The influence of guideline revisions on the process and outcome of hypertension management in general practice: A descriptive study

Figures & data

Table I.  Summary points of hypertension guidelines in studied period.

	Guideline 1 (1991) [1]	Guideline 2 (1997) [2]	Guideline 3 (2003) [3]
1. Diagnosis	DBP ≥ 95 mmHg	DBP ≥ 95 mmHg or SBP ≥ 160 mmHg	SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg
2. Indications medical treatment	DBP criterion for diagnosis and treatment	Both DBP and SBP criteria for diagnosis and treatment	Both DBP and SBP criteria for diagnosis and SBP criterion for treatment
	DBP < 100 mmHg: no medication DBP 100–104 mmHg: medication if two more risk factors present DBP ≥ 105 mmHg: always start medication	DBP < 100 and/or SBP < 160 mmHg: no medication DBP 100–104 and/or SBP 160–180 mmHg: medication if one or more other risk factors present DBP ≥ 105 and/or SBP ≥ 180 mmHg: always start medication	Based on risk function; medication indicated when 10-year absolute risk on cardiovascular morbidity or mortality ≥ 20% Patients with CVD, DM, familial dyslipidaemia, and patients with SBP ≥ 180 or DBP ≥ 100 mmHg: always start medication
3. Target of treatment	DBP < 90 mmHg	DBP < 90 or SBP < 160 mmHg	SBP < 140 (160 in healthy patient of 60 years and older without other risk factors) and DBP < 90 mmHg
4. Medical treatment	No protocol, choice doctor–patient; decision based on comorbidity, costs, and adverse drug events Patients with DM: 1) ACE-inhibitor	Protocols for patients with and without comorbidity Patients without comorbidity: 1) diuretic; 2) beta-blocker; 3) calcium channel blocker	Protocol for patients with and without comorbidity Without comorbidity: 1) diuretic; 2) beta-blocker; 3) ACE-inhibitor Patients with DM: protocol as without comorbidity

DBP: diastolic blood pressure; SBP: systolic blood pressure; CVD: cardiovascular disease; DM: diabetes mellitus; ACE: angiotensin-converting enzyme.

Table II.  Characteristics of study population (at time of diagnosis of hypertension).

	Cohort 1 (1992–1996) n=285	Cohort 2 (1998–2002) n=508	Cohort 3 (2004–2006) n=112
Mean (SD) age, years	54.8 (12.3)	59.2 (12.1)	60.3 (12.9) ^φ
Sex,%
Female	58.6	55.5	56.2
Male	41.4	44.5	43.8
Mean (SD) BMI, kg/m^2	27.6 (4.1)	28.5 (4.9)	28.1 (5.2)
Diabetes,%	3.2	15.9	11.6
Mean (SD) SBP, mmHg	175.1 (19.8)	179.0 (19)	175.1 (15.7)
Mean (SD) DBP, mmHg	105.7 (7.4)	101.7 (9.7)	98.7 (8.8)^φ

SBP: systolic blood pressure; DBP: diastolic blood pressure.

^φp<0.0001 for difference between cohorts.

Table III.  Two-year course of blood pressure per cohort.

	Cohort 1 (1992–1996) n=285	Cohort 2 (1998–2002) n=508	Cohort 3 (2004–2006) n=112
Mean SBP, mmHg	175.1	179.0	175.1
Mean 2-year SBP, mmHg	150.8	149.9	148.2
▵ SBP, diagnosis – 2 yr, mmHg	24.3	29.1	26.8
%▵ SBP, diagnosis – 2 yr	13.3^φ	15.7	14.9
Mean DBP, mmHg	105.7	101.7	98.7
Mean 2-year DBP, mmHg	88.8	85.6	85.3
▵ DBP, diagnosis – 2 yr, mmHg	16.8	16.1	13.4
%▵ DBP, diagnosis −2 yr	15.6	15.4	13.3*

SBP: systolic blood pressure; DBP: diastolic blood pressure.

^φp=0.002 compared to cohort 2, p=0.190 compared to cohort 3; *p=0.02 compared to cohort 1, p=0.027 compared to cohort 2.

Table IV.  Type of initial drug choice in patients who started on mono therapy.

	Cohort 1 (1992–1996) n=241	Cohort 2 (1998–2002) n=392	Cohort 3 (2004–2006) n=85
Type of drug
ACE-inhibitor	17.0	19.9	10.6
ARB	0	0.3	5.9
Beta-blocker	43.6	37.0	36.5*
CCB	12.9	3.8	3.5
Diuretic	26.6	37.8	43.5^φ
Other	0	1.3	0

ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; CCB: calcium channel blocker.

^φp=0.001 for difference between cohorts; *p=0.121 for difference between cohorts.

Table V.  Mono-duo-triple therapy per cohort at time of diagnosis and after 2 years of treatment (in% of patients).

	Cohort 1 (1992–1996) n = 285		Cohort 2 (1998–2002) n=508		Cohort 3 (2004–2006) n=112
	td	2 years	td	2 years	td	2 years
Number of antiHTs
0	0	7	0.2	4.3	1.8	0.9
1	84.6	32.6	77.2	31.1	75.9	44.6
2	15.1	36.8	19.9	42.1	19.6	32.1
≥3	0.4	23.4	2.8	22.4	2.7	22.3^φ

AntiHT: antihypertensive drug; td: time of diagnosis.

^φp=0.743 for difference between cohorts.

Van Binsbergen JJ, Grundmeyer HGLM, Van den Hoogen JPH, Van Kruysdijk M, Prins A, van Ree JW, et al. NHG-standaard hypertensie. Huisarts en Wetenschap 1991; 34: 389–95

 Google Scholar

Walma EP, Grundmeyer HGLM, Thomas S, Prins A, Van den Hoogen JPH, Van der Laan JR. NHG-standaard hypertensie (eerste herziening). Huisarts en Wetenschap 1997; 40(12)598–617

 Google Scholar

Walma EP, Thomas S, Prins A, Grundmeyer HGLM, Van der Laan JR, Wiersma T. NHG-standaard hypertensie (derde herziening). Huisarts en Wetenschap 2003; 46(8)435–49

 Google Scholar