Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38758.600116.AE (Published 16 March 2006) Cite this as: BMJ 2006;332:635
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Mant et al are not the first to point out that patients in primary
care are unlike those recruited to clinical trials.1 Neither was it
surprising that almost two thirds of patients were not managed according
to published guidelines. However it might be a mistake to assume that one
is a consequence of the other. It is questionable whether the publication
of yet more rigorously tested and evidence-based guidelines would be more
enthusiastically implemented.
General practitioners in South Yorkshire
reviewed their clinical practice and published their findings.2 They
suggest that even in the most committed practices the application of
guidelines is a function of the patient’s knowledge, the amount of ‘noise’
in the consultation and the general practitioner’s determination to apply
guidelines. In the last decade UK primary care has been offered
incentives, target payments, to take a public health approach. Patients on
the other hand steadfastly refuse to accept a reductionist view of their
needs. There are many and complex reasons why a patient may not seek a
prescription, referral or any other intervention and a different set of
reasons why their general practitioner might not offer one. It is this
research that might help to ‘target’ the ‘right’ patients arguably more
than yet another epidemiological study. The latter is challenging, the
former requires imaginative designs to explore in detail behaviour that is
difficult to observe in practice and will be strongly influenced by the
local context in which health care is delivered.
References
1. Mant J, McManus RJ, Hare H. Applicability to primary care of
national clinical guidelines on blood pressure lowering for people with
stroke: cross sectional study. BMJ 2006;332: 635-7.
2. Jiwa M, Freeman J, Fisher C, Schrecker G, Gordon M, Reid J. Factors
that impact on the application of guidelines in general practice: A review
of medical records and structured investigation of clinical incidents in
hypertension. Quality in primary care. 2005,13:215-22
Competing interests:
None declared
Competing interests: No competing interests
Mant et al (1) state that the results of PROGRESS are not applicable
to the stroke population in the community. One reason cited is that
patients in the community were 12 years older compared to those recruited
to PROGRESS. The authors explain the dangers of aggressive blood pressure
lowering for the over-80s and recommend further urgent studies.
There is still lack of guidance on blood pressure lowering in the
over-80s (2); however, this is no reason to deprive this group of
appropriate treatment. If, for example, a fit and active 81 year-old lady
has a minor stroke then it seems appropriate to treat hypertension
aggressively. It may be unethical for this lady to be recruited to a
placebo arm of a blood pressure lowering trial, and be deprived of
treatment that may prevent a stroke.
It is thus simply not possible to perform randomised-controlled
trials in all patient groups. Moreover, most studies actually ask more
questions than they answer. For many cases, treatment is decided following
discussion between patient and doctor, with the aid of the information
provided by randomised-controlled trials.
1 Mant J, McManus R, Hare R. Applicability to primary care of
national clinical guidelines on blood pressure lowering for people with
stroke: cross sectional study. BMJ 2006; 332: 635-637.
2 Williams B, Poulter NR, Brown MJ, Davis M, et al. The BHS
Guidelines Working Party Guidelines for Management of Hypertension: Report
of the Fourth Working Party of the British Hypertension Society, 2004 -
BHS IV. Journal of Human Hypertension 2004; 18: 139-185
Competing interests:
None declared
Competing interests: No competing interests
The study by Mant et al [1] provides more insights in to the missed
opportunities for prevention. Despite the fact that the practices selected
were active in research and the blood pressure [BP] control may have been
better than in the U.K. as a whole, for 80% of the patients systolic BP
was above the targets set by the British Hypertension Society [1]. There
were also notable paucities in aggressive combination therapy and this has
particular inference, given the huge burden of hypertension on stroke and
cardiovascular disease - 21400 stroke deaths and 41400 ischemic heart
disease deaths (approximately 42,800 strokes and 82,800 ischaemic heart
diseases saved, making a total of 125,600 events saved) each year in the
U.K. [2].
Thus, the emphasis by most BP management guidelines calling attention
to the need for more aggressive treatment targets [3] cannot be stressed
any further, given the disability-adjusted life-years and mortality
associated with the global burden of hypertension [4].
Nevertheless, one recent report [5] on primary care physicians
choices of antihypertensive and lipid-lowering therapy for subjects with
type 2 diabetes diagnosed with hypertension found considerable variation
between practices that were not explained by adjusting for age, sex,
prevalent coronary heart disease or study year; whilst trends in drug
utilisation were consistent with the evolving evidence base but there was
still wide variations in drug utilisation between practices. The question
therefore is not ‘Do we lower blood pressure in stroke patients?’ …. but
‘How do we best lower blood pressure?’
Hence, current available guidelines should continue to be used as evidence
base, and perhaps we should not be ageist, but rather take a more
belligerent approach in trying to tackle the major public health challenge
[4].
[1] Mant J, McManus RJ, Hare R. Applicability to primary care of
national clinical guidelines on blood pressure lowering for people with
stroke: cross sectional study BMJ, doi:10.1136/bmj.38758.600116.AE
(published 24 February 2006)
[2] He FJ, MacGregor GA. Cost of poor pressure control in the UK:
62000 unnecessary deaths per year. J Human Hypertens 2003; 17: 455-457.
[3] Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF
et al; British Hypertension Society. Guidelines for management of
hypertension: report of the fourth working party of the British
Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18(3): 139-185.
[4] Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J.
Global burden of hypertension: analysis of worldwide data. Lancet 2005;
365: 217–223.
[5] Gulliford MC, Charlton J, Latinovic R. Trends in
antihypertensive and lipid-lowering therapy in subjects with type II
diabetes: clinical effectiveness or clinical discretion? J Hum Hypertens
2005; 19(2):111-117.
Competing interests:
None declared
Competing interests: No competing interests
National Stroke Guidance is applicable to primary care
Editor,
In their recent article(1), Mant et al conclude that the national
clinical guideline on blood pressure lowering in stroke doesn’t apply to
the UK general practice population. I cannot accept this. They conclude
this because national guidance is largely based on the PROGRESS trial and
patients in general practice with prior stroke were older, had a greater
proportion of women and it had been longer since their stroke.. Whilst
the median time elapsed since stroke is 8 months in the study and 30
months in general practice patients, patients were included in PROGRESS if
they had a stroke between 2 weeks and 5 years beforehand(2). The authors
of the PROGRESS study stated in their final paragraph that the benefits
observed were independent of time since last stroke. The PATS study(3)
was a double-blind RCT comparing the thiazide-like diuretic indapamide
with placebo in 5665 Chinese patients who had been discharged previously
with stroke. The median elapsed time since their last stroke was 14
months. Treatment caused a 29% reduction in stroke over the subsequent 3
years. Further reassurance that initiation of antihypertensives is
beneficial beyond 8 months after a stroke.
Finally, the PROGRESS results were subsequently analysed further and
found to apply consistently by gender, age and geographical region(4).
It is only safe to conclude that national guidance on the management
of stroke should continue to apply to patients identified in general
practice pending further research. The results of PROGRESS and PATS taken
together support treatment of the patients within 5 years of a stroke with
thiazide diuretic plus or minus an ACE inhibitor whatever their age or
gender. If more certainty is required, then a pooled analysis of PATS,
PROGRESS and also of the 1000 or so patients with prior stroke included in
the HOPE trial(5) would be the logical next step.
1 Mant J, McManus RJ, Hare R. Applicability to primary care of
national clinical guidelines on blood pressure lowering for people with
stroke: cross sectional study. BMJ 2006; 332: 635-637.
2 PROGRESS collaborative group. Progress trial of perindopril-based
blood-pressure-lowering regimen among 6105 individuals with previous
stroke or transient ischaemic attack. Lancet 2001; 358: 1033-1041.
3 PATS Collaborating Group. Post-stroke antihypertensive treatment
study. A preliminary result. Chinese Med J 1995; 108: 710-717.
4 PROGRESS Collaborative Group. Perindopril-based blood
pressure lowering in individuals with cerebrovascular disease: consistency
of benefits by age, sex and region. J Hypertens 2004; 22: 653-9.
5 The Heart Outcomes Prevention Elaluation Study Investigators.
Effects of an angiotensin-converting enzyme inhibitor, ramipril, on
cardiovascular events in high-risk patients. N Engl J Med 2000; 342: 145-
153.
Competing interests:
I have lectured for and have consulted for Servier and other pharmaceuticals marketing antihypertensive drugs.
Competing interests: No competing interests