Stepwise treatment of uncontrolled high blood pressure in general practice

In the Netherlands, where patients with hypertension are typically managed in primary care, only half of them reach an office systolic blood pressure target below 140mmHg. Currently, the management of hypertension is embedded within the cardiovascular risk management (CVRM). Guidelines on CVRM recommend first of all adequate blood pressure readings. Lifestyle advising (e.g. reducing intake of salt, licorice, and alcohol, correct overweight and perform more everyday excercise) should be optimalised, preferably on a patient-centered basis. Attention should be paid to adherence to medication. Finally, blood pressure lowering medication should be prescribed sensibly in those with high blood pressure (i.e. preferably once daily, considering multiple drugs from different classes at a low dose rather than less drugs at the highest dose). We expect that a a systematic diagnostic work-up in this would result in improved blood pressure control.

The objective is to investigate whether application of a stepwise work-up strategy in primary care patients with uncontrolled hypertension results in better blood pressure control in a cost-effective manner.

Participants are asked to fill out 3-4 questionnaires at baseline and after 8 months of follow-up. Also, in both groups 24-hour blood pressure measurement will be conducted at baseline and after 8 months of follow-up. In both groups, blood samples will be taken after 8 months and at baseline if the patients had lab testing longer than 3 months ago. Participants in the intervention group will fill out, depending on how many steps they will need, another 4 questionnaires. They will have a maximum of 7 more consultations with their general practitioner or practice nurse.

Trained GP's will execute a protocol involving a stepwise approach. The first step will be 24-hour blood pressure messurement to exclude white coat hypertension. Depending on how many steps a patient needs to achieve a controlled blood pressure, questionnaires will be filled out by the patient considering lifestyle, physical activity, salt intake and adherence. After that, together with the patient, the GP will decide whether improvement of adherence and adjustment of medication is possible. The patient will be referred to an internist in case the blood pressure is still uncontrolled at the end of following this stepwise approach.