Blood pressure measurement at screening and in general practice

Evaluation of blood pressure measurements in first ambulatory neurological consultations: a missed part of the physical examination?

OBJECTIVE

To obtain a blood pressure reading is mandatory during either the general or specialized physical examination. This study describes factors associated with the accomplishment of blood pressure measurement in the first neurological consultation.

METHODS

We studied first ambulatory neurology consultations in a Mexican referral hospital. Demographic characteristics, diagnostic category of referral, final diagnosis and data on physical examination were collected to establish a logistic regression analysis in order to identify factors associated with the accomplishment of blood pressure measurement.

RESULTS

Over 8 months 778 outpatients were studied. The most frequent diagnoses for first consultation were headache (26%), epilepsy (14%) and stroke (13%). Only in 39% (n=301) of the outpatients blood pressure was registered, among them, 30% had normal blood pressure, 43% had 121-139/81-89 mmHg, 20% had 140-159/90-99 mmHg and 7% had ≥ 160/100 mmHg. The independent factors that favored the practice of BP determination in multivariable analysis were >65 years of age (odds ratio: 2.26; 95% confidence interval: 1.52-3.36) and headache complaint (odds ratio: 1.81, 95% confidence interval: 1.30-2.53). Notably, only 43% of patients with stroke had blood pressure registration, even when these stroke patients had blood pressure readings, they had higher blood pressure than with other diagnoses (p<0.05).

CONCLUSION

Blood pressure registration was frequently omitted from the first neurological consultation, particularly in outpatients who might need it the most.

Effects of dietary sodium and the DASH diet on the occurrence of headaches: results from randomised multicentre DASH-Sodium clinical trial

OBJECTIVES

Headaches are a common medical problem, yet few studies, particularly trials, have evaluated therapies that might prevent or control headaches. We, thus, investigated the effects on the occurrence of headaches of three levels of dietary sodium intake and two diet patterns (the Dietary Approaches to Stop Hypertension (DASH) diet (rich in fruits, vegetables and low-fat dairy products with reduced saturated and total fat) and a control diet (typical of Western consumption patterns)).

DESIGN

Randomised multicentre clinical trial.

SETTING

Post hoc analyses of the DASH-Sodium trial in the USA.

PARTICIPANTS

In a multicentre feeding study with three 30 day periods, 390 participants were randomised to the DASH or control diet. On their assigned diet, participants ate food with high sodium during one period, intermediate sodium during another period and low sodium during another period, in random order.

OUTCOME MEASURES

Occurrence and severity of headache were ascertained from self-administered questionnaires, completed at the end of each feeding period.

RESULTS

The occurrence of headaches was similar in DASH versus control, at high (OR (95% CI)=0.65 (0.37 to 1.12); p=0.12), intermediate (0.57 (0.29 to 1.12); p=0.10) and low (0.64 (0.36 to 1.13); p=0.12) sodium levels. By contrast, there was a lower risk of headache on the low, compared with high, sodium level, both on the control (0.69 (0.49 to 0.99); p=0.05) and DASH (0.69 (0.49 to 0.98); p=0.04) diets.

CONCLUSIONS

A reduced sodium intake was associated with a significantly lower risk of headache, while dietary patterns had no effect on the risk of headaches in adults. Reduced dietary sodium intake offers a novel approach to prevent headaches.

TRIAL REGISTRATION NUMBER

NCT00000608.

Systemic hypertension, headache, and ocular hemodynamics: a new hypothesis

The association between systemic hypertension and headache remains controversial and its pathophysiologic basis is uncertain. A rather characteristic early-morning pulsating headache is commonly seen in hypertensive patients, and a recent meta-analysis supports the link between these 2 entities. Epidemiologic evidence has paradoxically suggested a negative association between hypertension and headache. Unpredictable clinical association between severe hypertension and headache indicates that another cranial perfusion-related variable exerts a critical role. Neuroanatomically, head and neck pain primarily involves the ophthalmic division of the trigeminal nerve (V1). A link between systemic hypertension, pulsatile choroidal blood flow (CBF), and intraocular pressure (IOP) has been established. I propose that a trait ocular sympathetic hypofunction permits rapid episodic ocular choroidal overperfusion that stretches the ocular globe in the cohort of hypertensive patients with headache. Rapid distension of the pain-sensitive corneoscleral envelope can stimulate corneoscleral and iridial pain-sensitive V1 nerve endings and generate headache. Ocular tamponade function physiologically limits choroidal overperfusion. A higher basal IOP in some patients with moderate-to-severe hypertension may dampen pulsatile CBF and account for the negative epidemiologic link between sustained systemic hypertension and headache. Besides activation of the baroreceptor reflex, the association of hypalgesia with hypertension probably involves activation of the vasopressin-endorphin adaptive system consequent to mechanical stimulation of V1. The analogy between hypertensive headache and angle-closure glaucoma is rather limited because typical ocular and visual signs and symptoms of angle-closure glaucoma are not seen in hypertension-related headache. Hypertensive crises, including those associated with pheochromocytoma, are not accompanied by attacks of angle-closure glaucoma. Glaucoma is not associated with ocular choroidal congestion, but with reduced pulsatile CBF. The predisposition to develop angle-closure glaucoma is theoretically not associated with ocular autonomic hypofunction and should be conceptually dissociated from this hypothesis. The hypothesis can be evaluated by establishing significant circadian elevations of blood pressure, including nondipping nighttime pattern as well as circadian and periheadache measurements of IOP in patients with attacks of hypertension-related headache.

Detection of hypertension in accident and emergency departments

Routine blood pressure measurements are performed on all non-ambulatory patients attending the Accident and Emergency Department, Leicester Royal Infirmary, England. However, the patient's general practitioner is not always informed of the reading, even if it is found to be raised. One of the chief reasons for this omission is the fact that single, elevated blood pressure readings taken in an accident and emergency department are considered to be of doubtful significance. Sixty patients with a single, elevated blood pressure measurement were studied. Fifteen of these patients were found to continue to have an elevated blood pressure measurement when reviewed in a quiet, relaxed environment. Fourteen of these 15 patients are currently being treated for hypertension after independent assessment by their family practitioners. It was concluded that single, elevated blood pressure readings are useful indicators of hypertension in non-ambulatory patients attending accident and emergency departments. It is, therefore, important to inform general practitioners of incidentally raised blood pressure readings.

Hypertension screening in a primary care clinic

A chart audit of 250 randomly selected adult patients at a university-based family practice unit showed that 91.9% had attended the clinic during a five-year period (89.0% for males and 94.5% for females). Overall, 80.6% of the patients had their blood pressure recorded on the office chart in the five-year period (75.3% for males and 85.0% for females). For males 30-39 years old, however, the rate was only 54.5%. Flow sheets are suggested as a practical method for recording health maintenance items in an effort for the primary care physician to follow the recommended guidelines for hypertension screening.

A comparison of blood pressure control in hypertensive patients treated in hospital clinics and in general practice. The DHSS hypertension care computing project

Two thousand and twenty hypertensive patients of 45 years and over were treated and followed up for either 6 months, 12 months, 18 months or 2 years. Seventeen hundred and forty of these patients were seen in hospital outpatient clinics, 280 in general practice.The patients followed in general practice had an average blood pressure of 182/111 mmHg prior to treatment. The blood pressure after follow-up for 18-24 months averaged 156/97 mmHg. The corresponding results for the patients followed in hospital clinics were 195/115 mmHg untreated and 150/92 mmHg after follow-up.The untreated blood pressures were higher in the hospital patients (p < 0.001 for systolic, p < 0.05 for diastolic pressure) and the treated diastolic pressures at 18-24 months were lower in the hospital than the general practice group (p < 0.001). The hospital patients did not receive a greater variety of drugs but were prescribed them in higher doses. Blood pressure control was considered to be inadequate in many patients in both groups. At 18-24 months, 26 per cent of the general practice group had diastolic pressures of 105 mmHg or more, as had 13 per cent of the patients followed in the hospital clinics.

A comparison of hospital and general practice blood pressure readings using a shared-care record card

Shared-care blood pressure record cards were issued to 149 consecutive hypertensive patients attending our hospital clinic. In 108 (72.5 per cent), general practitioners entered readings they had obtained onto the cards. The use of the record card has proved helpful in the management of patients, and we are encouraged by the co-operation of the family doctors.A comparison of blood pressures measured in hospital and in general practice showed that general practitioners found systolic pressures to be an average of 5.5 mm Hg lower than hospital doctors, but there were no differences in diastolic pressure. In many cases, wide discrepancies were found both in hospital and general practice. We conclude that it is a myth that patients' blood pressures are lower when they consult their family doctor, or that outpatient blood pressure readings are falsely elevated by the stress of hospital attendance.

Mild hypertension: to treat or not to treat?

In the second half of this century, morbidity and mortality from cardiovascular disease has reached epidemic proportions. The major risk factor associated with cardiovascular disease has been found, from various epidemiological studies, to be elevated blood pressure. Therefore, a lot of energy has been expended in prospective therapeutic trials in attempting to detect whether treatment of high blood pressure is beneficial. In severe hypertension, where the risk to the individual is considerable, this benefit has been demonstrated with relative ease. However, it has not yet proven possible to show conclusive benefit of treatment in the mild group of hypertensives, which form the vast majority of patients seen in general practice. A different approach has been advocated where account is taken of other coincidental cardiovascular risk factors; their presence or absence should help the clinician decide whether to treat or not to treat in the individual case.

The management of hypertension--a study of records in general practice

We investigated the management of a group of 322 hypertensive patients by 71 general practitioners in the Lothian Health Board Area by a survey of the general practitioners' records. Eighty-five per cent of patients were diagnosed by the general practitioner and 57 per cent were cared for entirely by him. Two thirds of the patients were women. Hospital referral was more common in men and in patients with high initial blood pressures. One third of patients had only one blood pressure recorded before treatment. The result of treatment as measured by the latest diastolic blood pressure was similar for patients treated by the general practitioner and those referred to hospital, being 100 mm Hg or less in 77 per cent of patients.