Hypertension and blood pressure variability management practices among physicians in Singapore

Figures & data

Table 1 Recommendation from international guidelines commonly referred to in Singapore

	NICE 2011^Citation9	ESH/ESC 2013^Citation8	JNC8 2014^Citation7	JSH 2014^Citation10
Definition of hypertension (mmHg)	≥140/90 “and” daytime ABPM or HBPM average BP ≥135/85	≥140/90	ND	≥140/90 (clinic) ≥135/85 (HBPM) ≥130/80 (ABPM)
Initiation of drug therapy (mmHg)
Overall	≥160/100 or daytime ABPM ≥150/95	≥140/90	≥140/90 (age <60 y) ≥150/90 (age ≥60 y)	≥140/90
DM pts	ND	SBP ≥140	≥140/90	≥130/80
CKD pts	ND	SBP ≥140	≥140/90	≥130/80
Recommended agents	ACEI or ARB (age ≤55 y) CCB (age >55 y)	Diuretics, ACEI, BB, CCB and ARBs as mono- or combination therapy ACEI, ARB (DM pts) ACEI, ARB (renal dysfunction pts)	Thiazide-type diuretics, CCB, ACEI or ARB for initial treatment (including DM pts); include ACEI or ARB for CKD pts
Preferred diuretic	Thiazide-type agents*	Thiazide-type agents*	Thiazide-type agents	Thiazide-like agents
Initiate therapy with >1 agent	ND	Pts at high risk or with markedly elevated BP	>160/100, or if SBP/DBP is >20/>10 above goal	≥160/100
BP targets (mmHg)	<140/90 (overall) <135/85 (age <80 y) or <145/85 (age ≥80 y) using ABPM or HBPM	<140/90	<140/90 (age <60 y) <150/90 (age ≥60 y)	<140/90 (overall)** <150/90 mmHg (age >75 y, or <140/90, if tolerated)**
BP targets in DM (mmHg)	ND	<140/85	<140/90	<130/80**
BP targets in CKD (mmHg)	ND	SBP <140 (<130 for pts with overt proteinuria)	<140/90	<130/80**
Endorse significance of BPV	Yes	Yes	No	Yes

Notes:

* Usually chlorthalidone or indapamide.

** Based on clinic BP. All targets are 5 mmHg lower for HBPM values.

Abbreviations: ABPM, ambulatory BP monitoring; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, beta-blocker; BP, blood pressure; BPV, BP variability; CCB, calcium channel blocker; CKD, chronic kidney disease; DBP, diastolic BP; DM, diabetes mellitus; ESC, European Society of Cardiology; ESH, European Society of Hypertension; HBPM, home BP monitoring; JNC8, Eighth Joint National Committee; JSH, Japanese Society of Hypertension; ND, no data; pts, patients; NICE, National Institute for Health and Care Excellence; SBP, systolic BP; y, years.

Table 2 Physician and practice characteristics by specialty

Characteristics	GPs (n=30)	Cardiologists (n=20)	Nephrologists (n=10)
Male, n (%)	25 (83)	16 (80)	5 (50)
Age range, n (%)
31–40 years	4 (13)	3 (15)	7 (70)
41–50 years	11 (37)	11 (55)	2 (20)
51–60 years	9 (30)	3 (15)	1 (10)
61–70 years	5 (17)	1 (5)	0
>70 years	1 (3)	2 (10)	0
Post-residency practice duration, years	25	22	12
Practice setting, n (%)
GP clinic	15 (50)	0	0
Group practice	15 (50)	0	0
Restructured	0	8 (40)	9 (90)
Private	0	12 (60)	1 (10)
Patients with hypertension treated each month, n	138	214	140
Treated patients by comorbidity* (%)
No comorbidities	37	17	16
Diabetes	33	31	53
Hyperlipidemia	39	42	56
Stroke	6	13	13
Angina	4	31	17
Atrial fibrillation	3	18	12
Heart failure	4	17	19
Myocardial infarction	5	24	18
Others	0	1	32

Notes:

* Total percentages may be greater than 100% as patients may have more than 1 comorbidity.

Abbreviation: GPs, general practitioners.

Figure 1 Proportion of physicians considering different factors as part of BPV.

Abbreviation: BPV, blood pressure variability.

Figure 2 Proportion of physicians (overall and by specialty) using different BP cutoff values to diagnose hypertension using HBPM and ABPM (a cutoff of >135/85 mmHg is the one recommended in most guidelines).

Abbreviations: ABPM, ambulatory BP monitoring; BP, blood pressure; GPs, general practitioners; HBPM, home BP monitoring.

Figure 3 Drug use by patients managed using antihypertensive monotherapy.

Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARBs, angiotensin receptor blockers; BB FDC, beta-blockers fixed dose combination; Cardio, cardiologists; CCBs, calcium channel blockers; GPs, general practitioners; Nephro, nephrologists.

Figure 4 Target cutoff SBP/diastolic BP values for the initiation of drug therapy in patients with hypertension.

Abbreviations: BP, blood pressure; SBP, systolic BP.

Table 3 Reported physician use of different hypertension guidelines

Number of physicians (%)	Total (n=60)	GPs (n=30)	Cardiologists (n=20)	Nephrologists (n=10)
JNC8^Citation7	36 (60)	13 (43)	16 (80)	7 (70)
Singapore MOH^Citation32*	32 (53)	22 (73)	7 (35)	3 (30)
ESC/ESH^Citation8	27 (45)	9 (30)	15 (75)	3 (30)
NICE^Citation9	17 (28)	6 (20)	3 (15)	8 (80)
JSH^Citation10	6 (10)	0 (0)	0 (0)	1 (10)
None	2 (3)	1 (3)	0 (0)	0 (0)

Notes:

* Guidelines last revised in 2005 have been withdrawn and a new, updated edition is awaited.

Abbreviations: ESC, European Society of Cardiology; ESH, European Society of Hypertension; GPs, general practitioners; JNC8, Eighth Joint National Committee; JSH, Japanese Society of Hypertension; MOH, Ministry of Health; NICE, National Institute for Health and Care Excellence.

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