Hypertension and blood pressure variability management practices among physicians in Singapore

Abstract

Purpose: There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore.

Materials and methods: Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs.

Results: Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31-60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful.

Conclusion: There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore.

Keywords: antihypertensives; blood pressure; blood pressure monitoring; blood pressure variability; guidelines; hypertension.

Figure 1

Proportion of physicians considering different factors as part of BPV. Abbreviation: BPV, blood pressure variability.

Figure 2

Proportion of physicians (overall and by specialty) using different BP cutoff values to diagnose hypertension using HBPM and ABPM (a cutoff of >135/85 mmHg is the one recommended in most guidelines). Abbreviations: ABPM, ambulatory BP monitoring; BP, blood pressure; GPs, general practitioners; HBPM, home BP monitoring.

Figure 3

Drug use by patients managed using antihypertensive monotherapy. Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARBs, angiotensin receptor blockers; BB FDC, beta-blockers fixed dose combination; Cardio, cardiologists; CCBs, calcium channel blockers; GPs, general practitioners; Nephro, nephrologists.

Figure 4

Target cutoff SBP/diastolic BP values for the initiation of drug therapy in patients with hypertension. Abbreviations: BP, blood pressure; SBP, systolic BP.