Hypertension and blood pressure variability management practices among physicians in Singapore

Vascular Health and Risk Management Dovepress open access to scientific and medical research ORIGINAL RESEARCH Vascular Health and Risk Management downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Open Access Full Text Article Hypertension and blood pressure variability management practices among physicians in Singapore This article was published in the following Dove Press journal: Vascular Health and Risk Management 17 July 2017 Number of times this article has been viewed Sajita Setia 1 Kannan Subramaniam 2 Jam Chin Tay 3 Boon Wee Teo 4 1 Chief Medical Office, Medical Affairs, Pfizer Pte Ltd, Singapore; 2Global Medical Affairs, Asia Pacific Region, Pfizer Australia, West Ryde, NSW, Australia; 3Department of General Medicine, Tan Tock Seng Hospital, 4 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Purpose: There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore. Materials and methods: Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs. Results: Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31–60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful. Conclusion: There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore. Keywords: hypertension, blood pressure, guidelines, antihypertensives, blood pressure variability, blood pressure monitoring Introduction Correspondence: Sajita Setia Medical Affairs, Pfizer Pte Ltd, 80 Pasir Panjang Road, #16-81/82, Mapletree Business City, Singapore 117372 Tel +65 6403 8754 Fax +65 6722 4188 Email 275 submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2017:13 275–285 Dovepress © 2017 Setia et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/VHRM.S138694 Powered by TCPDF (www.tcpdf.org) Hypertension is an important risk factor for stroke and coronary heart disease and is a significant public health issue.1,2 At least 45% of deaths due to heart disease and 51% of deaths due to stroke have been attributed to hypertension.2 The global prevalence of hypertension in 2008 in adults aged 25 and over was approximately 40%, and elevated blood pressure (BP) is estimated to cause 7.5 million deaths each year worldwide.1 Hypertension is also highly prevalent in Singapore, where it affects about 1 in 4 residents aged 30–69 years and half of those aged 60–69 years.3 Dovepress Vascular Health and Risk Management downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Setia et al Effective treatment of hypertension has been shown to reduce the risk of myocardial infarction by 15–25%, stroke by 35–40% and heart failure by as much as 64%.4–6 All the current international guidelines recommend 4 main drug classes for treating hypertension: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and diuretics (Table 1).7–10 However, not all documents are consistent in their recommended target BP values for different patient groups due to a lack of consensus from clinical trial data. This is particularly the case for patients with comorbidities such as diabetes or chronic kidney disease (CKD), in whom BP control is particularly important (Table 1). It was previously recommended that the target BP for patients with CKD or diabetes mellitus was ≤130/80 mmHg.4 However, the Eighth Joint National Committee (JNC8) guidelines from the USA now suggest a more conservative target of <140/90 mmHg, which is the same as the recommendation for general population patients aged <60 years (Table 1).7 In the European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines, the diastolic BP target is 5 mmHg lower (<140/85 mmHg),8 taking into account the results of the Hypertension Optimal Treatment (HOT) study and the UK Prospective Diabetes Study (UKPDS) trials (Table 1).11–14 Japanese guidelines also include lower BP targets for diabetes and CKD patients,10 mostly likely taking the high risk of stroke in Japan into account.15 It is widely accepted that lowering BP to at least below the guideline-mandated targets is required to realize the benefits of antihypertensive therapy, particularly in patients with comorbidities such as diabetes or CKD.16,17 However, despite better understanding of the causes and consequences of hypertension and the availability of a range of effective antihypertensive agents, optimal BP control is often not achieved, even in those with important comorbidities.18–21 For example, nearly two-thirds (64.5%) of treated elderly patients with hypertension in Sing (...truncated)