Prevention of CHD by controlling CVD risk factors that accompany elevated blood pressure deserves a high priority because the risk of CVD in general, and of CHD its most common hazard is greatly influenced by the burden of associated risk factors. Multivariable risk formulations for quantifying the impact of a set of risk factors for development of CVD have been developed from Framingham Study data.
The composite risk factor score derived from it corresponds to the probability of an event over 10 years. Persons at high risk for CHD have been shown to also be at increased risk of other atherosclerotic vascular disease. This approach would also appear to be appropriate for persons with hypertension. Hypertension, dyslipidemia, and diabetes promote accelerated atherogenesis and correcting them stabilizes lesions and slows progression. Treatment is of proven benefit for initial and recurrent events without a penalty in overall mortality.
The prevalence of these conditions in the general population is unacceptably high and isolated occurrence of these major CVD risk factors relatively uncommon. Dyslipidemic persons and diabetics have a distinct excess of elevated blood pressure. These risk factors are components of the metabolic or insulin resistance syndrome.
However, because most of the ingredients of the syndrome are also components of the Framingham multivariable risk formulation, the value of detecting persons with the metabolic syndrome applies more to therapeutic choices than to risk stratification. Elevated blood pressure is at all ages a major risk factor for all clinical manifestations of atherosclerosis including CHD, brain infarction, peripheral artery disease, and heart failure.
The risk ratio is greatest for heart failure, but CHD is the most common hazard, equaling in incidence all the other hypertensive sequelae combined. Its high prevalence, powerful impact and controllability give it a high priority for detection, risk stratification, and treatment. Hypertension accelerates atherogenesis by a complex process involving coexisting risk factors all of which impair endothelial function.
Optimal cardiovascular protection of persons with elevated blood pressure requires more than simply lowering blood pressure. Each major risk factor that clusters with the elevated blood pressure must be corrected if optimal protection is to be afforded. Because the burden of risk factors accompanying hypertension is promoted by weight gain leading to visceral adiposity and insulin resistance weight control is of paramount importance.
Multivariate risk assessment enables health care providers to pull together all the major risk factor information and arrive at a composite risk estimate for patients with hypertension. Because the risk imposed varies over a wide range depending on the burden of associated risk factors, the absolute benefit to be derived from treatment depends on the pretreatment global risk. Volume 6 , Issue 7. The full text of this article hosted at iucr.
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Please review our Terms and Conditions of Use and check box below to share full-text version of article. A verage A nnual I ncidence M en A ge in Y ears W omen A ge in Y ears S ystolic BP mm H g 45—54 55—64 65—74 45—54 55—64 65—74 74— 8 16 16 3 6 12 — 11 18 23 5 9 17 — 19 31 37 9 16 22 — 29 43 52 9 24 20 — 35 62 78 16 36 45 Incidence rate per ; trends all significant in specified age and sex groups. Source: Neaton et al. Hypertension: Pathophysiology Diagnosis and Management.
Philadelphia, PA: Raven Press; Elevated systolic blood pressure as a cardiovascular risk factor. Am J Cardiol. Cardiovascular risk assessment in hypertension. Atlas of Hypertension. The reference list of each of the selected CPGs was reviewed and the number of Cochrane and non-Cochrane systematic reviews in each was recorded.
The end of search date for each CPG was checked to determine the available and relevant reviews prepared by the Cochrane Hypertension Group  by that date. For CPGs where the end-of-search date was not reported, the principal author was contacted. If there was no response from the author, it was assumed that search ended one year prior to publication of the CPG.
Two reviewers independently screened all the abstracts of the reviews prepared by the Cochrane Hypertension Group to assess their relevance to the general management of primary hypertension. The included CPGs were summarized descriptively according to diagnosis, assessment and management recommendations. For diagnosis and assessment, the following categories were used: identification of cardiovascular risk factors, blood pressure measurement methods, medical history, physical examination, subclinical organ damage, and laboratory investigations.
For management, the following categories were used: lifestyle modifications, initiation of therapy, type of therapy, adjustment of therapy, combination therapy, harms associated with the therapy, consideration of special groups e. The search strategy retrieved citations, of which were considered for full-text screening and 11 were included in the review Figure 1.
Table 1 displays the characteristics and methods related to CPG development. The size of the guideline development team varied from 7 to 65 members. The number of systematic reviews cited ranged from 5 to Table 1 shows the numbers of available and relevant reviews from the Hypertension Group for each CPG that could have potentially been used by the guidelines' development teams. The applicability Domain 5 and stakeholder involvement Domain 2 domains were scored consistently low across the CPGs Tables 2 — 3.
The overall quality of the CPGs ranged from 2. With the exception of the CAN CPG, all guidelines were either not recommended for use or were recommended for use with modifications. The degree of agreement among reviewers was tested using percentage of agreement for the rigour of development domain. Only two guidelines linked their grade of recommendations to the level of evidence MAL, CAN , yet they did not elaborate on the quality of studies contributing to the recommendations Table 4.
Agreement between these CPGs on the grade of recommendations was not observed. The other 7 CPGs did not disclose the level of evidence or how their recommendations were decided upon. The distinction between different settings office, home and ambulatory for measuring blood pressure and identifying patients as having hypertension was made in all CPGs except two POL, AUS. All CPGs recommended assessing hypertension in relation to other cardiovascular risk factors during patient assessment Table 5. All CPGs recommended inquiring about previous coronary artery disease, heart failure and chronic kidney disease Table 5.
All but one CPG POL recommended asking about past history of stroke and existing peripheral artery disease and retinopathy. All CPGs recommended assessing the patient's body mass index. All CPG suggested assessing fasting blood glucose, fasting blood cholesterol, creatinine, potassium and urine dipstick testing for glucose, blood hematuria , protein and albumin Table 5. Findings from guidelines about the management of hypertension are presented in Table 6.
All guidelines advocated similar life style changes as a cornerstone in the management of hypertension. Minor differences included recommendation of dietary supplements, increase of potassium intake, exercise, and stress and emotional management. All CPGs emphasized the need to stop smoking, maintaining weight, following nutritional guidelines, lowering sodium intake, limiting alcohol intake except for SAU and lowering fat intake except for AUS for hypertensive patients.
Most guidelines recommended the same criteria for initiating drug therapy; minor differences were noted regarding the duration of a life style modification trial before starting drug therapy. Most CPGs recommended use of any of the 5 classes of antihypertensive drugs angiotensin converting enzymes inhibitors, angiotensin receptor blockers, beta-blocker, calcium channel blockers or diuretics as first line therapy.
The CPGs also differed in their strategies of adjustment of therapy. Recommendations about drug combinations were variable across guidelines. Selection of therapeutic agents for compelling indications such as established cardiovascular disease or diabetes were similar, yet there were some differences in relative or absolute contraindication definitions.
The AUS suggested that this should occur every 6 weeks or as indicated which could be few days to 2 months. The SAU suggested monthly visits. Most of the CPGs clearly presented their recommendations.
However methodological gaps exist across the guidelines that should be addressed including clarifying the scope and purpose, ensuring representation of all stakeholders including consumers, developing guidelines with scientific rigour, supporting implementation of the recommendations and declaring the presence or absence of editorial independence. In general, the recommendations of the CPGs on diagnosis, assessment and non-pharmacological management were consistent despite scoring poorly in their rigour of development.
It is difficult to tell whether this happened because there was no evidence to guide or because the authors did not search and make use of the best available evidence. This finding is similar to that of Burgers, et al, who reviewed 15 CPGs for patients with diabetes from 13 countries . They found an international consensus in the recommendations despite the variation in cited evidence and preferential citation of evidence in each CPG. The influence of professional bodies such as the American Diabetes Association was suggested an important factor in explaining international consensus.
He concluded that globalization of recommended management of diabetes was not a simple consequence of the globalization of research evidence. For example, all the CPGs have embraced the concept of traditional or global cardiovascular risk assessment as a method for stratifying treatment which is presumably an evidence-based move, yet the level of evidence for this recommendation was not reported.
Keeping in mind the recent concerns as that the current methods for assessing risk may ignore some patient characteristics  ,  , that short-term assessment of cardiovascular risk may not translate directly into life-time risk estimates  , the recent calls for improving cardiovascular risk assessment  , the finding that externally validated tools for cardiovascular risk assessment may not fit well with certain populations with different baseline risks  and that there is no consensus among the guidelines for assessing cardiovascular risk in healthy checks on their approach and screening tests  , users of the CPGs may decide not to implement this recommendation.
A recent systematic review found that neither clinic nor home measurement had sufficient sensitivity or specificity compared to ambulatory-monitoring to be recommended alone as a diagnostic test.
Across the CPGs, major differences were related to the pharmacologic management of hypertension, namely, the selection of first-line treatment, adjustment of therapy and drug combinations. Even when CPG developers claimed that they related their grade of recommendations to the level of evidence, recommendations were not graded or were inconsistent. This variation may be related to the developers' search strategy, the process of selecting the scientific evidence and the way the recommendations were formulated.
As is the finding of earlier analysis of multiple CPGs on various condition, we found that guideline developers did not consistently use systematic reviews . Only two up-to-date reviews from the Cochrane Hypertension Group   were cited in the guidelines we reviewed. This finding is consistent with a recent analysis of NICE guidelines, which showed that one fifth of the CPGs referred to no Cochrane citations and two fifths referred to only 1—5 Cochrane reviews  although the majority were felt to directly address guideline questions.
It is surprising that despite the increased production of Cochrane reviews, recent CPGs barely referred to relevant reviews. The reasons for this need to be explored and the Cochrane Collaboration need to consider the practical means for increasing the uptake by guidelines developers.
First, only CPGs that were written in English were included; high-quality CPGs written exclusively in other languages might have been missed. It has been shown that restricting the search for systematic reviews to English language only did not affect the quality of most reviews .
A comparison of both instruments has shown that the GRS is less sensitive in detecting differences in guideline quality but it could predict important outcome measures related to guideline adoption .
Hypertension An Atlas Of Investigation And Management - yvoropijajif.gq
Third, our search was limited to January to September because it is believed that CPGs should be assessed for validity every 3 years  , . Despite these limitations, it is clear that more efforts are needed to improve the quality of the developed CPGs at the national or continental levels and to keep them up-to-date. With such variation and deficiencies in the methodological quality of CPGs, there is no guarantee that the recommendations would result in better health-related outcomes for patients with hypertension.
Guidelines for developing high-quality evidence-based guidelines' have been established by various organizations  — . Given the time-intensive and resource-intensive nature of CPG development, local adaptation of existing high-quality CPGs to the national context might be a more realistic approach to developing national or continental CPGs to avoid duplication of efforts . Use of the ADAPTE framework  may be considered by local and national implementation teams and guideline developers and  de novo guideline development would only be needed if no high quality guideline exists for a given topic.
Part of the work was presented as a poster presentation at the 19 th Cochrane Colloquium in Madrid, Spain October Keyword Title Author Topic. Hypertension; an atlas of investigation and management. Hypertension; an atlas of investigation and management.. No portion of this article can be reproduced without the express written permission from the copyright holder. Topics: Books.