We read with interest the study by Sheppard et al regarding missed opportunities in the prevention of cardiovascular disease in primary care.1 Recently-published ESH/ESC hypertension guidelines (2013) state that patients whose blood pressure fails to fall by at least 15/15 mmHg overnight (so-called ‘non-dippers’) should be diagnosed with hypertension.2 According to the guidelines:
‘... night-time blood pressure is a stronger [risk] predictor [of clinical cardiovascular outcomes] than daytime blood pressure’.2
NICE hypertension guidelines 2011 make no reference to identifying or treating ‘non-dippers’.3
We reviewed the use of ambulatory blood pressure monitoring (ABPM) in one Irish practice over a 3-year period from 1 January 2010 to 17 December 2012 and identified cases where treatment plans differed from the recommendations of the NICE guidelines 2011. We re-interpreted the data using 2013 ESH/ESC guidelines to include ‘non-dippers’ and compared the results with those obtained using NICE guidelines to highlight the implications of the 2013 guidelines on clinical practice.
Two hundred and forty-seven ABPMs from 202 patients (57.9% female, average age 62.5 years [standard deviation {SD} 15.6]) were included in the review. Of these, 59.5% (n = 147) of the recordings were abnormal according to the NICE guidelines. Of the abnormal recordings, 45.6% (n = 67) resulted in no change in patient management. When we re-interpreted the data using 2013 ESH/ESC guidelines, the number of abnormal recordings increased to 73.7% (n = 182).
Sheppard et al identified a number of possible explanations for differences between patient treatment plans and guideline recommendations, including GP judgement, polypharmacy issues and individual patient preferences. We propose an additional explanation: the incidence of clinical inertia, for example, reluctance to change the treatment regimen of the patient compliant with their antihypertensive medication(s) who on follow-up have a mildly abnormal ABPM.
Those opting to replace 2011 NICE guidelines with 2013 ESH/ESC guidelines will see an increase in the number of patients diagnosed with hypertension, given the inclusion of ‘non-dippers’ as outlined above, with increased workload as a consequence. Despite this, clinicians should attempt to minimise clinical inertia in the management of hypertension, given the positive benefits optimal treatment may have on the efficacy of vascular screening programmes and, ultimately, on patient outcomes.
- © British Journal of General Practice 2014