[Hypertension in general practice in Switzerland]. / L'hypertension artérielle au cabinet du médecin de famille en Suisse.

Arterial hypertension is a leading problem in general practice. Nevertheless, reliable epidemiological and outcome data on hypertensive patients obtained directly from GPs are scarce. We report some results of our GP cohort "HccHs" of the Institute of general practice Basel. Swiss GPs fill in relevant baseline and follow-up data of their own hypertensive patients in an internnn based questionnaire The first results show a good blood pressure control. 94% of 950 patients receive antihypertensive drug treatment. 24-hour-blood pressure-measurement is helpful for baseline diagnosis and in drug treated hypertensive patients. 24-hour-blood pressure-measurement identifies patients with elevated office but normal 24-hour blood pressure with good prognosis.

One-on-one long-term tutorials in general practitioners' practices - a successful new teaching concept in primary care medicine.

To improve teaching in practical and communicative skills and knowledge in day-to-day medical practice, in 1997 we introduced one-on-one tutorials in general practitioners' offices as a mandatory part of medical students' academic education. Students participate actively half a day per week in their 3rd and 4th academic years (out of 6) in the office or clinic of a trained personal tutor. We recruited 270 general practitioners in town or from surrounding rural areas for this purpose. 85% of students choose general practitioners as their tutors and 15 % tutors in hospitals. To test whether the tutorials' aims were achieved, in 2005 we performed a detailed questionnaire evaluation after seven years' experience of one-on-one tutorials. All 236 students involved were asked to participate. The response rate was almost complete (98%). 233 anonymous questionnaires were analysed. Students reported improvement in knowledge, social and communicative skills and personal motivation. The overall rating of the one-on-one tutorials obtained 5.3 on a 6 point scale and achieved the top ranking among all university medical faculty classes. In-practice long-term one-on-one medical student-general practitioner tutorials can be recommended for implementation.

Cardiovascular risk stratification in primary care patients with arterial hypertension: Results from the Swiss Hypertension Cohort Study (HccH).

AIMS: Few data are available on cardiovascular risk stratification in primary care patients treated for arterial hypertension. This study aimed at evaluating the cardiovascular risk profile of hypertensive patients included into the Swiss Hypertension Cohort Study according to the 2013 European Society of Hypertension/European Society of Cardiology Guidelines. METHODS: The Swiss Hypertension Cohort Study is a prospective, observational study conducted by the Centre for Primary Health Care of the University of Basel from 2006 to 2013. Patients with a diagnosis of arterial hypertension (office blood pressure measurement ≥140/90 mmHg) were enrolled. Office blood pressure measurement, cardiovascular risk factors, subclinical organ damage, diabetes mellitus, and established cardiovascular and renal disease were recorded at baseline and at an annual interval during routine consultations by general practitioners in Switzerland. RESULTS: In total, 1003 patients were eligible for analysis (55.6% male, mean age: 64.0 ± 13.2 years). At baseline, 78.5% of patients presented with either more than three additional cardiovascular risk factors, diabetes mellitus or subclinical organ damage, while 44.4% of patients had a high or very high overall cardiovascular risk. Cardiovascular risk factors and information about diabetes mellitus, established cardiovascular disease and renal disease were recorded mostly completely, whereas substantial gaps were revealed regarding the assessment of subclinical organ damage. CONCLUSION: The present findings demonstrate that the majority of primary care patients with arterial hypertension bear a substantial number of additional cardiovascular risk factors, subclinical and/or established organ damage. This emphasizes the need for continuous cardiovascular risk stratification and adequate treatment of arterial hypertension in Switzerland.

Physicians' ability to predict patients' adherence to antihypertensive medication in primary care.

Addressing adherence to medication is essential and notoriously difficult. The purpose of this study was to determine physicians' ability to predict patients' adherence to antihypertensive therapy. Primary care physicians were asked to predict the adherence to medication of their hypertensive patients (n=42) by using a visual analogue scale (VAS) at the beginning of the study period. The patients were asked to report their adherence to medication using a VAS. The adherence was then monitored by using a Medical Event Monitoring System (MEMS) for 42+/-14 d. The means+/-SD (range) of MEMS measures for timing adherence, correct dosing, and adherence to medication were 82+/-27% (0 to 100%), 87+/-24% (4 to 100%), and 94+/-18% (4 to 108%), respectively. The physicians' prediction of their patients' adherence was 92+/-15%. The Spearman rank correlations between the physician's prediction and the MEMS measures of timing adherence, correct dosing, and adherence to medication was 0.42 (p=0.006), 0.47 (p=0.002), and -0.02 (p=0.888), respectively. The patients reported their own adherence to medication at 98+/-2% (range 83 to 100%). The Spearman correlations between the reported and actual behaviours were 0.27 (p=0.08) for timing adherence, 0.25 (p=0.12) for correct dosing, and 0.11 (p=0.51) for adherence to medication. The physicians' ability to predict patients' adherence to antihypertensive medication is limited and not accurate for identifying non-adherent patients in clinical practice. Even patients themselves are unable to give accurate reports of their own adherence to medication.

Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea.

BACKGROUND: B-type natriuretic peptide levels are higher in patients with congestive heart failure than in patients with dyspnea from other causes. METHODS: We conducted a prospective, randomized, controlled study of 452 patients who presented to the emergency department with acute dyspnea: 225 patients were randomly assigned to a diagnostic strategy involving the measurement of B-type natriuretic peptide levels with the use of a rapid bedside assay, and 227 were assessed in a standard manner. The time to discharge and the total cost of treatment were the primary end points. RESULTS: Base-line demographic and clinical characteristics were well matched between the two groups. The use of B-type natriuretic peptide levels reduced the need for hospitalization and intensive care; 75 percent of patients in the B-type natriuretic peptide group were hospitalized, as compared with 85 percent of patients in the control group (P=0.008), and 15 percent of those in the B-type natriuretic peptide group required intensive care, as compared with 24 percent of those in the control group (P=0.01). The median time to discharge was 8.0 days in the B-type natriuretic peptide group and 11.0 days in the control group (P=0.001). The mean total cost of treatment was 5,410 dollars (95 percent confidence interval, 4,516 dollars to 6,304 dollars) in the B-type natriuretic peptide group, as compared with 7,264 dollars (95 percent confidence interval, 6,301 dollars to 8,227 dollars) in the control group (P=0.006). The respective 30-day mortality rates were 10 percent and 12 percent (P=0.45). CONCLUSIONS: Used in conjunction with other clinical information, rapid measurement of B-type natriuretic peptide in the emergency department improved the evaluation and treatment of patients with acute dyspnea and thereby reduced the time to discharge and the total cost of treatment.

High prevalence of newly detected hypertension in hospitalized patients: the value of inhospital 24-h blood pressure measurement.

OBJECTIVE: Screening for hypertension in hospitalized patients could reduce the number of individuals with unrecognized hypertension. We hypothesized that 24-h blood pressure monitoring is an adequate tool to detect unrecognized hypertension among inpatients. METHODS: Clinically stable inpatients in the Department of Internal Medicine, Department of Visceral Surgery and Department of Orthopaedics were included in the cross-sectional study. Every patient underwent inhospital 24-h blood pressure measurement. Previously unknown hypertension was defined as 24-h blood pressure of at least 125/80 mmHg in the absence of known hypertension. Forty-two patients had an additional 24-h blood pressure measurement after discharge, to compare mean inhospital and outpatient 24-h blood pressure values. RESULTS: In 314 consecutive inpatients, 24-h blood pressure measurement was performed. Among 139 patients without known hypertension, 53 were hypertensive. The mean routine and 24-h blood pressures in these patients were 135/77 and 137/82 mmHg, respectively. Thirty-seven of these patients had normal routine blood pressure and could be detected only by 24-h blood pressure measurement. Patients with unknown hypertension had a marked cardiovascular risk profile, 26 being at high or very high cardiovascular risk. However, documented cardiovascular disease was present in only seven patients, suggesting that effective treatment could prevent a considerable number of cardiovascular events. The agreement between inhospital and outpatient 24-h blood pressure measurement in 42 patients was good. CONCLUSIONS: By performing inhospital 24-h blood pressure measurement, a considerable number of patients with previously unknown hypertension can be detected.

Usefulness of B-type natriuretic peptide and C-reactive protein in predicting the presence or absence of left ventricular hypertrophy in patients with systemic hypertension.

The diagnosis of left ventricular (LV) hypertrophy, an independent predictor of death and cardiovascular events, is difficult without using echocardiography. This study tested the hypothesis whether C-reactive protein (CRP) and B-type natriuretic peptide (BNP) would be useful to exclude echocardiographic LV hypertrophy. Consecutive hypertensive outpatients were asked to participate. Exclusion criteria were overt heart failure, severe renal insufficiency or any other severe concomitant illness. A venous blood sample was taken to measure plasma CRP and BNP concentrations. Echocardiographic LV hypertrophy was defined as LV mass > or =125 g/m2 for men and > or =110 g/m2 for women. In total, 320 patients were studied, and 37 patients (12%) had echocardiographic LV hypertrophy. Patients with LV hypertrophy were significantly older and had higher CRP and BNP concentrations and higher systolic blood pressure than those without LV hypertrophy. The optimal cut-off points for the diagnosis of LV hypertrophy were 35 pg/ml for BNP (sensitivity 73%, specificity 72%) and 2.5 mg/L for CRP (sensitivity 68%, specificity 59%). Only 1 of 123 patients with values of BNP and CRP less than the optimal cut-off point had echocardiographic LV hypertrophy, resulting in a high negative predictive value of 99% for the 2 blood tests combined to exclude LV hypertrophy. In conclusion, in hypertensive patients, echocardiographic LV hypertrophy can be excluded on the basis of a single blood sample for the determination of BNP and CRP.

Impact of baseline echocardiography on treatment outcome in primary care patients with newly detected arterial hypertension: a randomized trial.

BACKGROUND: The objective of this study was to test whether baseline echocardiography in newly detected hypertension improves left ventricular mass index and blood pressure control. This is a randomized trial with primary care patients. METHODS: After routine clinical work-up 177 consecutive patients with newly detected hypertension were randomized according to result of their echocardiogram (echo group and control group). Treating physicians were encouraged to prescribe angiotensin II receptor antagonist therapy for patients with evidence of hypertensive target organ damage. Mean blood pressure (BP) and echocardiographic left ventricular mass index were measured at baseline and after 6 months of therapy in both groups. RESULTS: More patients with hypertensive target organ damage were identified in the echo group as compared to the control group (58 of 91 [64%] v 42 of 86 [49%] patients (difference 15%, 95% CI 1%-29%). In the echo group, 41 patients (45%) received angiotensin II receptor antagonist therapy as compared to 27 patients (31%) in the control group (difference 14%, 95% CI 0-28%). After 6 months, there were no differences in mean left ventricular mass index, mean diastolic 24-h ambulatory BP monitoring, or mean systolic and diastolic office BP between the two groups. CONCLUSIONS: In patients with newly detected hypertension, baseline echocardiography detects more patients with hypertensive target organ damage, but does not lead to a reduction in left ventricular mass index or improved BP control after 6 months of therapy.

C-reactive protein and B-type natriuretic peptides in never-treated white coat hypertensives.

Arterial hypertension has been associated with increased plasma concentrations of C-reactive protein (CRP) and B-type natriuretic peptide (BNP). This study tested the hypothesis that patients with white coat hypertension have lower plasma CRP and BNP concentrations than those with sustained hypertension. A total of 109 consecutive medical outpatients with never-treated office hypertension underwent ambulatory blood pressure monitoring and blood sampling to determine CRP and BNP concentrations. Patients with treated hypertension, lipid-lowering therapy, renal insufficiency or structural heart disease other than left ventricular hypertrophy were excluded. White coat hypertension was defined as office hypertension associated with mean daytime blood pressure values below 135/85 mmHg. A control group of 48 consecutive, age- and sex-matched patients without office hypertension were recruited during the same period. Twenty-six patients (24%) had white coat hypertension. There were no statistically significant differences in baseline variables between patients with sustained hypertension and white coat hypertensives, except for mean blood pressure values. Mean CRP was 3.2+/-5.1 mg/l in patients with white coat hypertension compared to 3.4+/-4.2 mg/l in those with sustained hypertension (p=0.79). Control patients had significantly lower CRP values than patients with either white coat or sustained hypertension (1.2+/-0.9 mg/l, p=0.002 and p=0.038, respectively). Mean BNP concentrations were 21+/-25 pg/l and 44+/-125 pg/l in white coat and sustained hypertensives, respectively (p=0.36). The plasma concentrations of CRP and BNP did not differ between patients with white coat hypertension and those with sustained hypertension.

Can airway obstruction be estimated by lung auscultation in an emergency room setting?

OBJECTIVE: Lung auscultation is a central part of the physical examination at hospital admission. In this study, the physicians' estimation of airway obstruction by auscultation was determined and compared with the degree of airway obstruction as measured by FEV(1)/FVC values. METHODS: Two hundred and thirty-three patients consecutively admitted to the medical emergency room with chest problems were included. After taking their history, patients were auscultated by an Internal Medicine registrar. The degree of airway obstruction had to be estimated (0=no, 1=mild, 2=moderate and 3=severe obstructed) and then spirometry was performed. Airway obstruction was defined as a ratio of FEV(1)/FVC <70%. The degree of airway obstruction was defined on FEV(1)/FVC as mild (FEV(1)/FVC <70% and >50%), moderate (FEV(1)/FVC <50% >30%) and severe (FEV(1)/FVC <30%). RESULTS: One hundred and thirty-five patients (57.9%) had no sign of airway obstruction (FEV(1)/FVC >70%). Spirometry showed a mild obstruction in 51 patients (21.9%), a moderate obstruction in 27 patients (11.6%) and a severe obstruction in 20 patients (8.6%). There was a weak but significant correlation between FEV(1)/FVC and the auscultation-based estimation of airway obstruction in Internal Medicine Registrars (Spearman's rho=0.328; P<0.001). The sensitivity to detect airway obstruction by lung auscultation was 72.6% and the specificity only 46.3%. Thus, the negative predictive value was 68% and the positive predictive value 51%. In 27 patients (9.7%), airway obstruction was missed by lung auscultation. In these 27 cases, the severity of airway obstruction was mild in 20 patients, moderate in 5 patients and severe in 2 patients. In 82 patients (29.4%) with no sign of airway obstruction (FEV(1)/FVC >70%), airway obstruction was wrongly estimated as mild in 42 patients, as moderate in 34 patients and as severe in 6 patients, respectively. By performing multiple logistic regression, normal lung auscultation was a significant and independent predictor for not having an airway obstruction (OR 2.48 (1.43-4.28); P=0.001). CONCLUSION: Under emergency room conditions, physicians can quite accurately exclude airway obstruction by auscultation. Normal lung auscultation is an independent predictor for not having an airway obstruction. However, airway obstruction is often overestimated by auscultation; thus, spirometry should be performed.

Value of a standard urinary dipstick test for detecting microalbuminuria in patients with newly diagnosed hypertension.

PRINCIPLES: Microalbuminuria may indicate target organ damage in hypertensive patients. However, testing for microalbuminuria is not yet consistently used in general practice. This may be partly due to a lack of data regarding the diagnostic value of practice-based dipstick testing in newly diagnosed hypertension. Objectives were to assess the diagnostic value of a standard dipstick test for urinary protein excretion. METHOD: 186 patients who had been newly diagnosed with hypertension were screened for microalbuminuria. A spot urine sample from each of the subjects was evaluated by using a standard dipstick test (Combur 10, Roche Diagnostics GmbH, Mannheim, Germany) in a primary care setting. The albumin/creatinine ratio was used as the "gold standard". RESULTS: Dipstick testing for protein was positive in 31 urine samples (16.7% of the test samples). The albumin/creatinine ratio was elevated in 33 samples (17.7% of the test samples). The sensitivity of detecting microalbuminuria was 26%, specificity 89%, positive predictive value 45%, and the negative predictive was 88%. Repeated dipstick testing 48 hours after the initial testing in 40 randomly selected patients showed a good reproducibility (98%). CONCLUSIONS: In a primary care setting a positive standard dipstick test of a random spot urine in patients with newly diagnosed hypertension may indicate the presence of microalbuminuria with high specificity. However, because of its low sensitivity, the standard urinary dipstick test can not be recommended as the sole method of screening for renal target organ damage. In addition standard dipstick testing is important to exclude confounding factors that can falsify the measurement of urinary protein excretion.

Diagnostic value of lung auscultation in an emergency room setting.

BACKGROUND: In daily routine, physicians use history, physical examination and technology-based information such as laboratory tests and imaging studies to diagnose the patients' disease. We determined the diagnostic value of lung auscultation in patients admitted to the Medical emergency room with chest symptoms. METHODS: Two-hundred-and forty-three consecutive patients (137 males), mean age 59.2 years were included. Internal Medicine registrars had to make a presumptive diagnosis, 1) after having taken the history and 2) after having auscultated the lungs. Thereafter, routine diagnostic procedures were performed. The estimated diagnosis was compared with the final diagnosis based on the written report to the Family Practitioner. RESULTS: Two-hundred-eighty-seven diagnoses were made. Eighteen percent of patients suffered from left heart failure, 13% from unexplained chest pain, 10.5% from chest wall pain, and 10.5% from pneumonia. Forty-one percent of the diagnoses were already correct when based only on the patient's history. Lung auscultation improved the diagnostic yield only in 1% and worsened it in another 3%. By multiple logistic regression, normal lung auscultation (OR 0.12 [95CI% 0.053-0.29]) was the independent predictor for not having a lung or heart disease. However, elevation of B-type natiuretic peptide (BNP) (OR 1.16 per 100 pg/ml (95CI% 1.004-1.35), wheezing (OR 0.023 [0.002-0.33]) and pCO2 (OR 0.25 (0.10-0.621) were independent predictors for having a heart disease, whereas wheezing (OR 7.41 [3.26-16.83]) and CRP (OR 1.008 per 10 units [1.003-1.014]) were risk factors for having a lung disease. CONCLUSION: In contrast to history taking, abnormal lung auscultation does not appear to contribute considerably to the final diagnosis in patients presenting with chest symptoms in an emergency room setting. However, normal lung auscultation is a valuable predictor for not having a lung or heart disease, whereas wheezing is a predictor for having a lung disease and not having a heart disease.

White coat effect and white coat hypertension in community pharmacy practice.

OBJECTIVE: The aim of the present study was to investigate whether a white coat effect (WCE) can be observed and quantified in community pharmacy practice. METHODS: In five community pharmacies of Basel, Switzerland, clients asking for blood pressure (BP) measurement were recruited to participate in a free of charge study. Blood pressure was measured in four different settings: pharmacy (using mercury sphygmomanometers), outpatient clinic (measurement by a nurse using mercury sphygmomanometers), self-measurement at home (using automated wrist devices) and daytime ambulatory BP (ABP) monitoring (using SpaceLabs 90207 monitors). WCE was defined as the difference between pharmacy or outpatient and daytime ABP. RESULTS: A total of 50 subjects completed all measurements (42% male, mean age 53.7 years+/-14.0). Blood pressure values of the different settings: (means in mmHg+/-SD, systolic; diastolic): pharmacy BP 129+/-19; 82+/-10, outpatient clinic BP 127+/-15; 82+/-10, home BP 119+/-15; 73+/-9, daytime ABP 124+/-10; 79+/-8. Pharmacy BP was significantly higher (P=0.03 systolic; P=0.02 diastolic) compared with daytime ABP and differences among subjects with antihypertensive medication (n=22) were even more significant (P<0.01). Individual differences were found between pharmacy BP and daytime ABP: +4.6+/-14.8; +2.9+/-8.3. Outpatient BP was significantly higher compared with daytime ABP in diastolic (P=0.04) but not in systolic values. Individual differences between outpatient BP and daytime ABP were +2.5+/-13.1; +2.8+/-9.2. 'Clinically important WCE' (>or=20 mmHg systolic or >or=10 mmHg diastolic) was observed in 24% of all subjects in the pharmacy and in 20% in the outpatient clinic. CONCLUSIONS: Our findings show that WCE and white coat hypertension exist in community pharmacy practice and are similar to the effects in an outpatient clinic.

Increased renovascular response to angiotensin II in persons genetically predisposed to arterial hypertension disappears after chronic angiotensin-converting enzyme inhibition.

OBJECTIVE AND METHODS: Functional changes in the kidneys of healthy men with (FH+) (n = 15) and without (FH-) (n = 15) family history of primary arterial hypertension were examined during administration of low-dose exogenous angiotensin II (A2) (1 ng/kg per min) before and after acute (1 mg intravenous enalaprilat) and chronic (7 days oral enalapril, 30 mg/day) angiotensin-converting enzyme (ACE) inhibition. RESULTS: Before chronic ACE inhibition, A2 increased mean arterial blood pressure (FH+, 8.7 +/- 0.8 mmHg; FH-, 8.9 +/- 0.9 mmHg), plasma immunoreactive A2 (FH+, 21 +/- 2 pg/ml; FH-, 18 +/- 3 pg/ml) and plasma aldosterone (FH+, 64 +/- 7 pg/ml; FH-, 56 +/- 6 pg/ml) to a similar degree in both groups. Chronic ACE inhibition had no impact on A2 blood pressure, plasma A2, or plasma aldosterone effects. A2 significantly increased renal vascular resistance in both groups (FH+, 3956 +/- 462 dyne s cm(-5); FH-, 2219 +/- 550 dyne s cm(-5)), but the effect was more pronounced in FH+ (P = 0.02). Glomerular hemodynamics, estimated by a modified Gomez model, revealed increased afferent and efferent responsiveness to A2 in FH+ subjects. These differences disappeared after chronic ACE inhibition when total, afferent and efferent sensitivities to A2 were similar in both groups. CONCLUSIONS: Systemic blood pressure and plasma aldosterone responses to A2 were similar in men with or without a genetic disposition to primary arterial hypertension. However, our data demonstrate that men with a family history of hypertension have increased renovascular sensitivity to A2, and that chronic ACE inhibition normalizes their sensitivity.

Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing.

OBJECTIVE: Patients, emergency department staff and hospital managers are often confronted with a prolonged length of stay of emergency department patients, with resulting overcrowding in the emergency department. We hypothesized that additional medical personnel would reduce the length of stay. METHODS: We prospectively studied consecutive patients managed in a medical emergency department by internal medicine residents during the evening shift. Data were collected on patients managed before (n=200) and after (n=160) the addition of a second physician on the shift. RESULTS: The addition of a physician in the busy evening shift decreased the length of stay from 176+/-137 to 141+/-86 min (mean+/-SD, P=0.012) for outpatients discharged after evaluation and management in the emergency department. The length of stay for emergency department inpatients admitted for hospitalization was not significantly reduced. CONCLUSION: An additional physician significantly reduced the length of stay of medical emergency department outpatients.

Acute cough illness in general practice - predictive value of clinical judgement and accuracy of requesting chest x-rays.

The aim of the study was to evaluate the accuracy of GPs' initial clinical judgement regarding presence or absence of pneumonia and to assess GPs' strategy for requesting chest X-rays in patients presenting with acute cough. GPs were asked to rate their suspicion of pneumonia based on clinical assessment alone and to protocol their decision to perform chest X-rays in 212 consecutive patients. These judgements were compared to the final diagnosis as determined by chest X-ray or uneventful recovery (four weeks). After history taking and physical examination, GPs are highly accurate in judging which patients presenting with acute cough may have pneumonia (PPV 80% [95% CI 0,66-0,89]) or not (NPV 100% [95% CI 0,97-1,0]), and in which patients chest X-rays are required or not (spearman's rho 0,54, p<0,0001).

Le but de l'étude était de mesurer la qualité de jugement clinique du médecin de famille en ce qui concerne la présence ou l'absence d'une pneumonie et d'évaluer la stratégie d'ordonner une radiographie du thorax chez des patients présentant une toux aiguë. Les médecins ont été invités à évaluer leur suspicion de pneumonie basée sur l'évaluation clinique et préciser leur décision d'ordonner une radiographie chez 212 patients consécutifs. Après l'anamnèse et l'examen clinique, les médecins de famille sont très méticuleux à juger quels patients présentant une toux aiguë ont une pneumonie (PPV 80% [IC 95% 0,66­0,89]) ou pas (NPV 100% [IC 95% 0,97­1,0]), et chez quels patients les radiographies du thorax sont nécessaires ou pas (spearman rho 0,54, p<0,0001).

Management and outcome of severely elevated blood pressure in primary care: a prospective observational study.

OBJECTIVE: In primary care the management of patients with acute severely elevated blood pressure (BP) is challenging. The aim of the study was to evaluate the initial management and outcome of patients presenting to their general practitioner (GP) with severe high blood pressure. METHODS: Twenty five general practitioners prospectively identified 164 patients presenting with severely elevated blood pressure (systolic BP >180 mm Hg and/or diastolic BP >110 mm Hg). At baseline, patients were categorised as having a hypertensive emergency, urgency or asymptomatic BP elevation. The therapeutic approach of the GPs was assessed and patient outcome at 12 month follow-up was analysed. RESULTS: Median age of 164 patents was 71 (range 22 to 97) years, 60 (37%) were male and 107 (65%) had pre-existing hypertension. Mean baseline systolic BP was 198 ± 16 (range 145 to 255) mm Hg, mean baseline diastolic BP was 101 ± 15 (range 60 to 130). In total, 99 (60%) of patients had asymptomatic BP elevation, 50 (31%) had hypertensive urgency, and 15 (9%) had a hypertensive emergency. Only around two thirds (61%) of patients were given immediate blood pressure lowering medication (most frequently calcium antagonists). Ten patients (6%) were immediately admitted to hospital. Systolic and diastolic BP declined significantly (p <0.01) between one and six hours after study inclusion (drop of systolic and diastolic BP, 24 ± 9 and 10 ± 1, respectively) and were significantly lower (p <0.01) at three month follow-up compared to the initial measurement (drop of systolic and diastolic BP, 37 ± 6 and 14 ± 4, respectively). On average systolic BP was still above target values after three months (148 ± 21). During 12 months of follow-up patients with hypertensive emergency, hypertensive urgency, and asymptomatic BP elevation experienced a cardiovascular event in 27% vs. 6% vs. 16%, of cases respectively (p = 0.17). CONCLUSION: The majority of 164 patients who presented with acutely and severely elevated blood pressure (BP >180 +/or >110 mm Hg) to their GPs was asymptomatic, had pre-existing hypertension and was managed in GP's office unless a hypertensive emergency was present. At three month follow-up mean systolic BP was still above target values.