European average.Conclusions: Rates of alcohol screening in patients with hypertension in primary health care may be increased by improving GPs knowledge of alcohol as a major risk factor for hypertension, increasing GPs education on alcohol and screening instruments, and providing reimbursement. This may increase treatment of alcohol problems in patients with hypertension and reduce hypertension.

Hypertension and Chronic Kidney Disease in Primary Care.

TBL enables a group of learners to engage in independent preparation through prereadings, check their knowledge with readiness assessments, and both share and build on their personal experience with each topic through robust small-group discussions. This TBL exercise uses case-based questions to enable learners to make a treatment plan for challenging cases of hypertension and to manage chronic kidney disease (CKD) in the primary care setting. This module serves as part of a series of team-based learning (TBL) modules in an internal medicine residency ambulatory medicine curriculum. The modules are delivered during the didactic half-days of the ambulatory week of our 3 + 1 block schedule. This particular module takes approximately 90 minutes to deliver and is intended to be moderated by an experienced primary care clinician. Learners who participated in this TBL felt that it increased their knowledge about hypertension and CKD; they gave it an average rating of 4.67/5 (n = 30). TBL has been heavily utilized in undergraduate medical education, and we have adapted the method to use it with small groups of resident physicians. It may also be suitable for other learners who will be responsible for the treatment of hypertension and CKD in the primary care setting (e.g., family medicine residents, advanced practice nurses, and physician assistants).

Diagnosis and Medication Treatment of Pediatric Hypertension: A Retrospective Cohort Study.

Pediatric hypertension predisposes children to adult hypertension and early markers of cardiovascular disease. No large-scale studies have examined diagnosis and initial medication management of pediatric hypertension and prehypertension. The objective of this study was to evaluate diagnosis and initial medication management of pediatric hypertension and prehypertension in primary care. Retrospective cohort study aggregating electronic health record data on >1.2 million pediatric patients from 196 ambulatory clinics across 27 states. Demographic, diagnosis, blood pressure (BP), height, weight, and medication prescription data extracted. Main outcome measures include proportion of pediatric patients with ≥3 visits with abnormal BPs, documented hypertension and prehypertension diagnoses, and prescribed antihypertensive medications. Marginal standardization via logistic regression produced adjusted diagnosis rates. Three hundred ninety-eight thousand seventy-nine patients, ages 3 to 18, had ≥3 visits with BP measurements (48.9% girls, 58.6% <10 years old). Of these, 3.3% met criteria for hypertension and 10.1% for prehypertension. Among practices with ≥50 eligible patients, 2813 of 12 138 patients with hypertension (23.2%; 95% confidence interval, 18.2%-28.2%) and 3990 of 38 874 prehypertensive patients (10.2%; 95% confidence interval, 8.2%-12.2%) were diagnosed. Age, weight, height, sex, and number and magnitude of abnormal BPs were associated with diagnosis rates. Of 2813 diagnosed, persistently hypertensive patients, 158 (5.6%) were prescribed antihypertensive medication within 12 months of diagnosis (angiotensin-converting enzyme inhibitors/angiotensin receptive blockers [35%], diuretics [22%], calcium channel blockers [17%], and β-blockers [10%]). Hypertension and prehypertension were infrequently diagnosed among pediatric patients. Guidelines for diagnosis and initial medication management of abnormal BP in pediatric patients are not routinely followed.

Exploring knowledge, attitudes, and practices toward older adults with hypertension in primary care.

PurposeHigh blood pressure increases the risk of cardiovascular and kidney diseases. The purpose of this study was to explore a baseline of hypertension knowledge, attitudes, and practices among older adults with hypertension at a sub-district Health Promoting Hospital in the Pathum Thani province of Thailand.Patients and methodsA cross-sectional study was conducted at the outpatient clinic of the sub-district Health Promoting Hospital, one of the primary care sectors, between January and March 2015, and a total of 144 cases were recruited. All clinical parameters were collected and a structured questionnaire was used. Data were analyzed by means of descriptive statistics and chi-square tests.ResultsMost of the participants (74.3%) were females, and their mean age was 66.1 years. Two-thirds (66.7%) were married, unemployed/retired (67.4%), and had completed elementary education (79.2%). The screenings showed that their mean blood pressure was 136.4 (±14.4)/79.2 (±10.1) mmHg, the group’s mean body mass index was 24.9 kg/m2 (± 3.6 kg/m2), and their mean waist circumference was 88.6 cm (±7.1 cm) for males and 85.7 cm (±6.8 cm) for females. In addition, their mean score of hypertension knowledge was high, and most of the participants had a neutral attitude toward hypertension; their practices in terms of dietary and exercise habits for controlling blood pressure were low in nature.ConclusionThis study indicated that increasing patients’ practices would be useful for promoting their healthy behaviors to achieve blood pressure control.

Reduction of mortality following better detection of hypertension and alcohol problems in primary health care in Spain.

Through a simulation study, we estimated the potential effects of better detection of hypertension and improved screening for alcohol problems with subsequent interventions. Results showed that if 50% of Spanish males between 40 and 64 years of age who are currently unaware of their hypertension become aware of their condition and receive the usual treatment, and 50% of these males with hypertension are screened for alcohol and are treated for hazardous drinking or alcohol use disorders, then the percentage of uncontrolled hypertension among men with hypertension decreases from 61.2% to 55.9%, i.e. by 8.6%, with about 1/3 of the effect due to the alcohol intervention. For women, likewise, these interventions would decrease the percentage of women in the same age group with uncontrolled hypertension by 7.4% (about 40% due to the alcohol intervention). The reduction of blood pressure in the population would avoid 412 premature CVD deaths (346 in men, 66 in women) within one year. Therefore, better detection of hypertension and screening for alcohol with subsequent interventions would result in marked reductions of uncontrolled hypertension and CVD mortality.

The role of alcohol in the management of hypertension in patients in European primary health care practices - a survey in the largest European Union countries.

BackgroundEven though addressing lifestyle problems is a major recommendation in most guidelines for the treatment of hypertension (HTN), alcohol problems are not routinely addressed in the management of hypertension in primary health care.MethodsInternet based survey of 3081 primary care physicians, recruited via the mailing lists of associations for general practitioners (GPs) in France, Germany, Italy, Spain and the UK. Clinical practice, attitudes, knowledge, education and training were assessed. Logistic regression to predict screening, brief intervention and treatment for alcohol dependence in the management of hypertension were assessed.ResultsOverall, about one third of the interviewed GPs reported sufficient screening in cases with HTN (34.0 %, 95 % confidence interval (CI):32.1–35.8 %). One out of five GPs screened and delivered brief interventions in HTN patients with hazardous consumption (22.2 %, 95 % CI: 20.6–23.8 %) and about one in 13 GPs provided treatment for HTN patients with alcohol dependence other than advice or brief intervention (7.8 %, 95 % CI: 6.8–8.9 %). Post-graduate training and belief in their effectiveness predicted interventions. There were marked differences between countries.ConclusionsWhile current interventions were overall low, marked differences between countries indicate that current practices could be improved. Education and post-graduate training seems to be key in improving clinical practice of including interventions for problematic alcohol consumption and alcohol dependence in primary health care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0529-5) contains supplementary material, which is available to authorized users.

PP.03.06] BASELINE DIFFERENCES ACCORDING TO THE PRESENCE OF HYPERTENSION IN PATIENTS INCLUDED IN THE STUDY IBERICAN

Objective: The objective of the study is to know the prevalence of hypertension (HT), cardiovascular risk factors (CVRF) and cardiovascular disease in the hypertensive patients compared to the non hypertensive in the IBERICAN study, in patients attended in primary care in Spain. Design and method: The IBERICAN study is a longitudinal, observational, and multicenter study in which are including subjects from 18 to 85 years of age, attended daily in primary care. It is estimated to reach a sample of 15,000 patients that will be followed at least 5 years. The baseline characteristics of a court are presented during the period of inclusion (n = 3.042). Results: 3.042 patients were included, 1.429 patients are HT (47.4), their average age was 65.3 ± 10.9 years, 50.5% women. The antiquity of the HT: 9.7 ± 6.4 years. Body mass index was 28.5 ± 5 kgm2. The degree of blood pressure control was 58.5%. 7.6% patients had microalbuminuria by albumina/creatinina ratio and a 0.7% had proteinuria, a 13.7% chronic kidney disease by CKD-EPI criteria. The prevalence of CVRF between HT vs non-HT were: Dyslipidemia 66.4% vs 35.9%, p < 0, 0001; Diabetes 30.6% vs 8.5%, p < 0, 0001; Obesity 44.4% vs 32.5%, p < 0, 0001; smoking 13.5% vs 22.7%, p < 0, 0001. Cardiovascular disease was 21.6% vs 10.2%, p < 0, 000, coronary heart disease 10.7% vs. 5.3%, p < 0, 000; stroke 6.5% VS 3%, p < 0,000; heart failure 4.8% vs 1.3%, p < 0,000 and peripheral arterial disease 5% vs 2%; p < 0,000. Conclusions: Patients with arterial hypertension in primary care are older, with a higher prevalence of cardiovascular risk factors and cardiovascular disease and worse control of blood pressure.

Práctica clínica en el manejo de la hipertensión y la diabetes en Atención Primaria: estudio ATENCION

Background and objectiveCardiovascular diseases are the main cause of death in the Spanish population. The detection and control of cardiovascular risk factors are fundamental in the prevention of cardiovascular disease. The main objectives of this study are to analyse the attitudes and therapeutic decisions of Primary Care (PC) physicians when treating hypertension (HT) and diabetes mellitus type 2 (DM2), with the aim of establishing the situation and eventually proposing improvement strategies. Material and methodA national ecological, multicentre, cross-sectional, and descriptive study was conducted in 2013. A questionnaire was used and 1,028 PC physicians took part in the study. ResultsA total of 92.9% of the investigators consulted have indicated that they follow the guidelines for evaluation, treatment, and diagnosis of HT, and 91.4% in the case of diabetes. The latter is diagnosed as a casual finding, while HT is diagnosed through active investigation in patients with other risk factors. Combined therapy takes more than 6 months to take effect in patients with HT, and between 8 and 9 months in diabetic patients. The percentage of non-compliance is similar (10-40%) in both pathologies. Around half the physicians questioned considered interaction with the specialist to be good or excellent (46% HT and 57.3% DM2). ConclusionsClinical practices in PC for HT and DM2 have some basic criteria in common. The interaction with the specialist is good, but there is a considerable margin for improvement

Self-care practice of patients with arterial hypertension in primary health care

Objective: to evaluate the practice of self-care performed by patients with systemic arterial hypertension inprimary health care. Methods: this is a descriptive and cross-sectional study, conducted with 92 individualswith arterial hypertension in a primary care unit. The data collection occurred through script and data analyzedusing descriptive statistics (frequency, mean and standard deviation) and through the understanding of theadaption between capacity and self-care demand. Results: it was identified as a practice of self-care: adequatewater intake, salt intake and restricted coffee, satisfactory sleep period, abstinence from smoking and alcoholism,continuing pharmacological treatment and attending medical appointments. As the demands: inadequatefeeding, sedentary lifestyle, had no leisure activities, self-reported stress, and limited knowledge. Conclusion:although patients performed treatment a few years ago, still showed up self-care deficits, highlighting the needfor nurses to advise and sensitize about the importance of self-care practice.

Early screening and brief intervention in alcohol misuse to improve the treatment of hypertension in primary care

Central nervous system (CNS) involvement by lymphoma is a complication associated, almost invariably, with a poor prognosis. The knowledge of the risk factors for CNS relapse is important to determine which patients could benefit from prophylaxis. Thus, patients with very aggressive lymphomas (such as lymphoblastic lymphoma or Burkitt's lymphoma) must systematically receive CNS prophylaxis due to a high CNS relapse rate (25–30%), while in patients with indolent lymphoma (such as follicular lymphoma or marginal lymphoma) prophylaxis is unnecessary. However, the question about CNS prophylaxis in patients with diffuse large B-cell lymphoma (DLBCL), the most common type of lymphoma, remains controversial. The information available is extensive, mainly based on retrospective and heterogeneous studies. There seems that immunochemotherapy based on rituximab reduces the CNS relapse rate. On the other hand, patients with increased serum lactate dehydrogenase plus more than one extranodal involvement seem to have a higher risk of CNS relapse, but a prophylaxis strategy based only on the presence of these 2 factors does not prevent all CNS relapses. Patients with involvement of testes or breast have high risk of CNS relapse and prophylaxis is mandatory. Finally, CNS prophylaxis could be considered in patients with DLBCL and renal or epidural space involvement, as well as in those cases with MYC rearrangements, although additional studies are necessary.La infiltración del sistema nervioso central (SNC) en pacientes con linfoma es una complicación que se asocia, casi invariablemente, a un pronóstico mortal. El conocimiento de los factores de riesgo de dicha infiltración es fundamental para determinar qué pacientes podrían beneficiarse de recibir una profilaxis. Mientras que los pacientes con linfoma muy agresivo (como linfoma linfoblástico y linfoma de Burkitt) deben recibir sistemáticamente profilaxis del SNC por su elevado riesgo de recaída neuromeníngea (25-30%), los pacientes con linfoma indolente (folicular o marginal, por ejemplo) no la reciben prácticamente nunca debido a su bajo riesgo de recaída en el SNC. Sin embargo, existe controversia sobre cuándo debe administrarse en pacientes con linfoma B difuso de célula grande (LBDCG), el subtipo más frecuente de linfoma. La información disponible en la bibliografía procede en su mayoría de estudios retrospectivos y heterogéneos. La evidencia parece apoyar la hipótesis de que la inmunoquimioterapia basada en rituximab reduce las recaídas en el SNC. La coexistencia de valores de lactato deshidrogenasa sérica elevados junto con más de una localización extraganglionar son factores de riesgo asociados con una mayor frecuencia de recaída neuromeníngea, aunque una estrategia basada solo en administrar profilaxis en presencia de ambos factores no previene todas las recaídas. Los pacientes con infiltración testicular y de mama tienen un elevado riesgo de recaída en el SNC y deben recibir profilaxis. Podría considerarse, asimismo, la profilaxis de la recaída neuromeníngea en casos de LBDCG con infiltración renal o del espacio epidural, o en aquellos que presenten reordenamientos del gen MYC, aunque hacen falta más estudios que investiguen estos aspectos.

Type D Personality and Essential Hypertension in Primary Care: A Cross-Sectional Observational Study Within a Cohort of Patients Visiting General Practitioners.

To estimate the relationship between type D personality and essential hypertension among patients visiting their GPs for any health problem, 101 hypertensive and 138 nonhypertensive patients were consecutively recruited and assessed using the Type D Personality Scale (DS14). The predictive value of type D personality was determined using a logistic regression model, taking into account the differences in recognized confounders between groups. Type D personality in the hypertension group was twice as frequent as in the no hypertension group and hypertension was more frequent among type D than non-type D patients. Logistic regression showed a significant predictive value of type D personality for hypertension, adjusting for sex, age, body mass index, family history of hypertension, living condition, education, and employment. Therefore, type D personality was strongly related to hypertension and it was a noteworthy predictor of hypertension in a real-world cohort of primary care patients.

Разработка амбулаторного опросника для больных с повышенным артериальным давлением

Aim — to develop a questionnaire for evaluation awareness of hypertension, risk factors, treatment and blood pressure (BP) control in patients with raised BP which allows justified decision making on improvement the results of medical care delivered to patients with hypertension in primary care. Material and Methods — Literature review with using E-library and PubMed databases was conducted to search questionnaires previously developed in clinical studies for patients with hypertension. Validated questionnaires for assessment adherence to treatment, excessive use of alcohol and alcohol abuse were reviewed separately. The results of literature review were considered in development of a new questionnaire designed for using in polyclinic. Results — Questionnaire containing 16 questions was developed. The questionnaire allows evaluation the following aspects: awareness of BP elevation, having a tonometer at home and frequency of BP self-measurement, taking antihypertensive drugs, medication adherence (Morisky-Green scale), a frequency of addressing for primary, secondary and emergency care, presence of modifiable risk factors: smoking, alcohol abuse (CAGE questionnaire), interest in specialized follow-up program. Developed questionnaire was approbated in a polyclinic of worker’s settlement located in Saratov region. 80% of patients gave their agreement to answer the questions. Filling the questionnaire was taking about five minutes. Questions were intuitively clear, did not need any clarifications. It is possible to implement the questionnaire as well as interview conducted by a doctor or a nurse as patients’ self-reporting. The most convenient way of use is an interview conducted by a nurse. Conclusion — The developed questionnaire allows evaluation of general aspects of treatment ov raised BP from a patient’s view as well as revealing removable barriers to effective BP control achievement in routine work of primary care unit.

Printed educational messages fail to increase use of thiazides as first-line medication for hypertension in primary care: a cluster randomized controlled trial [ISRCTN72772651

BackgroundEvidence on the effectiveness of printed educational messages in contributing to increasing evidence-based clinical practice is contradictory. Nonetheless, these messages flood physician offices, in an attempt to promote treatments that can reduce costs while improving patient outcomes.This study evaluated the ability of printed educational messages to promote the choice of thiazides as the first-line treatment for individuals newly diagnosed with hypertension, a practice supported by good evidence and included in guidelines, and one which could reduce costs to the health care system.MethodsThe study uses a pragmatic, cluster randomized controlled trial (randomized by physician practice group).SettingThe setting involves all Ontario general/family practice physicians.Messages advising the use of thiazides as the first-line treatment of hypertension were mailed to each physician in conjunction with a widely read professional newsletter. Physicians were randomized to receive differing versions of printed educational messages: an “insert” (two-page evidence-based article) and/or one of two different versions of an “outsert” (short, directive message stapled to the outside of the newsletter). One outsert was developed without an explicit theory and one with messages developed targeting factors from the theory of planned behaviour or neither (newsletter only, with no mention of thiazides).The percentage of patients aged over 65 and newly diagnosed with hypertension who were prescribed a thiazide as the sole initial prescription medication. The effect of the intervention was estimated using a logistic regression model estimated using generalized estimating equation methods to account for the clustering of patients within physician practices.ResultsFour thousand five hundred four physicians (with 23,508 patients) were randomized, providing 97 % power to detect a 5 % absolute increase in prescription of thiazides. No intervention effect was detected. Thiazides were prescribed to 27.6 % of the patients who saw control physicians, 27.4 % for the insert, 26.8 % for the outsert and 28.3 % of the patients who saw insert + outsert physicians, p = 0.54.ConclusionsThe study conclusively failed to demonstrate any impact of the printed educational messages on increasing prescribing of thiazide diuretics for first-line management of hypertension.Trial registration ISRCTN72772651 Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0486-3) contains supplementary material, which is available to authorized users.

Evaluation of the quality of care of a multi-disciplinary Risk Factor Assessment and Management Programme for Hypertension (RAMP-HT).

BackgroundThere is some evidence to support a risk-stratified, multi-disciplinary approach to manage patients with hypertension in primary care. The aim of this study is to evaluate the quality of care (QOC) of a multi-disciplinary Risk Assessment and Management Programme for Hypertension (RAMP-HT) for hypertensive patients in busy government-funded primary care clinics in Hong Kong. The objectives are to develop an evidence-based, structured and comprehensive evaluation framework on quality of care, to enhance the QOC of the RAMP-HT through an audit spiral of two evaluation cycles and to determine the effectiveness of the programme in reducing cardiovascular disease (CVD) risk.Method/DesignA longitudinal study is conducted using the Action Learning and Audit Spiral methodologies to measure whether pre-set target standards of care intended by the RAMP-HT are achieved. A structured evaluation framework on the quality of structure, process and outcomes of care has been developed based on the programme objectives and literature review in collaboration with the programme workgroup and health service providers. Each participating clinic is invited to complete a structure of care evaluation questionnaire in each evaluation cycle. The data of all patients who have enrolled into the RAMP-HT in the pre-defined evaluation periods are used for the evaluation of the process and outcomes of care in each evaluation cycle. For evaluation of the effectiveness of RAMP-HT, the primary outcomes including blood pressure (both systolic and diastolic), low-density lipoprotein cholesterol and estimated 10-year CVD risk of RAMP-HT participants are compared to those of hypertensive patients in usual care without RAMP-HT.DiscussionThe QOC and effectiveness of the RAMP-HT in improving clinical and patient-reported outcomes for patients with hypertension in normal primary care will be determined. Possible areas for quality enhancement and standards of good practice will be established to inform service planning and policy decision making.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0291-0) contains supplementary material, which is available to authorized users.

Accuracy of self-monitored blood pressure for diagnosing hypertension in primary care.

To assess the diagnostic accuracy of recommendations for self-monitoring blood pressure (BP) for diagnosing hypertension in primary care. Two hundred and forty-seven consecutive participants with raised (≥130 mmHg systolic) BP measured by their general practitioner from four primary care practices in the United Kingdom underwent 28 days of self-monitoring followed by 24-h ambulatory BP monitoring (ABPM). Diagnostic accuracy of the first 7 days of self-monitored BP (minimum 4 days, discarding readings on day 1) in detecting hypertension with ambulatory blood pressure was taken as reference. Two hundred and three participants were included, 109 (53.7%) of whom were diagnosed with hypertension using daytime ambulatory BP. The average of days 2-7 self-monitored BP correctly classified 150 of 203 participants [sensitivity 93.6%, 95% confidence interval (CI) 87.2-97.4%; specificity 51.1%, 95% CI 40.5-61.5%). However, the average of days 2-5 self-monitoring correctly classified 152 of 203 participants due to better specificity (53.2%, 95% CI 42.6-63.6%). In sensitivity analysis, diagnostic accuracy was not improved by inclusion of readings beyond day 5, and inclusion of readings taken on day 1 had no impact on diagnostic accuracy. Self-monitoring in the clinic was more accurate than readings taken by the general practitioner, but not self-monitoring outside of the clinic. Hypertension can be ruled out in the majority of patients with elevated clinic BP using the average of the first 5 consecutive days of self-monitored BP, supporting lower limits for self-monitoring readings in current guidelines. Performing readings beyond day 5 and including readings taken on the first day had no clinical impact on diagnostic accuracy.

Severity of obesity and management of hypertension, hypercholesterolaemia and smoking in primary care: population-based cohort study.

Obesity and obesity-associated cardiovascular risk are increasing worldwide. This study aimed to determine how different levels of obesity are associated with the management of smoking, hypertension and hypercholesterolaemia in primary care. We conducted a cohort study of adults aged 30–100 years in England, sampled from the primary care electronic health records in the Clinical Practice Research Datalink. Prevalence, treatment and control were estimated for each risk factor by body mass index (BMI) category. Adjusted odds ratios (AOR) were estimated, allowing for age, gender, comorbidity and socioeconomic status, with normal weight as reference category. Data were analysed for 247 653 patients including 153 308 (62%) with BMI recorded, of whom 46 149 (30%) were obese. Participants were classified into simple (29 257), severe (11 059) and morbid obesity (5833) categories. Smoking declined with the increasing BMI category, but smoking cessation treatment increased. Age-standardised hypertension prevalence was twice as high in morbid obesity (men 78.6% women 66.0%) compared with normal weight (men 37.3% women 29.4%). Hypertension treatment was more frequent (AOR 1.75, 1.59–1.92) but hypertension control less frequent (AOR 0.63, 0.59–0.69) in morbid obesity, with similar findings for severe obesity. Hypercholesterolaemia was more frequent in morbid obesity (men 48.2% women 36.3%) than normal weight (men 25.0% women 20.0%). Lipid lowering therapy was more frequent in morbid obesity (AOR 1.83, 1.61–2.07) as was cholesterol control (AOR 1.19, 1.06–1.34). Increasing obesity category is associated with elevated risks from hypertension and hypercholesterolaemia. Inadequate hypertension control in obesity emerges as an important target for future interventions.

Ambulatory blood pressure monitoring is ready to replace clinic blood pressure in the diagnosis of hypertension: pro side of the argument.

Since the introduction of lightweight ambulatory blood pressure (BP) monitoring (ABPM) devices into clinical use in the late 1980s, there has been a huge increase in their contribution not only to fundamental research on the diurnal patterns of BP in humans, but increasingly for the diagnosis of hypertension. Clearly, the recognition of the value of multiple readings for accuracy and the detection of white coat, masked, and nocturnal hypertension has been critical to correctly determine the extent and impact of hypertension in the community. Importantly, the prognostic value of ABPM for cardiovascular events has been a major impetus for the promotion of its widespread adoption in primary care. National and International guidelines have largely been supportive of this move, and the United Kingdom leads the way by adopting ABPM to diagnose hypertension in primary care.1 Thus, the question of whether ABPM is ready to replace clinic measurements for the diagnosis of hypertension is passe for some but still relevant for others. In either case, the arguments for and against need to be carefully considered as there are major implications to the way cardiovascular healthcare services are delivered. The case for using ABPM for the diagnosis is strong given that clinic measurements even when performed to best practice standards misdiagnose hypertension in ≈30% of individuals (see below). The evidence is so convincing that the medico-legal issue of NOT performing ABPM to diagnose hypertension has been raised.2 On the contrary, there is resistance to using ABPM particularly in some quarters exemplified by the editorial in 2011 that suggested that ABPM is not ready for prime time.3 The arguments presented are largely related to resources and costs and suggested alternatives. In order therefore to consider this important question, we need to first evaluate the medical imperative for the use of …

Evidence for pharmacist care in the management of hypertension.

Hypertension is a major risk factor for cardiovascular diseases and mortality, affecting about 20% to 30% of North American adults.1,2 Although treatment of hypertension can substantially reduce this risk,3 hypertension in primary care remains underdetected, undertreated and poorly controlled.2,4,5 For example, despite substantial improvement, half of North American–treated patients with hypertension remain uncontrolled.2,4,5 Innovative models of care are therefore needed to improve patient outcomes, particularly in light of the heavy workload and shortage of family physicians in most health care systems. Some authors advocate a greater use of community-based models of care6 with the involvement of nonphysician clinicians, such as pharmacists and nurses, as a promising avenue to improve hypertension care and, more broadly, chronic disease management.7-9 Given their accessibility and drug therapy expertise, pharmacists are a logical choice and a valuable asset to improve hypertension management—alone or via team-based care.7,10-13 Indeed, there have been many trials of pharmacist care. We recently combined and updated 2 systematic reviews and meta-analyses of randomized controlled trials evaluating the effect of pharmacist interventions—alone or as part of collaborative care—on blood pressure outcomes among outpatients.12,14 Details about the type of pharmacist intervention (including description and frequency), the involvement of other health care professionals within collaborative care setting, the care setting and the characteristics of participants were also examined.14 The research methods (search strategy, study selection and data extraction) are given in detail in the original publication.14

Improvement of management of hypertension by implementation of alcohol screening and subsequent interventions in primary practice

Hypertension and alcohol use are both part of the five most important risk factors for burden of disease in Western Europe, mainly because of their impact on non-communicable diseases (NCD). Both risk factors are prevalent with high overlap among patients in primary care. Implementation of a screening for alcohol among patients of hypertension in primary care followed by brief intervention for problem alcohol use or formal treatment for people with alcohol dependence could constitute an important step to reach the goals of the Global WHO Action Plan for Prevention and Control of NCD. In addition, such an intervention could improve the management of hypertension. In a working group of experts from clinical practice and research the rationale and potential barriers for this intervention were discussed and steps for implementation in primary care were developed.