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Scope, draft for panel discussion, 05.01.2011
GUIDELINE TITLE:
Management of adult patients with essential hypertension in
primary care
INITIATOR:
Health Insurance Fund
TARGET AUDIENCE:
family physicians, primary care nurses
PATIENT POPULATION
COVERED:
Adults (>18-years) with essential hypertension, including
-
patients with pre-existing cardiovascular disease and/or diabetes
(type II or I)
-
elderly, defined as over 75 years
-
Screening and prevention of hypertension in adult population
(should be covered by another national guideline (on cardiovascular
prevention), reference to be included in the final guideline);
Smoking cessation strategies (covered by another national
guideline, but note that final guideline will have recommendation
about advice to stop smoking);
Exact diagnosis and management of secondary hypertension;
Hypertension during pregnancy (covered by another national
guideline, reference to be included in the final guideline);
Diagnosis and management of children and adolescents with
hypertension (need for a separate guideline to be assessed);
Management of dyslipidaemia and weight problems (covered by
another national guideline, reference to be included in the final
guideline);
Management of hypertensive crisis, hypertensive emergencies;
Management of patients with hypertension and end stage renal
disease.
TOPICS NOT COVERED:
-
-
-
THE INTRODUCTION WILL INCLUDE:
A short summary of diagnostic criteria for hypertension, e.g. from the prevention guideline,
including number of blood pressure measurements needed and technique for blood pressure
measurement.
DRAFT QUESTIONS:
Diagnosis
1. To confirm the diagnosis of hypertension:
Should all adult patients with suspected hypertension be investigated with
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Scope, draft for panel discussion, 05.01.2011
24 hour ambulatory blood pressure monitoring
compared to standard blood pressure measures?
(Critical outcomes: accuracy of 24 ambulatory blood pressure monitoring, positive predictive
value, negative predictive value)
2. To investigate possible end organ damage:
Should all patients with confirmed hypertension be investigated with
 Urinalysis
 Fasting plasma glucose measurement
 ECG
 S-crea
 GFR estimation
 Albuminuria measurement
 S-cholesterol measurement
 Lipid profiling
 Retinal examination (fundoscopy)
 Echocardiography
(Critical outcomes: positive predictive value, negative predictive value, cost-effectiveness?)
Non-pharmacological treatment
3. Should all patients with confirmed hypertension be offered
dietary advice concerning salt restriction,
compared with no salt restriction?
(Critical outcomes - see the list developed by the panel attached (Panel – considering the relative
safety and low cost, should we be satisfied with BP reduction here?))
4. Should all patients with confirmed hypertension have
exercise programs recommended,
compared with no such recommendation?
(Critical outcomes: see the list developed by the panel attached)
Pharmacological treatment, first line therapy
5. Should all adult patients with confirmed hypertension be offered as initial therapy:
Any combination treatment with
 ACEI plus thiazide OR
 ACEI plus BBL
 ACEI plus CCB
 ACEI plus ARB
 ARB plus thiazide
 ARB plus BBL
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 ARB plus CCB
 ARB plus thiazide
 CCB + thiazide
compared with any monotherapy (ACEI OR BBL OR CCB OR ARB OR THZ)
(Critical outcomes: see the list developed by the panel attached)
6. Should all elderly (>75 years) adult patients with confirmed essential hypertension be offered as
initial therapy monotherapy with
ARB compared to any other class (ACEI OR BBL OR CCB OR THZ)
ACEI compared to any other class (BBL OR CCB OR ARB OR THZ)
CCB compared to any other class (ACEI OR BBL OR ARB OR THZ)
BBL compared to any other class (ACEI OR CCB OR ARB OR THZ)
THZ compared to any other class (ACEI OR BBL OR CCB OR ARB)?
(Critical outcomes: see the list developed by the panel attached)
7. Should all elderly (>75 years) adult patients with confirmed hypertension be offered as initial
therapy:
Any combination treatment with
 ACEI plus thiazide OR
 ACEI plus BBL
 ACEI plus CCB
 ACEI plus ARB
 ARB plus thiazide
 ARB plus BBL
 ARB plus CCB
 ARB plus thiazide
 CCB + thiazide
compared with any monotherapy (ACEI OR BBL OR CCB OR ARB OR THZ)
(Critical outcomes: see the list developed by the panel attached, note that importance of adverse
effects may need to be considered).
8. Should adult patients with newly diagnosed hypertension and co-morbidities (Panel to define,
what should be covered: CHF, diabetes, CAD?) be offered as initial therapy:
Any combination treatment with
 ACEI plus thiazide OR
 ACEI plus BBL
 ACEI plus CCB
 ACEI plus ARB
 ARB plus thiazide
 ARB plus BBL
 ARB plus CCB
 ARB plus thiazide
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 CCB + thiazide
compared with any monotherapy (ACEI OR BBL OR CCB OR ARB OR THZ)
(Critical outcomes: see the list developed by the panel attached)
9. Should adult patients with newly diagnosed hypertension and co-morbidities (define CHF,
diabetes, CAD?) be offered as initial therapy monotherapy with
ARB compared to any other class (ACEI OR BBL OR CCB OR THZ)
ACEI compared to any other class (BBL OR CCB OR ARB OR THZ)
CCB compared to any other class (ACEI OR BBL OR ARB OR THZ)
BBL compared to any other class (ACEI OR CCB OR ARB OR THZ)
THZ compared to any other class (ACEI OR BBL OR CCB OR ARB)?
(Critical outcomes: see the list developed by the panel attached)
10. Should adult patients with high initial blood pressure (Panel to define: SBP ≥ … or DBP ≥…) be
offered as initial therapy:
Any combination treatment with
 ACEI plus thiazide OR
 ACEI plus BBL
 ACEI plus CCB
 ACEI plus ARB
 ARB plus thiazide
 ARB plus BBL
 ARB plus CCB
 ARB plus thiazide
 CCB + thiazide
compared with any monotherapy (ACEI OR BBL OR CCB OR ARB OR THZ)
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
Pharmacological treatment, second line therapy
11. Should patients with hypertension, started on monotherapy, that have not responded to initial
treatment, be offered
Increased dose of same drug
Compared to an alternative drug within the same class?
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
12. Should patients with hypertension, started on monotherapy, that have not responded to initial
treatment, be offered
Increased dose of same drug
Compared to an alternative drug from another class?
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(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
13. Should patients with hypertension, started on monotherapy, that have not responded to initial
treatment, be offered
Increased dose of same drug
Compared to any combination of drugs from different classes?
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
14. Should patients with hypertension, started on monotherapy, that have not responded to initial
treatment, be offered
An alternative drug from another class
Compared to any combination of drugs from different classes?
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
15. Should patients with hypertension, started on combination treatment, that have not responded to
initial treatment, be offered
Increased dose of same drugs
Compared to alternative drugs from the same classes?
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
16. Should patients with hypertension, started on combination treatment, that have not responded to
initial treatment, be offered
Increased dose of same drugs
Compared to alternative drugs from different classes?
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
17. Should patients with hypertension, started on combination treatment, that have not responded to
initial treatment, be offered
Alternative dual combination treatment
Compared to combination with a third class?
(Critical outcomes: see the list developed by the panel attached, note that importance of
adverse effects may need to be considered)
18. In patients on treatment for hypertension, what strategies should be offered to improve
adherence? (Panel: will need to refine the list of strategies)
 Strategy 1 compared to doing nothing
 Strategy 2 compared to doing nothing
 Effective strategy 1 compared to Effective strategy 2
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 Combining effective strategies compared to any single effective strategy
HEALTHCARE SETTING:
Which patients with hypertension must/can be treated in primary care level?
What are the reasons to refer a patient to a specialist ?
Are there patient sub-groups who should /must be treated by specialist?
ECONOMIC EVALUATION:
Cost-utility/cost-minimisation analyses to be carried out when making
recommendations involving a choice between alternative interventions which may
cause a budget impact of measurable size (Health Insurance Fund to refine).
EVALUATION OF GUIDELINE IMPLEMENTATION:
Expected increase in proportion of adults with hypertension treated by family
physicians compared to cardiologists/other specialist;
Decrease in amount of variations (diagnostics, treatment) in primary care hypertension
treatment;
Increase in number of consultations (non-pharmacological interventions) performed
by family nurses;
Better BP control rates;
Exact indicators to be aligned in line with guideline recommendations.
UPDATING THE GUIDELINE:
After 5 years or when relevant evidence becomes available.
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OUTCOME RATINGS BY THE PANEL
The rating scale is
1-3: not important
4-6: important
7-9: critically important for decision making.
Mortality
8,7
CV Mortality
7,9
Stroke
7,89
Health related quality of life
7,7
Myocardial Infarction
7,5
Hypertensive emergencies
7
End stage renal disease
7
Development of new episode of cardiac failure
6,5
Vascular dementia
6,3
cost of therapy
6,2
Blood pressure control
5,8
Hospitalisation for cardiovascular reasons
5,8
Renal function, GFR
5,3
Withdrawals for adverse effects
5,2
Adverse effect - Sexual dysfunction
5,1
New onset of diabetes while on therapy
4,56
Hospitalisation for any reason
4,5
Progression to retinopathy
4,4
Adverse effect - Cough
4,3
Adverse effect - ankle oedema
3,5
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