UK recommendations to change dramatically how a patient's blood pressure is monitored could save many lives if adopted here too, writes PROF EOIN O'BRIEN
HIGH BLOOD pressure, which is the commonest cardiovascular disease, is diagnosed in primary care and in hospital clinics using the traditional technique of measurement with a mercury sphygmomanometer and stethoscope, even though this technique has been shown to be grossly inaccurate.
Since the technique was introduced into clinical practice more than a century ago, we have landed men on the moon, encircled Mars, invented the automobile and the aeroplane and, most importantly, revolutionised the technology of science with the microchip. Why, we might ask, has medicine ignored scientific evidence? But now all must change.
The National Institute for Health and Clinical Excellence (NICE) is the body that recommends how practice and treatment of illness is conducted in the UK. The stated mission of NICE is to “base our clinical guidelines on the best available research evidence, with the aim of improving the quality of healthcare”.
This body has gained such respect and scientific credibility over the years that its guidelines influence national policy on healthcare delivery across the world. NICE has just published a consultation draft of its 2011 guideline for the management of hypertension in primary care.
This document will have a profound effect on how we diagnose and manage high blood pressure in the future. Introducing the need for change, the guideline reminds us at the outset that at least one-quarter of the adult population of the UK have hypertension, and more than half of those over the age of 60, but as the demographics of the UK shifts towards an older, more sedentary and obese population, the prevalence of hypertension and its requirement for treatment will continue to rise.
We are also reminded that high blood pressure is the major cause of stroke and that bringing blood pressure down to normal prevents this catastrophic complication. These admonitions apply equally to Ireland.
The NICE guideline states that 24-hour ambulatory blood pressure measurement (ABPM) “should be implemented for the routine diagnosis of hypertension in primary care”. (That involves measuring blood pressure for 24 hours as the patient goes about their normal routine.)
NICE provides a detailed cost-benefit analysis that shows clearly that the use of ABPM would result in substantial savings to the National Health Service. The guideline recognises “the considerable challenges for implementation of this recommendation”, which effectively means that about 13 million patients in the UK will have to undergo ABPM.
The recommendation of NICE will be applied, quite rightly, to practice in Ireland too. Although more general practitioners in Ireland use ABPM than their colleagues in the UK, the new Minister for Health, Dr James Reilly, will have to make funding available for the widespread use of the technique in primary care.
He should not see this as a deterrent but rather welcome it as a means of preventing strokes and heart attacks with the potential for enormous savings in the future. If blood pressure control were achieved in Ireland, 5,000 strokes could be prevented each year. The daunting reality is that less than half of the patients on treatment have their blood pressure controlled.
One of the first steps towards making ABPM available would be to provide reasonable reimbursement to general practitioners for performing ABPM. The Minister should examine the potential for making ABPM available in pharmacies, a practice that is growing in popularity here.
Finally, the Minister must seize the opportunity to establish a national registry of ambulatory blood pressure by using systems that are capable of providing online analysis with an interpretative report and storage of data for demographic and scientific research.
Such a system for ABPM has been pioneered here and is in use in more than 100 primary care practices across the State.
Another consideration that should exercise the new Minister is the potential for engaging patients with high blood pressure in the management of their own illness.
It is remarkable how much more involved patients become in managing a chronic illness, such as hypertension, when they are actively informed as to the state of their blood pressure control. This can be done readily by providing patients with an ABPM report that clearly states the success or otherwise of treatment and management strategies.
If the Minister wishes to make a major and immediate impact on the nation’s health, the NICE guideline provides the scientific and economic justification for making ABPM available to all patients with hypertension or suspected hypertension.
The computerised methodology for doing so is available and has been tried and proved. What is needed is an imaginative vision that could improve the cardiovascular health of the nation dramatically by reducing stroke and the other cardiovascular consequences of high blood pressure.
Eoin O’Brien is professor of molecular pharmacology, The Conway Institute, University College Dublin and vice-president, Irish Heart Foundation. e-mail: eobrien@iol.ie
