General practitioners' management of hypertension in elderly patients

Prevalence, management and control of hypertension in older adults on admission to hospital

Introduction

The aim of this study was to explore the prevalence and management of hypertension among older adults on admission to hospital and to assess the choice of antihypertensive pharmacotherapy in light of relevant comorbid conditions using the national treatment guideline.

Materials and methods

A retrospective cross sectional study of 503 patients aged 65 years or older admitted to a large metropolitan teaching hospital in Sydney Australia was conducted. The main outcome measures were prevalence of hypertension, blood pressure (BP) control, antihypertensive medication use and the appropriateness of antihypertensive medications.

Results

Sixty-nine percent (n = 347) of the study population had a documented diagnosis of hypertension and of these, approximately one third were at target BP levels on admission to hospital. Some concerns regarding choice of antihypertensive noted with 51% of those with comorbid diabetes and 30% of those with comorbid heart failure receiving a potentially inappropriate antihypertensive agent.

Conclusions

Despite the use of antihypertensive pharmacotherapy, many older adults do not have optimal BP control and are not reaching target BP levels. New strategies to improve blood pressure control in older populations especially targeting women, those with a past history of myocardial infarction and those on multiple antihypertensive medications are needed.

Hypertension in older patients, a retrospective cohort study

BACKGROUND

It is unknown to what extent General Practitioners (GPs) manage hypertension (HT) differently in older patients, as compared to younger age groups. The purpose of our study was to compare HT management in older patients to younger age groups.

METHODS

We performed a retrospective cohort study of patients of 159 GP's practices in the Integrated Primary Care Information (IPCI) database. The study period lasted from September 2010 through December 2012. The study population consisted of all patients aged 60 years or older with at least one blood pressure (BP) measurement during the inclusion period, without pre-existent HT, diabetes mellitus (DM) or atherosclerotic cardiovascular disease at time of study start. Study outcomes were a diagnosis of HT within one month after cohort entry and the use of antihypertensive medication within 4 months after cohort entry in HT diagnosed patients. We compared the incidence of outcomes between the age groups, stratified by systolic blood pressure (SBP). Logistic regression analysis was used to assess the influence of age-adjusted SBP Z-scores, age and gender on the outcomes.

RESULTS

We included 19,500 patients from 159 GP's practices of whom 1,181 (6.1 %) were newly diagnosed with HT. Corrected for age-adjusted SBP, older patients were less likely to be diagnosed with HT (odds ratio per year age increase 0.98, p < 0.001). Corrected for age-adjusted SBP, no significant effect of age on the probability of treatment in newly diagnosed HT patients was observed (p = 0.82).

CONCLUSIONS

This study showed that GPs are less inclined to diagnose HT with increasing patient age, but do not withhold treatment when they diagnose HT in older patients.

Prevalence, prescribing and barriers to effective management of hypertension in older populations: a narrative review

Objectives

Hypertension is the leading modifiable cause of mortality worldwide. Unlike many conditions where limited evidence exists for management of older individuals, multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults. Understanding the impact of age on how the prevalence of hypertension and the role of pharmacotherapy in managing hypertension among older persons is a critical element is the provision of optimal health care for older populations. The aim of this study was to explore how the prevalence of hypertension changes with age, the evidence regarding pharmacological management in older adults and to identify known barriers to the optimal management of hypertension in older patients.

Methods

A review of English language studies published prior to 2013 in Medline, Embase and Google scholar was conducted. Key search terms included hypertension, pharmacotherapy, and aged.

Results

The prevalence of hypertension was shown to increase with age, however there is good evidence for the use of a number of pharmacological agents to control blood pressure in older populations. System, physician and patient related barriers to optimal blood pressure control were identified.

Conclusions

Despite good evidence for pharmacological management of hypertension among olderpopulations, under treatment of hypertension is an issue. Concerns regarding adverse effects appearcentral to under treatment of hypertension among older populations.

Maximizing the benefit of treatment in mild hypertension:three simple steps to improve diagnostic accuracy

BACKGROUND

Most patients only have three measurements of blood pressure before being labelled as hypertensive. This may lead to inaccurate classification, unnecessary treatment and dilution in treatment benefit for the population.

AIM

To examine the accuracy of current methods of diagnosing mild hypertension, and to explore ways to improving targeting of antihypertensive treatment without entailing lengthy observation.

DESIGN

Re-analysis of published data.

METHODS

We tested current diagnostic methods using the data for 3965 individuals who were followed for a year in the placebo arm of the MRC Mild Hypertension Trial. We calculated the proportion selected for treatment by current methods and the diagnostic accuracy, using average blood pressure beyond 6 months as representing 'true' long-term blood pressure. We examined the benefit of averaging blood pressures, of prolonging observation modestly and of estimating within-person blood pressure variability.

RESULTS

Prolonging observation to 3 months selects a smaller (by about 12%) proportion of the sample for treatment, a proportion similar to that defined as 'truly' hypertensive. The diagnostic accuracy of current methods is poor, with up to 69% discrepancy in classification. This discrepancy was improved by up to 18% in absolute terms by prolonging observation to 3 months and using average blood pressures. Identifying those individuals with low within-person variability allows marked improvement in the prediction of 'true' hypertension.

DISCUSSION

Although some inaccuracy in the diagnosis of hypertension is inevitable, observation for 3 months, averaging blood pressures and estimating within-person blood pressure variability can markedly improve upon current practice.

Prescribing pattern of antihypertensive drugs by family physicians and general practitioners in the primary care setting in Bahrain

The aim was to determine whether there are differences among family physicians (FPs) and general practitioners (GPs) in terms of their preference for different classes of antihypertensives, either alone or in combinations, in uncomplicated cases of hypertension and to determine the extent of adherence to WHO/ISH guidelines. We have analysed prescribing of antihypertensives by qualified family physicians (FPs) (n=77) and compared this with that of general practitioners (GPs) (n =41) by auditing 1791 prescriptions of FPs and 914 prescriptions of GPs, issued to patients with uncomplicated hypertension, at 15 out of 20 health centres in Bahrain. The choice of antihypertensive(s) by FPs and GPs was comparable and conformed with the WHO/ISH guidelines as regards preference for: (i) beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers (CCBs) as monotherapy; (ii) two-drug combinations (diuretic-beta-blocker; beta-blocker-CCB); (iii) three-drug combinations (diuretic-beta-blocker-CCB; diuretic-beta-blocker-ACE inhibitor; beta-blocker- ACE inhibitor-CCBs), and (iv) choice of drug used for the elderly either alone (CCBs) or as combinations (diuretic-beta-blocker; beta-blocker-CCB and diuretic-beta-blocker-ACE inhibitor; diuretic-beta-blocker-CCB). In several instances prescribing by both FPs and GPs was not in accordance with the WHO/ISH guidelines: reluctance to prescribe diuretics as monotherapy; use of suboptimal combinations (beta-blocker-ACE inhibitor); and extensive use of beta-blockers and irrational use of immediate-release nifedipine in elderly. A statistically significant prescribing difference between FPs and GPs was evident in the following: beta-blockers as monotherapy (P =0.01), diuretic-CCB (P=0.046), and diuretic-CCB-methyldopa (P=0.01) combination, and immediate-release nifedipine monotherapy in the elderly (P=0.027), were prescribed more often by the GPs. However, beta-blocker-ACE inhibitor-CCB combination was more often prescribed by FPs (P=0.046). Remarkable differences in prescribing pattern of antihypertensives between the FPs and GPs were evident. Although the general pattern supported a superior prescribing profile of the FPs as expected, there is a need for improved prescribing by both GPs and FPs. Educational programmes, both graduate and residency training, and continuing professional education, should specifically address these deficiencies in order to assure quality primary health care.

Predictors of normotension on withdrawal of antihypertensive drugs in elderly patients: prospective study in second Australian national blood pressure study cohort

OBJECTIVES

To identify simple long term predictors of maintenance of normotension after withdrawal of antihypertensive drugs in elderly patients in general practice.

DESIGN

Prospective cohort study.

SETTING

169 general practices in Victoria, Australia.

PARTICIPANTS

503 patients aged 65-84 with treated hypertension who were withdrawn from all antihypertensive drugs and remained drug free and normotensive for an initial two week period; all were followed for a further 12 months.

MAIN OUTCOME MEASURES

Relative likelihood of maintaining normotension 12 months after drug withdrawal; relative likelihood of early return to hypertension after drug withdrawal.

RESULTS

The likelihood of remaining normotensive at 12 months was greater among younger patients (65-74 years), patients with lower "on-treatment" systolic blood pressure, patients on single agent treatment, and patients with a greater waist:hip ratio. The likelihood of return to hypertension was greatest for patients with higher "on-treatment" systolic blood pressure.

CONCLUSIONS

Age, blood pressure control, and the number of antihypertensive drugs are important factors in the clinical decision to withdraw drug treatment. Because of consistent rates of return to antihypertensive treatment, all patients from whom such treatment is withdrawn should be monitored indefinitely to detect a recurrence of hypertension.

Age-related bias in the management of hypertension: a national survey of physicians' opinions on hypertension in elderly adults

BACKGROUND

This study surveyed opinions and self-reported practices of physicians involved in the care of elderly individuals regarding geriatric hypertension management and included a national random sample (n = 1060) of health care professionals in the United States.

METHODS

This is a cross-sectional self-conducted survey using a questionnaire developed to assess the opinions related to blood pressure (BP) and aging, BP selection, BP target, lifestyle modifications, and first-line drug choice. We also tested the impact of the patient's age on the respondents' answers. A national random sample (n = 1060) of health care professionals in the United States was selected.

RESULTS

We received 412 (39%) questionnaires. Thirty-five percent considered that the increase in BP with age is a normal process of aging, and 25% considered treating hypertension in an 85-year-old patient to have more risks than benefits. Sixty-nine percent considered systolic blood pressure to be the most important pressure. Respondents were more likely to start antihypertensive therapy at a lower BP and target a lower BP in 65-year-old patients compared with 85-year-old patients (p <.001). Respondents were more likely to recommend lifestyle modifications in 65-year-old patients compared with 85-year-old patients (p <.001). Only 13-17% recommend higher potassium consumption. Diuretics (p =.032) and beta-blockers (p =.005), but not other antihypertensives, are less likely to be used as first-line drugs by respondents in the very old.

CONCLUSIONS

Health care professionals' understanding of BP changes with aging, BP selection and BP target levels, lifestyle modification counseling (especially concerning potassium consumption), and drug selection deviates in some aspects from the national recommendations especially in the very old. Improving these opinions could have a significant impact on the control rates of geriatric hypertension.

Family physicians' and general practitioners' approaches to drug management of diabetic hypertension in primary care

RATIONALE, AIMS AND OBJECTIVES

To compare the pharmacotherapeutic approaches to diabetic hypertension of family physicians (FPs) and general practitioners (GPs).

METHODS

A retrospective prescription-based study was conducted in 15 out of a total of 20 health centres, involving 115 primary care physicians--77 FPs and 38 GPs, representing 74% of the primary care physicians of Bahrain. Prescriptions were collected during May and June 2000 to comprise a study population of 1266 diabetic-hypertensive patients.

RESULTS

As monotherapy, angiotensin-converting enzyme (ACE) inhibitors (37.9%) and beta-blockers (38.3%) were the most commonly prescribed classes of antihypertensives by FPs and GPs, respectively. Calcium channel blockers (CCBs) were ranked third by both categories of physicians. For two-drug combinations, a beta-blocker and an ACE inhibitor was the combination of choice for both physician categories. Patients managed by the FPs were more likely to receive a beta-blocker-CCB combination (17.4 vs. 14.9%) or a diuretic-ACE inhibitor combination (16.7 vs. 11.4%) and less likely to receive a beta-blocker-diuretic combination (11.8 vs. 16.7%) than those managed by the GPs. The proportion of patients receiving antihypertensive combinations was 40.6 and 38.5% for FPs and GPs, respectively. While the GPs prescribed CCB as a monotherapy to the elderly most often, the FPs choice was a beta-blocker. Diuretics were less preferred by both FPs and GPs. Beta-blocker-ACE inhibitor was again the most preferred combination of both FPs and GPs. FPs prescribed CCB-beta-blocker combinations more often than GPs (P = 0.01), whereas CCB-ACE inhibitor combinations were less preferred (P = 0.09). A trend towards excessive use of short-acting nifedipine as monotherapy for elderly patients, both by FPs and by GPs, was noticed. Glibenclamide, alone or in combination with metformin, was the foremost antidiabetic drug prescribed by FPs and GPs. Middle-aged (45-64 years) patients seen by GPs were more likely to receive glibenclamide than those treated by FPs (P = 0.001) and less likely to receive gliclazide (P = 0.01). Combinations of a beta-blocker with either glibenclamide or insulin were prescribed considerably more often by GPs.

CONCLUSIONS

Within the same practice setting, a substantial difference was observed between FPs and GPs in terms of preference for different classes of drugs in the management of diabetic hypertension. The compliance of both FPs and GPs was suboptimal; overall, the compliance of the FPs was closer to the recommended guidelines, however. Educational programmes should specifically address these inadequacies in order to improve the quality of health care.

The effect of 24 h blood pressure levels on early neurological recovery after stroke

OBJECTIVES

To assess the influence of 24 h blood pressure (BP) levels on functional recovery 1 week after stroke and the effect of antihypertensive therapy on 24 h BP levels.

DESIGN

Prospective study of patients admitted to hospital over 1 year with first in a lifetime stroke who underwent 24 h BP and casual measurements. Setting. Medical wards in a teaching hospital. Subjects. Of 160 patients, 72 patients admitted to hospital within 24 h of stroke onset were investigated. Patients with conditions and therapy that interfered with autonomic and sympathetic function were excluded. Interventions. All subjects underwent 24 h BP and casual recordings on admission to hospital and at day seven after stroke. The mean 24 h, day and night systolic BP (SBP) and diastolic BP (DBP) and their differences (nocturnal BP dip) were recorded. Patients were divided into three groups according to whether they were taking antihypertensive therapy during the first week: (i) no therapy, (ii) therapy continued after stroke, and (iii) new therapy introduced. Main outcome measures. Functional recovery (Rankin Scale 0-1) and neurological improvement [Scandinavian Stroke Scale (SSS) >/=3 points] by 1 week of stroke. Change in circadian 24 h BP over 1 week.

RESULTS

For each 10 mmHg difference between day and night time DBP, the odds for making a complete recovery were 4.63 (95% CI: 1.57-13.7, P=0.01). For each 10 mmHg difference between day and night SBP, the odds for making an improvement in neurological status was 2.24 (95% CI: 1.16-4.32; P=0.016). Significant falls in 24 h DBP (P=0.01), daytime SBP (P=0.005) and mean arterial BP (MABP) (P=0.04) over 1 week were demonstrated in patients who had just commenced antihypertensive therapy (P=0.001).

CONCLUSION

An increase in day to night time BP change is favourable in short-term outcome after acute stroke. Significant falls in BP are more likely in patients started on antihypertensive therapy for the first time. Further research is required to understand the effects of circadian BP rhythm on stroke outcome.

Addressing barriers to change: an RCT of practice-based education to improve the management of hypertension in the elderly

BACKGROUND

In the future, primary care groups (PCGs) will have to consider how best to apply audit and education to fulfil their commitment to clinical governance and to facilitate the implementation of research findings.

AIM

To establish whether an exploration of 'barriers to change' can enhance the effectiveness of an educational intervention designed to improve the management of hypertension in the elderly.

METHOD

A parallel-arm, randomized, single-blind, controlled trial of practice-based educational visits in 18 practices. These practices had previously taken part in a multipractice audit of the management of hypertension in the elderly. Both groups received outreach visits in their own practice, during which they received the results of the previous audit. The nine 'intervention' practices were encouraged to explore barriers that would prevent them from implementing pertinent research findings. The control group was not encouraged to do this. The main outcome measure of the trial was determined in advance as 'the stated management of systolic hypertension in patients aged 70 to 79'. A secondary endpoint was the stated management of a specific patient scenario. The endpoints were tested by questionnaire before and after the educational intervention.

RESULTS

For the primary endpoint, there was a statistically significant difference in the stated threshold for treating systolic hypertension between intervention and control groups after the visits (161.8 mmHg versus 167.2 mmHg; P = 0.007). For the secondary endpoint, there was also a statistically significant difference between the two groups, after the visits, in their willingness to treat a 70-year-old male with mild hypertension (89% of doctors would treat in the intervention group versus 57% in the control group; P = 0.047).

CONCLUSION

The effectiveness of an educational intervention is significantly improved by addressing the barriers preventing practitioners from implementing the findings of research.

[Treatment patterns of hypertension in 1996. Data from the Quebec Family Practice, University of Sherbrooke registry]

OBJECTIVE

To describe the treatment of hypertension, alone or in combination with associated conditions, by a group of general practitioners in the FAMUS network and to compare these treatment patterns to the recommendations of the Canadian Hypertension Society Consensus.

DESIGN

Descriptive study based on data collected by 233 physicians in the FAMUS provincial register on hypertensive patients treated in 1996.

PARTICIPANTS

Developed between 1992 and 1996, the register contains 52,505 patients, 9,094 of whom have high blood pressure. These patients consulted their general practitioners for a complete examination. The data concern the risk factors for cardiovascular disease and include the list of medications prescribed.

MAIN OUTCOME MEASURES

Evaluation of the proportions in which various classes of medications were prescribed, and the most common combinations in relation to the presence or absence of associated conditions.

RESULTS

Of the 4,049 hypertensive patients seen in 1996, 50.2% were treated with one medication; 32.9% were treated with more than one medication; and 16.9% received no antihypertensive medication. The most frequently prescribed medications were calcium channel blockers (26.1%), followed by diuretics (25.3%), angiotensin-converting enzyme inhibitors (24.3%), and beta-blockers (20.0%). Other agents made up the remaining 4.3% of prescriptions. The proportions were similar for patients without complications who received one medication.

CONCLUSIONS

Results of this study suggest that the new molecules are widely used and that treatment patterns differ from the recommendations of the Canadian Hypertension Society Consensus, particularly in the absence of associated conditions.

Stroke services in general practice--are they satisfactory?

BACKGROUND

The contribution of general practice and primary care teams to stroke care has received surprisingly little attention despite research evidence on the importance of coordinated care.

AIM

To determine general practitioners' (GPs') and their patients' satisfaction with hospital and community services for stroke patients in Grampian Region, Scotland.

METHOD

A questionnaire survey of 138 stroke patients and their GPs was carried out six weeks after each patient was discharged home between June 1995 and January 1996. Outcomes measured were GP and patient satisfaction with services, Barthel Index, Hospital Anxiety and Depression scores, London Handicap Score, and Homsat and Hospsat scores (satisfaction with stroke services).

RESULTS

Response rates of 95% (131) for GPs and 91% (125) for patients were obtained. GPs and patients were generally satisfied with services. Stroke patients were more likely to have had contact with their GP than with any other service. Adverse comments from GPs focused on problems with hospital discharge letters. At six weeks, patients received an average of 2.5 community services and 1.5 hospital services, but there was wide variation across disability groups.

CONCLUSIONS

Levels of satisfaction were high, but the wide range and variation in services used by patients emphasized the complexity of the primary care of stroke patients; the need for coordination, review and effective links with hospital; and the key role of the GP.

A survey of management practices for isolated systolic hypertension

OBJECTIVE

To determine the management practices of clinicians for patients with isolated systolic hypertension, with particular attention to treatment thresholds, medication choices, and target blood pressures.

DESIGN

Self-administered questionnaire.

SETTING

Edmonton, Alberta, a large Canadian city.

PARTICIPANTS

A random sample of 348 family physicians and 125 internists.

MEASUREMENTS

Demographics of the respondents, first and second choice of antihypertensives, treatment thresholds, and target blood pressures for patients with isolated systolic hypertension.

RESULTS

Excluding 54 nondeliverable questionnaires, a response rate of 67% (281 surveys) was obtained. The responding clinicians reported treatment thresholds and target blood pressures consistent with the evidence from randomized clinical trials and the recommendations of the Canadian Hypertension Society and the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Thiazide diuretics were recommended as first line therapy by 74% of internists and 58% of family physicians. Angiotensin converting enzyme inhibitors were the most frequently chosen second line drug (27% of internists and 45% of family physicians).

CONCLUSIONS

The reported management practices of this group of clinicians are consistent with the evidence from randomized clinical trials and the recommendations of national consensus guidelines.

Contemporary practice patterns in the management of newly diagnosed hypertension

OBJECTIVE

To determine what proportion of patients with hypertension are managed in accordance with guidelines established by the Canadian Hypertension Society.

DESIGN

Retrospective medical record review.

SETTING

Outpatients seen in primary care offices and internal medicine referral clinics in Edmonton.

PATIENTS

All 969 adults who presented with a new diagnosis of essential hypertension from Sept. 1, 1993, to Dec. 31, 1995.

OUTCOME MEASURES

Initial laboratory tests performed, advice concerning nonpharmacologic treatment given, antihypertensive drugs prescribed and any contraindications to thiazide diuretics or beta-adrenergic blocking agents documented.

RESULTS

The mean age of the 969 patients in the sample was 52.5 years; 129 (13%) of the patients were older than 70 years of age; and 500 (52%) were women. Most of the patients (704, 73%) had mild or moderate diastolic hypertension. In the 617 patients who underwent laboratory tests related to hypertension, the creatinine level was determined in 466 (76%), the cholesterol level in 372 (60%), a urinalysis was conducted in 378 (61%), the serum potassium level was checked in 343 (56%), the sodium level in 323 (52%) and an electrocardiogram was performed in 303 (49%). Liver function tests, which are not recommended in the guidelines, were performed in 338 patients (55%). Although there were differences in prescribing among physicians in the 711 patients given first-line therapy, most (238, 34%) were prescribed angiotensin-converting-enzyme (ACE) inhibitors. Lifestyle modification, without drug therapy, was suggested for 180 (25%) of the patients. Although the guidelines recommend their use for first-line drug therapy, only 82 patients (12%) were given beta-adrenergic blocking agents and only 75 (11%) were given thiazide diuretics. Of the patients who were prescribed an antihypertensive other than a thiazide or beta-adrenergic blocking agent as first-line drug therapy, only 161 (43%) had a documented contraindication to thiazides or beta-adrenergic blocking agents.

CONCLUSIONS

There is variation in the contemporary care of patients with hypertension. Further studies are required to determine the reasons underlying physicians' noncompliance with the evidence-based guidelines established by the Canadian Hypertension Society.

Prognostic value of admission blood pressure in patients with intracerebral hemorrhage. Keio Cooperative Stroke Study

BACKGROUND AND PURPOSE

Patients with acute stroke on admission to the hospital are often found to have high blood pressure. The purpose of the present study was to investigate the prognostic value of admission blood pressure in patients with acute intracerebral hemorrhage, including putaminal, thalamic, subcortical, cerebellar, and pontine hemorrhage.

METHODS

A total of 1701 patients with intracerebral hemorrhage of the putamen (n = 776; mean +/- SD age, 58 +/- 14 years) thalamus (n = 538; 63 +/- 12 years), subcortex (n = 153; 61 +/- 16 years), cerebellum (n = 110; 64 +/- 11 years), and pons (n = 124; 59 +/- 13 years) were examined. The mean blood pressure on admission in patients with a fatal outcome was compared with that in patients who survived.

RESULTS

The mean age in each patient group (putaminal, thalamic, subcortical, cerebellar, and pontine hemorrhage) with fatal outcome was older than that with nonfatal outcome, while ANCOVA indicated no correlation between age and blood pressure on admission or age and volume of hematoma. The mean arterial blood pressure on hospital admission was 126.9 +/- 25.8 mm Hg (+/-SD) in cases of putaminal. 127.4 +/- 22.6 mm Hg in thalamic, 116.4 +/- 20.6 mm Hg in subcortical, 123.5 +/- 23.9 mm Hg in cerebellar, and 133.0 +/- 26.0 mm Hg in pontine hemorrhage. The mean blood pressure on admission in patients with a fatal outcome among those with putaminal (136.0 +/- 36.3 mm Hg) and thalamic (133.2 +/- 22.1 mm Hg) hemorrhage was significantly higher than that in those with a nonfatal outcome (123.8 +/- 20.6 mm Hg for putaminal, 101.6 +/- 22.5 mm Hg for thalamic) (P < .01). No correlation between mean blood pressure and outcome was observed in the patients with subcortical (116.5 +/- 22.2 mm Hg for nonfatal, 114.9 +/- 22.0 mm Hg for fatal outcome), cerebellar (125.2 +/- 22.2 mm Hg, 116.9 +/- 28.8 mm Hg), and pontine (129.9 +/- 23.8 mm Hg, 136.0 +/- 27.7 mm Hg) hemorrhage. The volume of hematoma on admission in patients with fatal outcome with putaminal (58.2 +/- 24.4 mL), thalamic (27.0 +/- 13.1 mL), subcortical (32.9 +/- 14.4 mL), and cerebellar (31.4 +/- 28.6 mL) hemorrhage was greater than that in those with nonfatal outcome (20.8 +/- 11.4 mL, 7.1 +/- 4.8 mL, 18.3 +/- 10.6 mL, and 8.1 +/- 4.2 mL, respectively; P < .01), while no correlation between volume of hematoma and outcome was observed in patients with pontine hemorrhage.

CONCLUSIONS

The above data suggest that an increased mean blood pressure and volume of hematoma on admission in putaminal and thalamic hemorrhage were related to increased mortality, while in patients with subcortical, cerebellar, and pontine hemorrhage, the mean blood pressure was not related to the clinical outcome.

Prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom, 1980-95: systematic literature review

OBJECTIVE

To determine the prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom.

DESIGN

Review of 62 studies of the appropriateness of prescribing identified from seven electronic databases, from reference lists, and by hand searching of journals. A nominal group of 10 experts helped to define the appropriateness of prescribing.

SETTING

General practice in the United Kingdom.

MAIN OUTCOME MEASURES

Prevalences of 19 indicators of inappropriate long term prescribing representing five dimensions: indication, choice of drug, drug administration, communication, and review.

RESULTS

Prevalences of potentially inappropriate prescribing varied by indicator and chronic condition, but drug dosages outside the therapeutic range consistently recorded the highest rates. The lowest rates were generally associated with indicators of the choice of the drug, except cost minimisation. Communication is studied less frequently than other dimensions of prescribing appropriateness.

CONCLUSIONS

The evidence base to support allegations of widespread inappropriate prescribing in general practice is unsound. Although inappropriate prescribing has occurred, the scale of the problem is unknown because of limitations associated with selection of a standard, publication bias, and uncertainty about the context of prescribing decisions. Opportunities for cost savings and effectiveness gains are thus unclear. Indicators applicable to individual patients could yield evidence of prescribing appropriateness.

Knowledge, attitude and practice (kap) of primary health care physicians and nurses towards hypertension: a study from dammam, saudi arabia

OBJECTIVE

To evaluate the quality of management of hypertensive patients attending Primary Health Care Center (PHC) in Dammam city and to determine factors that possibly affect it.

DESIGN

A cross sectional study and direct interview.

SETTING

Dammam city.

SUBJECTS

All doctors and nurses from a randomly selected sample of Primary Health Care Centers during April 1994.

MAIN MEASURES

Measuring the knowledge, attitude and practice of doctors and nurses about hypertension management.

RESULTS

Hypertension is regarded as an important health problem in Saudi Arabia in the opinion of majority of doctors (80'0) and nurses (69%). Almost half of the doctors and nurses believe that nurses are sufficiently qualified to measure blood pressure of patients. Most of the doctors (96.7%) and nurses (86%) depend merely on face-to-face education of patients Thirty percent of doctors and 34% of nurses think that the care for hypertensive patients in their Primary Health Care Centers is inadequate.

CONCLUSIONS AND RECOMMENDATIONS

Offering on job training of both physicians and nurses on hypertension management. Producing a well planned protocol on the national level. Implementing a total quality management and medical audit system to PHC centers.

A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health

OBJECTIVE

To review the available evidence in order to identify effective interventions which health services alone or in collaboration with other agencies could use to reduce inequalities in health.

METHODS

A search of the literature was undertaken using a number of databases including Medline (from 1990), Applied Social Science Index and Abstracts (1987-1994), and the System for Information on Grey Literature in Europe (1984-1994), on a large range of key words. Studies were included if they assessed interventions designed to reduce inequalities in health or improve the health of a population group relevant to the review, and could be carried out by a health service alone or in collaboration with other agencies. Only studies evaluating interventions using an experimental design were included. Papers in any language were considered. In addition, systematic reviews of the research on the effectiveness of health promotion and the treatment of conditions where there are significant health inequalities were identified in order to illustrate the potential for reducing inequalities in health.

RESULTS

94 studies were identified which satisfied all the inclusion criteria and 21 reviews were included. A number of interventions have been shown to improve the health of groups who are disadvantaged by socio-economic class, ethnicity or age and, if properly targeted, could be expected to reduce health inequalities. If a health intervention is being used, there should be evidence that it has an impact on health status. Attention should then be given to the way in which the intervention is delivered and the characteristics of a programme to promote implementation. Characteristics of successful interventions specifically aimed at reducing health differentials include: systematic and intensive approaches to delivering effective health care; improvement in access and prompts to encourage the use of services; strategies employing a combination of interventions and those involving a multi-disciplinary approach; ensuring interventions address the expressed or identified needs of the target population; and the involvement of peers in the delivery of interventions. However, these characteristics alone are not sufficient for success, nor are they universally necessary.

CONCLUSIONS

Although it is likely that the most significant contributions to reducing health inequalities will be in improving economic and social conditions and the physical environment, there are interventions which health services, either alone or in collaboration with other agencies, can use to reduce inequalities in health.

Withdrawal of antihypertensive therapy in the elderly. The issues

Studies of antihypertensive drug withdrawal suggest that at least 20% of selected older patients with hypertension can remain normotensive without drug treatment for periods of up to 5 years. Success of drug withdrawal is greater in those patients controlled on low dose monotherapy who have low on-treatment blood pressure (BP), are not overweight and who have no ECG evidence of left ventricular hypertrophy. Compliance with lifestyle advice may increase the chance of successful drug withdrawal. Unfortunately, many older hypertensive patients have poorly controlled BP despite treatment with antihypertensive drugs, and are overweight. These factors limit opportunities for drug withdrawal although they may not be so much of a problem in the very elderly. Patient who could be considered for a trial of antihypertensive drug withdrawal are those unhappy with such therapy who also: (a) have well controlled BP on monotherapy with no significant target organ damage, (b) have 'white-coat' hypertension, or (c) are very elderly (> 80 years). The withdrawal of antihypertensive drugs can improve drug-induced metabolic abnormalities and symptoms, and appears safe providing there is a gradual reduction in drug dosages and close follow-up to detect a return to hypertension.

Management of hypertension in the elderly: attitudes of general practitioners and hospital physicians

1. The attitudes of general practitioners and hospital physicians to the management of hypertension in the elderly, were examined by responses to a postal questionnaire distributed within the Northern Region, concerning the management of a healthy 75 year old male non-smoker with sustained diastolic or isolated systolic hypertension. 2. Two hundred and fourteen (64%) general practitioners and 127 (70%) hospital physicians responded to the questionnaire. General practitioners stated they would most commonly measure to the nearest 2 mm Hg (47%) as compared with nearest 5 mm Hg (61%) by physicians; P < 0.05. When measuring diastolic blood pressure 16% general practitioners and 31% physicians would use phase IV sounds; P < 0.01. 3. Median levels of hypertension, confirmed by repeated readings, at which antihypertensive therapy would be commenced were similar: 180 (150-230)/100(90-120) mm Hg vs 180 (150-200)/100 (90-120) mm Hg; median (range). The stated use of non-pharmacological methods to lower blood pressure before starting drug therapy was similar (74% vs 63%). General practitioners were more likely to prescribe a thiazide diuretic (70% vs 54%) and less likely to prescribe a calcium channel blocker (14% vs 28%) as first line therapy; data for diastolic hypertension, P < 0.001. 4. Considerable variation exists amongst both general practitioners and physicians in their stated assessment and management of a healthy elderly non-smoking male with sustained hypertension. General practitioners and physicians have similar stated thresholds for treating hypertension but differ in their choice of first line therapy. (ABTRACT TRUNCATED AT 250 WORDS)

Treatment preferences, return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (the General Practitioner Hypertension Practice Study)

OBJECTIVES

To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists.

DESIGN

Mailed case report questionnaires.

SUBJECTS

Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments.

MAIN OUTCOME MEASURES

Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice.

RESULTS

The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization.

CONCLUSIONS

GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.

Hypertension in the elderly

Elderly people have a very high prevalence of hypertension, which markedly increases their risk for cardiovascular morbidity and mortality. Convincing evidence demonstrates the effectiveness of antihypertensive therapy in reducing these risks significantly. With appropriate caution, most elderly hypertensives can be treated and thereby protected from many of the debilities of old age.

Epidemiology of stroke. Importance of preventive pharmacological strategies in elderly patients and associated costs

Stroke is a major cause of death and disability in developed countries. The incidence of stroke increases exponentially with age, yet, traditionally, many medical practitioners have been reluctant to treat hypertension in older patients. Since 1991, the results of 3 major trials--the British Medical Research Council (MRC) trial of treatment in older adults, the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) and the Systolic Hypertension in the Elderly Program (SHEP)--have conclusively established the benefits of treating older patients (> 60 years) with both diastolic and isolated systolic hypertension. International guidelines for the management of hypertension--including the Fifth Report of the Joint National Committee, the 1993 report of the World Health Organization and the International Society of Hypertension and the second report of the British Hypertension Society Working Party--have all been modified to reflect the emerging evidence concerning the benefits of treating older patients. Cost-effectiveness data are similarly in accord with giving high priority to the treatment of older individuals with hypertension.

General practitioners' knowledge of and attitudes to the management of hypertension in elderly patients

BACKGROUND

It is not known whether the results from randomized controlled trials influence general practitioners' knowledge of and attitudes to clinical practice.

AIM

This study set out to assess general practitioners' knowledge of and attitudes to the management of hypertension in patients aged 65 years and over after the publication of three randomized controlled trials.

METHOD

A cross-sectional survey of principals in general practice was undertaken using a self-administrated questionnaire. The study was confined to 35 randomly selected general practices whose patient catchment area lay within the boundary of Northamptonshire Family Health Services Authority. A total of 92 general practitioners from 27 practices responded. The main outcome measures were: the reported use of a protocol to manage elderly patients with hypertension; method and frequency of blood pressure measurement; influence of patients' age on diagnosing and initiating treatment of hypertension; and use of non-pharmacological and pharmacological therapies.

RESULTS

Eighty four per cent of the general practitioners reported starting treatment only after measuring blood pressure on three separate occasions; 99% measured blood pressure with the patient seated while 29% also measured blood pressure while the patient was standing. Half of the respondents reported treating patients with isolated systolic hypertension once systolic blood pressure exceeded 179 mmHg. All the general practitioners reported recommending non-pharmacological treatment prior to drug therapy; 83% would use a diuretic as their drug of first choice.

CONCLUSION

It appears that despite the publication of several sets of guidelines for the management of hypertension in elderly people, based on randomized controlled trials, there is still considerable variation in the knowledge and attitudes of general practitioners. However, compared with a previous survey in Leicestershire in 1991, the general practitioners in this study reported a lower blood pressure threshold for initiating treatment of elevated blood pressure in elderly patients, including those with isolated systolic hypertension, which may in part be attributed to the introduction of the guidelines.

Factors affecting changes in blood pressure after acute stroke

BACKGROUND AND PURPOSE

We sought to establish the pattern of blood pressure (BP) change after hospitalization for acute hemispheric stroke.

METHODS

In 292 patients from the Leicester teaching hospitals with acute hemispheric stroke within the previous 24 hours (139 men; median age, 75 years [range, 42 to 98 years]), we prospectively studied BP changes between admission, 24 hours, 1 week, and 4 to 6 weeks. Changes were assessed in relation to the main stroke risk factors, stroke type and severity, and antihypertensive drug treatment. All subjects were followed up for 1 week, with 117 subjects followed up for 4 to 6 weeks. Changes were assessed by repeated-measures ANOVA, and Student's t tests were used to compare group pairs.

RESULTS

Systolic and diastolic BP fell by 12 mm Hg (95% confidence interval [CI], 8 to 15 mm Hg) and 7 mm Hg (95% CI, 5 to 9 mm Hg), respectively, in the first 24 hours and 22 mm Hg (95% CI, 18 to 25 mm Hg) and 12 mm Hg (95% CI, 10 to 14 mm Hg), respectively, during the first week (all changes significant at P < .01) but no further thereafter. In those patients receiving no antihypertensive medication before or after stroke, the pattern of change was similar to that of the whole group. Previously diagnosed hypertensive subjects (n = 106) had higher initial BP values than did normotensive subjects, although by 1 week the levels were not significantly different. Patients with cerebral hemorrhage confirmed by computed tomography (n = 20) had higher systolic BP, but not diastolic BP, throughout the first week than those with cerebral infarction (n = 89). The severity of stroke, age, and previous stroke history did not appear to alter the BP pattern. Stroke patients who were moderate to heavy alcohol consumers had lower convalescent systolic BP levels than lighter drinkers or abstainers.

CONCLUSIONS

We have demonstrated a marked fall in systolic and diastolic BP levels during the first 7 days after acute hemispheric stroke, with little change thereafter. Higher initial systolic BP values were found in patients with cerebral hemorrhage compared with those with cerebral infarct. Moderate to heavy alcohol consumption before stroke was associated with a greater systolic BP decline in the first week after the event compared with stroke patients who were light drinkers or abstainers.

A double-blind trial of captopril or bendrofluazide in newly diagnosed senile hypertension

Hypertension is a major risk factor for stroke and heart disease in the elderly. Eighty-one hypertensive subjects with mild cognitive impairement, aged over 70 years, were drawn from a community screening programme and randomized to either 12.5 mg captopril twice daily or 2.5 mg bendrofluazide daily in a double-blind trial. Subjects were excluded if they had previously received antihypertensive treatment. The mean blood pressure was reduced from 193/101 mmHg to 154/87 mmHg by captopril and from 188/102 mmHg to 151/89 mmHg by bendrofluazide after 24 weeks; there was no significant difference between the two drugs. Seven subjects withdrew due to adverse events. Adverse events occurred more frequently during the 2-week placebo phase than during active treatment with either drug. The only significant detrimental changes in pre-existing conditions were in 3 subjects (2 captopril, 1 bendrofluazide) who were noted to have worsening of their cataracts. One subject on captopril and 4 subjects on bendrofluazide became hypokalaemic. The trial results support the use of captopril as an alternative to bendrofluazide as a first-line antihypertensive agent in the community for elderly people, but large studies are required to measure accurately effects on significant morbidity and mortality.