Effect of guideline revisions by the Swiss Society of Hypertension on blood pressure control in hypertensive patients from primary care
Recommendations for blood pressure goals have considerably changed across time, in particular for high-risk patients with diabetes mellitus and/or renal dysfunction. Before 2009, Swiss Society of Hypertension (SSH) guidelines recommended lowering blood pressure to <135/85 mm Hg and after 2009 to <130/80 mm Hg in high-risk patients. It remains unclear whether guideline changes for blood pressure targets are associated with reductions in blood pressure in hypertensive patients treated in primary care. The objective was to report the association between guideline change and blood pressure target achievement, as well as the prevalence of blood pressure target achievement according to guidelines and to identify factors associated with blood pressure target achievement in a Swiss primary care sample of treated hypertensive patients.
We used longitudinal data from the Swiss Hypertension Cohort Study, which was a prospective, observational study conducted by the Centre for Primary Health Care of the University of Basel from 2006 to 2013. General practitioners (GPs) enrolled 1003 patients attending their practice with a pre-existing diagnosis of arterial hypertension or office blood pressure measurement ≥140/90 mm Hg and assessed office blood pressure, cardiovascular risk factors, subclinical organ damage, diabetes mellitus, and established cardiovascular and renal disease. Mixed-effects regression models were used to estimate the associations of (1) the change in hypertension guidelines in 2009 with blood pressure and antihypertensive therapy in high-risk patients, and (2) cardiovascular risk factors with blood pressure target achievement in patients with complicated and uncomplicated hypertension. Models were adjusted for sociodemographic and health-related covariates. Missing data were imputed using a “multiple imputation by chained equation” approach.
At baseline, hypertensive patients were on average 65.9 ± 12.5 years old and 55% were male. Blood pressure targets were achieved in 47% of patients with uncomplicated hypertension and in 13% of high-risk patients at baseline. In multivariable analyses adjusted for potential confounding factors, a visit by high-risk patients after 2009 was associated with decreased systolic office blood pressure (−5.40 mm Hg, 95% confidence interval [CI] −8.08 to 2.73) and a trend towards an increased use of pharmacological combination therapy (odds ratio [OR] 1.85, 95% CI 0.94 to 3.63; p = 0.073) compared with a visit before 2009. Neither a reduction of diastolic blood pressure nor an increase of blood pressure target achievement in high-risk patients was observed after 2009. High-risk patients were slightly more likely to achieve blood pressure targets at later follow-up visits than at baseline (OR 1.35, 95% CI 0.98 to 1.86; p = 0.068). In patients with uncomplicated hypertension, factors associated with the likelihood to achieve blood pressure goals were the increased use of pharmacological combination therapy (OR 1.19 per combination increase: e.g., dual therapy vs monotherapy, 95% CI 1.02 to 1.40), left ventricular hypertrophy (OR 0.58, 95% CI 0.36 to 0.93), older age (OR 1.19 per 10 years, 95% CI 1.02 to 1.40) and the number of follow-up examinations (OR 1.44 per follow-up visit, 95% CI 1.21 to 1.72).
Overall, blood pressure goal attainment remains low for treated hypertensive patients followed up by primary care physicians in Switzerland. Independent of known confounding factors for blood pressure, the 2009 guideline change in high-risk patients was associated with a reduction in systolic office blood pressure together with an increase in pharmacological combination therapy. These results highlight primary care physicians’ efforts to implement blood pressure guidelines. Further, blood pressure goal attainment was more likely to be achieved in later follow-up visits, indicating that it takes time and regular follow-up visits with the GP to meet blood pressure goals.
- Estoppey D, Paccaud F, Vollenweider P, Marques-Vidal P. Trends in self-reported prevalence and management of hypertension, hypercholesterolemia and diabetes in Swiss adults, 1997-2007. BMC Public Health. 2011;11(1):114.https://doi.org/10.1186/1471-2458-11-114
- Danon-Hersch N, Marques-Vidal P, Bovet P, Chiolero A, Paccaud F, Pécoud A, et al. Prevalence, awareness, treatment and control of high blood pressure in a Swiss city general population: the CoLaus study. Eur J Cardiovasc Prev Rehabil. 2009;16(1):66–72. doi:.https://doi.org/10.1097/HJR.0b013e32831e9511
- Guessous I, Bochud M, Theler JM, Gaspoz JM, Pechère-Bertschi A. 1999-2009 Trends in prevalence, unawareness, treatment and control of hypertension in Geneva, Switzerland. PLoS One. 2012;7(6):e39877.https://doi.org/10.1371/journal.pone.0039877
- Walther D, Curjuric I, Dratva J, Schaffner E, Quinto C, Rochat T, et al. High blood pressure: prevalence and adherence to guidelines in a population-based cohort. Swiss Med Wkly. 2016;146:w14323.https://doi.org/10.4414/smw.2016.14323
- Wolf-Maier K, Cooper RS, Banegas JR, Giampaoli S, Hense H-W, Joffres M, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA. 2003;289(18):2363–9.https://doi.org/10.1001/jama.289.18.2363
- Liu L, Zhang Y, Liu G, Li W, Zhang X, Zanchetti A ; FEVER Study Group. The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients. J Hypertens. 2005;23(12):2157–72.https://doi.org/10.1097/01.hjh.0000194120.42722.ac
- Mancia G, Parati G. Importance of smooth and sustained blood pressure control in preventing cardiovascular morbidity and mortality. Blood Press Suppl. 2001;10(3):26–32.https://doi.org/10.1080/08037050152518339
- Zanchetti A. Hypertension-related mortality and morbidity. J Hypertens. 2015;33(10):1979–80.https://doi.org/10.1097/HJH.0000000000000725
- Horr S, Nissen S. Managing hypertension in type 2 diabetes mellitus. Best Pract Res Clin Endocrinol Metab. 2016;30(3):445–54.https://doi.org/10.1016/j.beem.2016.06.001
- Chen G, McAlister FA, Walker RL, Hemmelgarn BR, Campbell NR. Cardiovascular outcomes in framingham participants with diabetes: the importance of blood pressure. Hypertension. 2011;57(5):891–7.https://doi.org/10.1161/HYPERTENSIONAHA.110.162446
- Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL, et al. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. J Am Soc Nephrol. 2004;15(5):1307–15.https://doi.org/10.1097/01.ASN.0000123691.46138.E2
- Cushman WC, Whelton PK, Fine LJ, Wright JT, Jr, Reboussin DM, Johnson KC, et al.; SPRINT Study Research Group. SPRINT Trial Results: Latest News in Hypertension Management. Hypertension. 2016;67(2):263–5.https://doi.org/10.1161/HYPERTENSIONAHA.115.06722
- Moran AE. Still on the Road to Worldwide Hypertension Control. Circulation. 2016;134(6):451–4 doi:.https://doi.org/10.1161/CIRCULATIONAHA.116.023960
- Brenner R, Waeber B, Allemann Y. Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Swiss Med Wkly. 2011;141:w13169.https://doi.org/10.4414/smw.2011.13169
- Corcillo A, Pivin E, Lalubin F, Pitteloud N, Burnier M, Zanchi A. Glycaemic, blood pressure and lipid goal attainment and chronic kidney disease stage of type 2 diabetic patients treated in primary care practices. Swiss Med Wkly. 2017;147:w14459. doi:.https://doi.org/10.4414/smw.2017.14459
- Papadopoulou E, Angeloudi E, Karras S, Sarafidis P. The optimal blood pressure target in diabetes mellitus: a quest coming to an end? J Hum Hypertens. 2018;32(10):641–50.https://doi.org/10.1038/s41371-018-0079-5
- Pechère-Bertschi A, Stalder H. Nachweis einer arteriellen Hypertonie. Primary Care. 2003;3:547–53. doi:https://doi.org/10.4414/pc-d.2003.05803
- Swiss Society of Hypertension. Guidelines 2015 [cited 2016 August 31]. Available from: http://www.swisshypertension.ch/docs/guidelines_2015_d_leaflet.pdf.
- Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–219.https://doi.org/10.1093/eurheartj/eht151
- Liakos CI, Grassos CA, Babalis DK. ESH/ESC Guidelines for the Management of Arterial Hypertension: What Has Changed in Daily Clinical Practice? High Blood Press Cardiovasc Prev. 2015;22(1):43–53. doi:.https://doi.org/10.1007/s40292-014-0071-2
- Bangalore S, Kumar S, Lobach I, Messerli FH. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation. 2011;123(24):2799–810, 9, 810.https://doi.org/10.1161/CIRCULATIONAHA.110.016337
- Gerstein HC, Miller ME, Genuth S, Ismail-Beigi F, Buse JB, Goff DC, Jr, et al.; ACCORD Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med. 2011;364(9):818–28.https://doi.org/10.1056/NEJMoa1006524
- Borm K, Lüscher S, Müller B. Erste Behandlungsschritte beim neuentdeckten Diabetes mellitus Typ 2 – praktische Tipps. Schweiz Med Forum. 2012;12(48):929–35. doi:.https://doi.org/10.4414/smf.2012.01343
- Zeller A, Haehner T, Battegay E, Martina B. Diagnostic significance of transferrinuria and albumin-specific dipstick testing in primary care patients with elevated office blood pressure. J Hum Hypertens. 2005;19(3):205–9.https://doi.org/10.1038/sj.jhh.1001803
- Zeller A, Sigle JP, Battegay E, Martina B. Value of a standard urinary dipstick test for detecting microalbuminuria in patients with newly diagnosed hypertension. Swiss Med Wkly. 2005;135(3-4):57–61.
- Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al.; National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137–47.https://doi.org/10.7326/0003-4819-139-2-200307150-00013
- Lee JH, Huber J. Multiple imputation with large proportions of missing data: How much is too much? United Kingdom Stata Users’ Group meetings. 2011:23.
- Raghunathan TE, Lepkowski JM, Van Hoewyk J, Solenberger P. A multivariate technique for multiply imputing missing values using a sequence of regression models. Surv Methodol. 2001;27(1):85–96.
- Azur MJ, Stuart EA, Frangakis C, Leaf PJ. Multiple imputation by chained equations: what is it and how does it work? Int J Methods Psychiatr Res. 2011;20(1):40–9.https://doi.org/10.1002/mpr.329
- Rubin DB. Inference and missing data. Biometrika. 1976;63(3):581–92. doi:.https://doi.org/10.1093/biomet/63.3.581
- van Buuren S. How many imputations? Flexible Imputation of Missing Data. Boca Raton, FL: Chapman & Hall/CRC Press; 2012.
- Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York: J. Wiley & Sons; 1987.
- Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342(8883):1317–22.https://doi.org/10.1016/0140-6736(93)92244-N
- Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–30.https://doi.org/10.1136/bmj.318.7182.527
- Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3(9):e003610.https://doi.org/10.1136/bmjopen-2013-003610
- Kjeldsen SE, Aksnes TA, Ruilope LM. Clinical implications of the 2013 ESH/ESC hypertension guidelines: targets, choice of therapy, and blood pressure monitoring. Drugs R D. 2014;14(2):31–43.https://doi.org/10.1007/s40268-014-0049-5
- Swiss Society of Hypertension. Guidelines: Arterial Hypertension (General) 2019 [cited 2019 December]. Available from: http://www.swisshypertension.ch/DOCS_PUBLIC/Pocketcard_Uebersicht_D_WEB.pdf.
- Argulian E, Grossman E, Messerli FH. Misconceptions and facts about treating hypertension. Am J Med. 2015;128(5):450–5.https://doi.org/10.1016/j.amjmed.2014.11.015
- Balijepalli C, Bramlage P, Lösch C, Zemmrich C, Humphries KH, Moebus S. Prevalence and control of high blood pressure in primary care: results from the German Metabolic and Cardiovascular Risk Study (GEMCAS). Hypertens Res. 2014;37(6):580–4.https://doi.org/10.1038/hr.2014.40
- Sharma AM, Wittchen HU, Kirch W, Pittrow D, Ritz E, Göke B, et al.; HYDRA Study Group. High prevalence and poor control of hypertension in primary care: cross-sectional study. J Hypertens. 2004;22(3):479–86.https://doi.org/10.1097/00004872-200403000-00009
- Tocci G, Rosei EA, Ambrosioni E, Borghi C, Ferri C, Ferrucci A, et al. Blood pressure control in Italy: analysis of clinical data from 2005-2011 surveys on hypertension. J Hypertens. 2012;30(6):1065–74.https://doi.org/10.1097/HJH.0b013e3283535993
- van den Berg N, Meinke-Franze C, Fiss T, Baumeister SE, Hoffmann W. Prevalence and determinants of controlled hypertension in a German population cohort. BMC Public Health. 2013;13(1):594.https://doi.org/10.1186/1471-2458-13-594
- Streit S, Gussekloo J, Burman RA, Collins C, Kitanovska BG, Gintere S, et al. Burden of cardiovascular disease across 29 countries and GPs’ decision to treat hypertension in oldest-old. Scand J Prim Health Care. 2018;36(1):89–98.https://doi.org/10.1080/02813432.2018.1426142
- Jaussi A, Noll G, Meier B, Darioli R. Current cardiovascular risk management patterns with special focus on lipid lowering in daily practice in Switzerland. Eur J Cardiovasc Prev Rehabil. 2010;17(3):363–72.https://doi.org/10.1097/HJR.0b013e328333c1d9
- Fang J, Alderman MH, Keenan NL, Ayala C, Croft JB. Hypertension control at physicians’ offices in the United States. Am J Hypertens. 2008;21(2):136–42.https://doi.org/10.1038/ajh.2007.35
- Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339(27):1957–63.https://doi.org/10.1056/NEJM199812313392701
- Chobanian AV. Clinical practice. Isolated systolic hypertension in the elderly. N Engl J Med. 2007;357(8):789–96.https://doi.org/10.1056/NEJMcp071137
- Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Left ventricular mass and incidence of coronary heart disease in an elderly cohort. The Framingham Heart Study. Ann Intern Med. 1989;110(2):101–7.https://doi.org/10.7326/0003-4819-110-2-101
- Leibowitz D, Bursztyn M, Jacobs JM, Ein-Mor E, Stessman J. High prevalence of left ventricular hypertrophy in octogenarian women: The Jerusalem Longitudinal Cohort Study. Blood Press. 2010;19(2):86–91.https://doi.org/10.3109/08037050903516292
- de Simone G, Roman MJ, Koren MJ, Mensah GA, Ganau A, Devereux RB. Stroke volume/pulse pressure ratio and cardiovascular risk in arterial hypertension. Hypertension. 1999;33(3):800–5.https://doi.org/10.1161/01.HYP.33.3.800
- Gosse P, Pichot V, Guilhot M, Dauphinot V, Da Costa A, Barthelemy JC, et al. Relationship of cardiac involvement with arterial stiffness in a general population of 65-year-olds in the PROOF study. J Hypertens. 2010;28(2):389–94.https://doi.org/10.1097/HJH.0b013e328333d1a4
- Zhang Y, Lelong H, Kretz S, Agnoletti D, Mourad JJ, Safar ME, et al. Characteristics and future cardiovascular risk of patients with not-at-goal hypertension in general practice in France: the AVANT’AGE study. J Clin Hypertens (Greenwich). 2013;15(4):291–5.https://doi.org/10.1111/jch.12082
- Handschin A, Brighenti-Zogg S, Mundwiler J, Giezendanner S, Gregoriano C, Martina B, et al. Cardiovascular risk stratification in primary care patients with arterial hypertension: Results from the Swiss Hypertension Cohort Study (HccH). Eur J Prev Cardiol. 2019;26(17):1843–51.https://doi.org/10.1177/2047487319856732
- Abdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians’ familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrol. 2014;15(1):64.https://doi.org/10.1186/1471-2369-15-64
- Solini A, Grossman E. What Should Be the Target Blood Pressure in Elderly Patients With Diabetes? Diabetes Care. 2016;39(Suppl 2):S234–43.https://doi.org/10.2337/dcS15-3027
- Camm AJ, Fox KAA. Strengths and weaknesses of ‘real-world’ studies involving non-vitamin K antagonist oral anticoagulants. Open Heart. 2018;5(1):e000788.https://doi.org/10.1136/openhrt-2018-000788