Beyond the Evidence of the New Hypertension Guidelines. Blood pressure measurement – is it good enough for accurate diagnosis of hypertension? Time might be in, for a paradigm shift (I)

Abstract

Despite widespread availability of a large body of evidence in the area of hypertension, the translation of that evidence into viable recommendations aimed at improving the quality of health care is very difficult, sometimes to the point of questionable acceptability and overall credibility of the guidelines advocating those recommendations.The scientific community world-wide and especially professionals interested in the topic of hypertension are witnessing currently an unprecedented debate over the issue of appropriateness of using different drugs/drug classes for the treatment of hypertension. An endless supply of recent and less recent "drug-news", some in support of, others against the current guidelines, justifying the use of selected types of drug treatment or criticising other, are coming out in the scientific literature on an almost weekly basis. The latest of such debate (at the time of writing this paper) pertains the safety profile of ARBs vs ACE inhibitors.To great extent, the factual situation has been fuelled by the new hypertension guidelines (different for USA, Europe, New Zeeland and UK) through, apparently small inconsistencies and conflicting messages, that might have generated substantial and perpetuating confusion among both prescribing physicians and their patients, regardless of their country of origin.The overwhelming message conveyed by most guidelines and opinion leaders is the widespread use of diuretics as first-line agents in all patients with blood pressure above a certain cut-off level and the increasingly aggressive approach towards diagnosis and treatment of hypertension. This, apparently well-justified, logical and easily comprehensible message is unfortunately miss-obeyed by most physicians, on both parts of the Atlantic. Amazingly, the message assumes a universal simplicity of both diagnosis and treatment of hypertension, while ignoring several hypertension-specific variables, commonly known to have high level of complexity, such as: -accuracy of recorded blood pressure and the great inter-observer variability, -diversity in the competency and training of diagnosing physician, -individual patient/disease profile with highly subjective preferences, -difficulty in reaching consensus among opinion leaders,

Transient Hypertension

“…Single measurement of BP can often overestimate diagnosis of Hypertension up to in 20-30% of individuals and also likely to miss out true hypertension in 1/3 of individuals [2]. So the formore individuals are often mis classified as true Hypertension and often treated for same with antihypertensives.…”

“…Ambulatory blood pressure monitoring is helpful in deciding blood pressure is sustained hypertension or transient HT [2][3][4].…”

“…Blood pressure variations also depend on individual accuracy and competence in recording BP, instrumental errors and type of BP recording device [2].…”

An investigative case study at local hospital into the current reliability of blood pressure sphygmomanometers

“…It is an important vital sign as to the indication of the current state of health of the patient (Pater, 2005). Through the obtainment of ABP measurement results decisions related to diagnosis, prognosis and therapy are adopted (James et al, 2014;Mendonça, 2012;Mendonça et al, 2012).…”

Diretrizes brasileiras de hipertensão arterial: realidade da enfermagem em hospital especializado

“…In the study it was found that 59.6 % of the appliances used are of the aneroid type, but 27.1 % of doctors did not check the appliance calibration as suggested (9) . Moreover, in a review article on the effectiveness of the Guidelines for a precise diagnosis of hypertension, questions arose about the recommendation of medication as regards the use of a diuretic as a first option; lack of professionals' knowledge about imprecise equipment, calibration and the physical environment in conditions adjusted to the patient Thus, the apparent ease of using the measurement of arterial pressure to define, classify and diagnose hypertension is questioned, since the recommended guidance are not followed in full (10) . When we analyzed a study conducted by means of interviews and direct observations with a sample of 105 health professionals, in a public hospital in the interior of the state of São Paulo, which compared the evaluation of techniques for measuring AP, we found a significant difference between the measurements of Nurses and Nursing Aides, who obtained 40 % of correct answers in the stages of the procedures; whereas the nursing and medicine docents, doctors and academics obtained around 70 %.…”