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TITLE: MANAGEMENT OF
HYPERTENSION IN PRIMARY CARE SETTING – UPDATE04
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Citation:
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Diagnosis and
Management of Hypertension in the Primary Care Setting. Washington, DC:
VA/DoD Evidence-Based Clinical Practice Guideline Working Group, Veterans
Health Administration, Department of Veterans Affairs , and Health Affairs,
Department of Defense, November 1999. Office of Quality and Performance
publication 10Q-CPG/HTN-99. (Update 2004).
Office of Quality and Performance publication 10Q-CPG/HTN-04.
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Completion
Date:
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June 2003; June
2004
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Release
Date:
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August 2004
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Source(s):
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Washington
(DC): The Hypertension Guideline was developed by and for clinicians from
the Department of Veterans Affairs (VA) and the Department of Defense
(DoD); 2004. Various Pages.
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Adaptation:
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The guideline
draws heavily from the Seventh Report of
the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC-7), 2003.
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Guideline
Status:
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This is the
current release of the guideline update -2004. An update is targeted for 2006.
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Developer(s):
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Veterans Health Administration (VHA), Department of
Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [U.S.]
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Funding
Source:
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United States
Government
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Committee:
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The
Hypertension Working Group
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Group
Composition:
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The
list
of contributors to the guideline includes nurses,
nephrologists, cardiologists, pharmacists, internal medicine and
primary care physicians, and experts in the field of guideline
and algorithm development.
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Disease/Condition:
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Hypertension
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Category:
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Screening,
Diagnosis, Treatment, and Management
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Intended
Users:
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Clinical staff
including physicians, nurses, nurse practitioners, physician assistants,
and clinical pharmacists
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Target
Population:
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Persons
eligible for care in the VA or DoD health care delivery system.
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Contact
Person(s):
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VA:
Peter Glassman, MD
VA Medical Center
11301 Wilshire Blvd.
Los Angeles, CA
(310) 478-3711 x48337
peter.glassman@med.va.gov
DoD:
G. Dodd Denton, CDR MC USN
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GOALS/OBJECTIVES
- Describe the critical decision points in the
management of hypertension.
- Provide a clear and comprehensive guideline
incorporating current information and practices for practitioners
throughout the DoD and Veterans Health Administration system.
- Improve local management of patients with
hypertension and patient outcomes.
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INTERVENTIONS AND PRACTICES
The Guideline consists of two algorithms—a screening
algorithm and a treatment algorithm. The treatment algorithm addresses
distinct aspects of:
- Assessment and Triage
- Pharmacotherapy
- Diet
and Lifestyle Modification
- Follow-up
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OUTCOMES CONSIDERED
Systolic and diastolic blood
pressure readings.
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MAJOR RECOMMENDATIONS
The guideline is formatted as two algorithms, with
annotations. Presentation of the algorithms is intended to assist the
clinician in reviewing and identifying key points that are comprehensively
discussed in the guideline document.
- The diagnosis of hypertension is usually not made on
a first visit; blood pressure elevations can be classified.
- A subset of hypertensive patients requires drug
therapy; risk stratification should determine therapy.
- Clinicians should begin by prescribing lifestyle
modification in all patients with hypertension and prehypertension.
- Clinicians should enlist patient participation in
lifestyle modification.
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CLINICAL ALGORITHM ARE
PROVIDED FOR:
Algorithm
A - Screening for Abnormal Blood Pressure
Algorithm
B - Management of Elevated Blood Pressure
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TYPE OF EVIDENCE
The guideline is supported by the literature in a
majority of areas, with evidence-based tables and references throughout the
document. The evidence consists of key clinical randomized controlled
trials and longitudinal studies in the area of hypertension. Where existing
literature is ambiguous or conflicting, or where scientific data are
lacking on an issue, recommendations are based on the expert panel’s
opinion and clinical experience. The guideline contains a bibliography and
discussion of the evidence supporting each recommendation.
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DESCRIPTION OF METHODS TO
COLLECT EVIDENCE
The algorithm and annotations were based on an exhaustive review of the literature.
The goal of the literature review was to provide a systematic basis for the
development of an evidence-based guideline. The inclusion criteria for the
literature search were related to the population being studied (adult) and
the treatment setting (primary care).
The Medical Subject Headings (MeSH) terms used for the search included key
therapies in hypertension, study characteristics, and study design.In this
search, study characteristics were those of analytic studies, case-control
studies, retrospective studies, cohort studies, longitudinal studies,
follow-up studies, prospective studies, cross-sectional studies, clinical
protocols, controlled clinical trials, RCTs, intervention studies, and
sampling studies.
Study design included crossover studies,
double-blind studies, matched pair analysis, meta-analysis, random
allocation, reproducibility of results, and sample size.
See Guideline Introduction.
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METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE
The literature search was followed by critical analysis of the literature,
primarily by the clinical experts. To promote the evidence-based approach,
the quality of evidence was rated using a hierarchical rating scheme. The
value of a hierarchical rating scheme is that it provides a systematic
means for evaluating the scientific basis for health care services (3).
The rating scheme used for this guideline is based on a system used by the
Agency for Health Care Policy and Research. Decision points in the
algorithm are annotated, and the primary source documents for the
annotation are graded.
The Grading Scheme Used For The Guideline
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TABLE
1: Quality of Evidence (QE)
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I
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At least one properly done RCT
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II-1
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Well designed controlled trial without randomization
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II-2
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Well designed cohort or case-control analytic study
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II-3
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Multiple time series, dramatic results of
uncontrolled experiment
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III
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Opinion of respected authorities, case reports, and
expert committees
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TABLE
2: Overall Quality
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Good
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High grade evidence (I or II-1) directly linked to
health outcome
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Fair
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High grade evidence (I or II-1) linked to
intermediate outcome; or
grade evidence (II-2 or II-3) directly linked
to health outcome
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Poor
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Level III evidence or no linkage of evidence to
health outcome
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TABLE
3: Net Effect of the Intervention
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Substantial
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More than a small relative impact on a frequent
condition with a substantial burden of suffering; or
A large impact on an infrequent condition with
a significant impact on the individual patient level.
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Moderate
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A small relative impact on a frequent condition with
a substantial burden of suffering; or
A moderate impact on an infrequent condition
with a significant impact on the individual patient level.
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Small
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A negligible relative impact on a frequent condition
with a substantial burden of suffering; or
A small impact on an infrequent condition with
a significant impact on the individual patient level.
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Zero or Negative
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Negative impact on patients; or
No relative impact on either a frequent
condition with a substantial burden of suffering; or an infrequent
condition with a significant impact on the individual patient level.
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TABLE
4: Grade the Recommendation
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A
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A strong recommendation that the intervention is
always indicated and acceptable
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B
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A recommendation that the intervention may be
useful/effective
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C
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A recommendation that the intervention may be
considered
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D
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A recommendation that a procedure may be considered
not useful/effective, or may be harmful
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I
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Insufficient evidence to recommend for or against -
the clinician will use clinical judgment
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REVIEW METHODS
Peer Review
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ENDORSERS
VHA 's National Clinical Practice Guideline Council
DoD/VA Clinical Practice Guidelines Working Group
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QUALIFYING STATEMENTS
Clinical practice guidelines, which are increasingly being used in health
care, are seen by many as a potential solution to inefficiency and
inappropriate variations in care. Guidelines should be evidenced-based as
well as based upon explicit criteria to ensure consensus regarding their
internal validity. However, it must be remembered that the use of
guidelines must always be in the context of a health care provider's
clinical judgment in the care of a particular patient. For that reason, the
guidelines may be viewed as an educational tool analogous to textbooks and
journals, but in a more user-friendly tone.
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GUIDELINE AVAILABILITY
Electronic copies available from:
The Office of Quality and Performance web site.
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Copy Statement: No copyright restrictions apply
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