Download Halfdan Petursson

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
•
To model the implications of recent
European guidelines for the management of
arterial hypertension
A. Prevalence of individuals “at risk” for CVD
B. Clinical workload associated with recommended
measures
•
•
Number of follow-up visits/year
Number of physicians needed (general practitioners?)
• 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
0
2
3-4
3-4
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
• Excluded if:
– blood pressure <120/80 mmHg
– no information available about any of the other risk factors
The risk factors
HUNT 2
1. Age
2. Smoking
3. Dyslipidemia (total- and HDL cholesterol)
4. Waist circumference
5. 1° relatives with CVD
6. 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
Age standardised prevalence
Total: 100% = 100 000 adults after standardisation
Data from those included only (51 066)
Age standardised prevalence
Age standardised prevalence
The excluded
group
Average
risk
6.6%
+
Low
risk?
<21%
= <25%
Do 75% or more have
risk above average?
99%
of
all
50-64
y.o.
Average risk?
should attend
regular
6,6%
follow-up visits or receive
drug treatment for high bp!
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
• 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:
– 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 recommendations
0
2
3-4
3-4
Mortality from CVD per 100.000
1970-2006
Denmark
Finland
France
Iceland
Italy
Netherlands
Norway
Spain
Sweden
United
Kingdom
WHO Health for all database, Aug 2008