Awareness of General Practitioners toward Hypertension Management.

INTRODUCTION: The silent killer, hypertension (HTN), is a significant risk factor for cardiovascular disease. In India, HTN has a major public health effect on cardiovascular health and health-care systems. AIM: The present study was aimed to evaluate the awareness of general practitioners (GPs) toward HTN management and also their approach toward management.
MATERIALS AND METHODS: The present study was a questionnaire-based assessment study. A total of 100 GPs were included in the study as our study sample. All the participants were well informed about the study and after that those who were willing to participate were enrolled after obtaining a written informed consent.
RESULTS: The common presenting symptoms of hypertensive patients were predominantly morning headache (71%), dizziness (41%), palpitation (39%), and fatigability (29%). Majority (84%) practiced cuff placement method covering about 2/3rd of the arm at heart level. The preferred position while blood pressure (BP) examination of patient by majority of practitioners was while sitting (53%). The number of readings usually taken for measuring BP for each patient was as follows: one (3%), two (42%), and three (55)%.
CONCLUSION: Although GPs in our study are well informed and up to date on certain aspects of HTN diagnosis and treatment, they may still lack an appropriate approach to HTN history taking, diagnosis, and treatment. Copyright:

INTRODUCTION

The silent killer, hypertension (HTN), is a significant risk factor for cardiovascular disease. In South Asia, high blood pressure (BP) is the third most important risk factor for disease attributable burden (2010). In India, HTN has a major public health effect on cardiovascular health and health-care systems. In India, HTN is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths. HTN is one of the leading causes of death in the world, according to the WHO.[123]

According to a study of global data on the global burden of HTN in 2005, 20.6% of Indian men and 20.9% of Indian women had HTN. By 2025, Indian men and women's HTN rates are expected to rise to 22.9% and 23.6%, respectively.[34] According to the WHO figures from 2008, 32.5% of Indians had high BP (33.2% in men and 31.7% in women).[5]

Regardless of the above-mentioned high prevalence, literature shows that the percentage of people who are unaware of, untreated, or even uncontrolled HTN is substantially higher across the world. In general, 50%–75% of hypertensive patients are not properly treated. In India, the majority of hypertensive patients are completely unaware of their disease. This is due to a lack of understanding and screening for HTN in adults.

Primary care physicians play a critical role in the national health system as the first point of contact for patients, their families, and the community. In India, general practitioners (GPs) offer comprehensive primary health care to people of all ages and are the health system's first point of contact.

Previous studies on evaluating doctors' adherence to HTN recommendations had some flaws. Since HTN only occurs in around 20% of cases and is almost always followed by other risk factors, treating comorbidities is a significant consideration to consider while assessing doctors' adherence to HTN guidelines.[6]

The attitudes of doctors toward recommendations have a big impact on how they are implemented in clinical practice. Doctors' intentions to use guidelines can be predicted based on their attitudes toward them, which are affected by a number of factors including their awareness, prior clinical experience, views about guidelines, outcome expectations, peer perceptions, and the features of the guidelines.[7]

Therefore, the present study was aimed to evaluate the awareness of GPs toward HTN management and also their approach toward management.

MATERIALS AND METHODS

The present study was a questionnaire-based assessment study. This cross-sectional study was conducted in U. P. University of Medical Sciences, Saifai, Etawah, U. P. and United Institute of Medical Sciences, Prayagraj, U. P.

A total of 100 GPs were included in the study as our study sample. All the participants were well informed about the study and after that those who were willing to participate were enrolled after obtaining a written informed consent.

A detailed questionnaire was prepared keeping in view the Joint National Committee guidelines and from standard books of internal medicine. The questionnaire covered information regarding the below-mentioned parameters:

BP measurement techniques used by them in routine

Diagnosis of pre-HTN and HTN

Estimation of new cases of HTN

Their idea regarding role of nonpharmacological measures used in the treatment of both pre-HTN and HTN

Level of BP to start pharmacological treatment

Their preferred choice regarding prescribing antihypertensive agents.

Each participant was personally visited and questionnaire was filled accordingly. The questionnaire was thoroughly checked after being filled for any leftovers. The data thus collected from all the 100 GPs were compiled on Microsoft excel sheet for further statistical analysis.

Statistical analysis

Results thus obtained were subjected to statistical analysis using Statistical Package for theSocial Sciences (SPSS, version 21.0; SPSS Inc., Chicago, IL, USA). All the data were represented as frequency, means, and percentages. Appropriate tables and graphs were used to represent the significant findings of the study.

RESULTS

A total of 100 practitioners were included in the present study. They comprised of 90 males and 10 females [Figure 1].

Figure 1

Gender distribution

According to majority of GPs, common presenting symptoms of hypertensive patients were as follows: morning headache (71%), dizziness (41%), palpitation (39%), and fatigability (29%) [Table 1].

Table 1

Common presenting symptoms of hypertension

Common presenting symptoms	Frequency (%)
Morning headache	71 (71)
Dizziness	41 (41)
Palpitation	39 (39)
Fatigability	29 (29)

In relation to method of BP measurement, 58 (58%) of the GPs examined peripheral pulses initially during clinical examination. Further, in Table 2, based on technique of BP measurement by the GPs, it was observed that the majority (84%) practiced cuff placement method covering about 2/3rd of the arm at heart level. The preferred position while BP examination of patient by majority of practitioners was while sitting (53%), in supine position (34%), and both by standing and supine position (14%). The number of readings usually taken for measuring BP for each patient was as follows: one (3%), two (42%), and three (55%).

Table 2

Methods of blood pressure measurement used by general practitioners in the present study

Method of blood pressure measurement	Frequency (%)
Cuff placement
Covering 2/3rd of arm at heart level	83 (83)
Preferred position of patient
Sitting	53 (53)
Supine	34 (24)
Standing, supine	14 (14)
Number of readings of blood pressure taken for diagnose hypertension
One	3 (3)
Two	42 (42)
Three	55 (55)

According to different tests required, an advised by the GP during examination and diagnosis of a new case of HTN included: electrocardiogram (ECG) by (96%), serum creatinine (79%), complete lipid profile (91%), urine analysis (71%), random blood sugar (88%), and serum K levels (69%) [Figure 2].

Figure 2

Initial tests prescribed for newly diagnosed cases of hypertension

Once diagnosed, 82% of the GPs were of the opinion that patients should be advised healthy food habits such as less intake of preserved and high salt content foods. In addition, 86% were of the opinion that exercises such as walking and yoga should be included in the daily routine as weight loss proves to be helpful in lowering BP in borderline cases such as prehypertensive obese and overweight patients.

Maximum GPs were well aware regarding the use of angiotensin-converting enzyme (ACE) inhibitor and beta-blocker for treatment of HTN and also well words with their side effects. Sedatives were identified as the first-line treatment for reducing BP by 48% of people, either alone or in conjunction with antihypertensive agents. For treating extremely high BP, 71% of GPs administered sublingual antihypertensive agents.

DISCUSSION

The present study was aimed to evaluate the awareness of management of HTN among GPs. A total of 100 practitioners were included in the present study.

In the diagnosis and treatment of HTN, accurate measurement and understanding of BP are critical. Previous studies on measuring doctors' adherence to HTN recommendations had some shortcomings, according to the literature review. Since HTN only occurs in around 20% of cases and is almost always followed by other risk factors, treating comorbidities are a significant aspect to consider while evaluating doctors' adherence to HTN guidelines. Various studies have used survey data to assess adherence to guidelines, but they had drawback of focusing on self-reported habits, which are often subject to bias.

In the present study, there were 60 males and 40 females. The common presenting symptoms of hypertensive patients were as follows: morning headache (71%), dizziness (41%), palpitation (39%), and fatigability (29%). The common presenting symptoms of hypertensive patients were predominantly – morning headache (71%), dizziness (41%), palpitation (39%), and fatigability (29%). Further, based on technique of BP measurement by the GPs, it was observed that the majority (84%) practiced cuff placement method covering about 2/3rd of the arm at heart level. The preferred position while BP examination of patient by majority of practitioners was while sitting (53%), in supine position (34%), and both by standing and supine position (14%). The number of readings usually taken for measuring BP for each patient was as follows: one (3%), two (42%), and three (55%).

In similarity, Deshpande et al.[8] reported that 20% of GPs were not applying BP cuff properly for BP measurement. Only 18% and 16.6% could diagnose isolated diastolic hypertension (IDH) and isolated systolic hypertension, respectively (ISH), and 21% and 29% would have considered treatment of IDH and ISH, respectively. Nearly 48% consider treating pre-HTN using nonpharmacological measures. Only 21% use thiazide diuretics for uncomplicated HTN and 50% use beta-blockers in coronary artery disease patients. In their study, most of the GPs in Western Vadodara were well aware and updated about the initial laboratory investigations, nonpharmacological measures, and complications of HTN but lack an effective approach toward history taking for HTN, technique for measurement of BP, diagnosis, and treatment of IDH and ISH.

In another such study by Mishra and Singh,[9] cuff placement at heart level was practiced by 84%, of the GPs and preferred position of patient was sitting (52%). The number of readings of BP was 1 by 2%, 2 by 40%, and 3 by 58%. Investigation preferred by GP was ECG by 91%, urine examination by 68%, serum creatinine by 82%, lipid profile by 80%, ultrasound of abdomen by 35%, serum potassium level by 72%, and RBS by 98%. Common symptoms reported were morning headache by 70%, dizziness by 45%, palpitation by 52%, easy fatigability by 57%, and impotence by 48%. The difference was significant (P < 0.05). Most of the GPs were well aware and updated about the initial laboratory investigations, symptoms, and techniques.

A total of 1051 GPs were approached for a study by Jafar et al.,[10] and 1000 (95%) agreed to participate. Overall, 30.6% (29.0% to 32.3%) and 79.7% (78.3% to 81.0%) of GPs used incorrect BP cut-offs to diagnose HTN in patients aged 60 and ≥60 years, respectively. Just 34.7% of GPs (33.0% to 36.3%) started appropriate HTN treatment for the elderly.

Similarly, in yet another study, Ale and Braimoh[11] concluded that there was a gap between guideline recommendations and HTN care in Nigeria which was further widened by primary care physicians unawareness of the guidelines. Popularizing HTN guidelines among primary care physicians may significantly improve HTN care and reduce the burden of disease.

For the treatment of HTN, a comprehensive lifestyle change is needed. Before recommending dietary and lifestyle change, baseline knowledge about diet and lifestyle is needed, but majority of the GPs in our study do not appear to enquire about it in their practice. Despite the fact that most GPs prescribe nonpharmacological interventions to their hypertensive patients, failing to obtain baseline information can result in insufficient therapy. Furthermore, nonpharmacological treatments for pre-HTN are also underutilized.

We observed that maximum GPs were well aware regarding the use of ACE inhibitor and beta-blocker for treatment of HTN and also well words with their side effects. Sedatives were identified as the first-line treatment for reducing BP by 48.0% of people, either alone or in conjunction with antihypertensive agents. Thiazide diuretics were only used on rare occasions. For treating extremely high BP, 71% of GPs administered sublingual antihypertensive agents.

HTN is quickly diagnosed using low-cost technologies, and it can be treated with appropriate and safe drugs. HTN management is thus one of the most cost-effective public health treatments. To improve management, it is critical to choose the right prescription for the patient's needs; it is also critical to detect drug side effects to increase patient compliance and prevent treatment complications. Heart failure has been shown to be a strong indicator of improved guidelines adherence in previous studies. The wide range of antihypertensive groups recommended by guidelines (diuretics, ACE inhibitors, BB, ARB, and aldosterone antagonists) tends to be a possible reason for doctors' effective adherence to guidelines when treating heart failure patients.

CONCLUSION

Thus, we can conclude that, although GPs in our study are well informed and up to date on certain aspects of HTN diagnosis and treatment, they may still lack an appropriate approach to HTN history taking, diagnosis, and treatment. This research provides insight into the understanding of recent recommendations and developments for the treatment of HTN by GPs, which can be used in the future to achieve better management at the primary health-care level.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.