1. Current European guidelines for management of arterial hypertension: Are they adequate for use in primary care? Halfdan Petursson Linn Getz Johann Agust Sigurdsson Irene Hetlevik

2. Objectives To model the implications of recent European guidelines for the management of arterial hypertension A.Prevalence of individuals “at risk” for CVD B.Clinical workload associated with recommended measures Number of follow-up visits/year Number of physicians needed (general practitioners?)

4. Treatment recommendations are based on combined risk estimate “A new” risk factor: –High pulse pressure* in the elderly No further definition in the guidelines! ≥ 60 mmHg in individuals > 55 years of age * Pulse pressure = Systolic BP – diastolic BP

5. Treatment recommendations 0 2 3-4 3-4

6. HUNT 2 Every adult invited Participation > 2/3 –76% of women –67% of men 65,028 individuals 20-89 years old 51,066 (79%) eligible for our model

7. Exclusion criteria Excluded if: –blood pressure <120/80 mmHg –no information available about any of the other risk factors

8. The risk factors HUNT 2 1.Age 2.Smoking 3.Dyslipidemia (total- and HDL cholesterol) 4.Waist circumference 5.1° relatives with CVD 6.Pulse pressure of the elderly Guidelines but not HUNT 2 Fasting blood values: triglycerids, glucose, LDL Left ventricular hypertrophy indicated on echo/EKG Renal disease, microalbuminuria

9. Age standardised prevalence Total: 100% = 100 000 adults after standardisation Data from those included only (51 066)

10. Age standardised prevalence

11. Average risk6.6% Do 75% or more have risk above average? + Low risk? <21% The excluded group = <25%

12. Average risk? 6,6% 99% of all 50-64 y.o. should attend regular follow-up visits or receive drug treatment for high bp!

13. How many physicians are needed? Follow-up visits / 100,000 adults / year = 296,624 Number of GP positions = 296,624 / 3,000 consultations / year = 99 99 physicians needed for bp control only per 100,000 adults Current status in Nord-Trøndelag: –87 GPs / 100,000 adults

14. Conclusions Clinical practice guidelines overestimate the risk Fail to define a manageable number of people “at risk” Fundamental problem regarding the theoretical framework Only ethically justifiable if –practical feasibility, –sustainability, and –social determinants of health are considered

15. Funding Funding: –The Icelandic Family Physicians Research Fund HUNT 2 –HUNT Research Center, Faculty of Medicine NTNU –Norwegian Institute of Public Health –Nord-Trøndelag County Council –Levanger Hospital, Nord-Trøndelag

17. Treatment recommendations 0 2 3-4 3-4

19. WHO Health for all database, Aug 2008 Mortality from CVD per 100.000 1970-2006 Denmark Finland France Iceland Italy Netherlands Norway Spain Sweden United Kingdom