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.

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.

Primary care emergency services utilization in German-speaking Switzerland: a population-based cross-sectional study.

BACKGROUND: Traditionally, emergency consultations have been done by a general practitioner (GP) in Switzerland. Over the last years, there seems to have been a shift between general practice to hospital emergency ward utilisation. There are several local initiatives of general practitioners and hospitals to change the organisation of emergency care. To plan a new organisation form of emergency care, delivery should be based on population based data. OBJECTIVE: The aim of the study was to investigate the epidemiology and distribution of emergency consultations of primary care in a hospital and in a practice of general practitioners. In addition, factors of clinical performance in emergency consultations are of great public health interest. METHODS: For this survey, all emergency patient contacts of general practitioners from the catchment area of Bülach, serving 27 088 inhabitants, were assessed by a questionnaire during the fourth quarter of 2006. Sex, age, time, duration of the contact and triage diagnosis were assessed. In addition, all patients seen by the emergency ward at the local hospital were assessed. Contact rates and hospitalisation rates per 100 000 inhabitants were determined. In addition, a multiple linear regression model was performed to determine factors associated with consultation time as a marker for clinical performance. RESULTS: Between October 1th and December 31th 2006, 1001 patient contacts were registered at the same time period in the hospital and general practice. The patient contact rate was 94.8 contacts per 100 000 inhabitants per day, and the hospitalisation rate was 9.1 patient per 100 000 inhabitants. Patients seen at the hospital were older than in general practice (41.2 ± 22.8 vs. 32.6 ± 26.3 years) and consultation and waiting time was longer in the hospital than consultation time with the GP (144.8 ± 106.5 vs. 19.6 ± 17.6 minutes). CONCLUSION: Nearly 1 out of 1000 inhabitants were looking for emergency primary care help, and 10% of the patients were seen urgently by general practitioners and hospital staff and were hospitalised. These numbers are important information for planning emergency primary care facilities. The most prevalent triage diagnoses in practice are infections, traumatological reasons and ENT-problems, whereas in hospital the most frequent triage diagnosis is a traumatological disorder, followed by thoracic pain and infections. In addition, GP's treat patients more rapidly than a hospital does and treat patients in shorter time intervals.

[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.

Cardiovascular risk stratification in unselected primary care patients with newly detected arterial hypertension.

Cardiovascular risk (CVR) stratification in patients with arterial hypertension is essential. Few data are available on CVR factors (CVRFs), hypertensive target organ damage (TOD) and overall CVR in medical outpatients with newly detected arterial hypertension. General medical patients entering the Medical Outpatient Department of the University Hospital Basel, Switzerland, were screened for elevated office blood pressure (OBP of >140/90 mm Hg). Patients with newly detected arterial hypertension (elevated OBP at two consultations) underwent a work-up that included fundoscopy, urinalysis, ambulatory blood pressure (ABP) monitoring, ECG and echocardiography. CVR was calculated according to the 1999/2003 World Health Organization/International Society of Hypertension (WHO/ISH) guidelines. A total of 2615 outpatients were screened. Of 580 patients with elevated first OPB, 207 were treated for hypertension, 98 refused to participate, 8 were early dropouts and 36 had a normal second OBP. Data from 212 patients were analyzed (mean age 53+/-14 years). The first and second OBP readings were 162+/-6/100+/-6 and 153+/-14/96+/-9 mm Hg, respectively. Mean ABP was 134+/-12/83+/-9 mm Hg, and sustained hypertension was found in 76.9% of patients. Among patients with hypertension according to OPB monitoring, 61.3% had 1 or 2 CVRFs, and 33.0% had >or=3 CVRFs. Evidence of TOD, diabetes or associated clinical conditions (ACCs), such as renal or cardiovascular disease, was found in 26.4, 5.6 and 7.1% of patients, respectively. In terms of CVR, 2.4% of patients were at low risk, 25.9% at medium risk and 71.7% at high risk. No differences existed between white coat and sustained hypertensives regarding CVRFs, TOD or ACCs. Comprehensive analysis in patients with newly detected arterial hypertension revealed a surprisingly high prevalence of CVRFs, TOD and ACCs, indicating high CVR in the majority of these patients.

Does nonmedical hospital admission staff accurately triage emergency department patients?

OBJECTIVES: Utilization of hospital emergency departments (EDs) is continuously increasing. Though nurses and physicians are ultimately responsible for the definite triage decisions, initial ED patient triage is frequently performed by hospital admission staff. This study analyzes the quality of assessment of the severity of emergencies and the choice of treatment unit made by hospital admission staff. METHODS: One thousand fifty-nine consecutive surgical and medical patients entering the ED of the University Hospital Basel during an 11-day period were independently assessed by hospital admission staff without formal medical training, ED nursing staff, and ED physicians. Emergencies were classified by severity (intervention within minutes/hours/days) or by severity and resource utilization (immediate intervention with/without life-threatening condition, delayed intervention with high/low/no demand of resources). Emergency assessment and triage decision (surgical/medical, outpatient/inpatient treatment) were documented independently by all three ED staff groups. RESULTS: In 64% of the cases, initial assessment by admission staff corresponded with the final assessment by the ED physician. Concordance was, however, poor (kappa=0.23). Underestimation of the severity occurred in 7.5% of cases without severe or lethal consequences. Ninety-four percent of patients were treated in the unit to which they were originally triaged by the admission staff. CONCLUSION: Triage quality regarding the choice of treatment unit was found to be excellent, whereas the quality of the assessment of the severity of the emergency by nonmedical ED admission staff was acceptable. ED patients have to be assessed by medical staff early after admission to ensure adequate and timely interventions.

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.

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.

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.

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.

Routine blood pressure measurements do not predict adverse events in hospitalized patients.

PURPOSE: Countless blood pressure measurements are performed every day for almost every hospitalized patient. We analyzed the value of routine blood pressure measurements on patient care in an unselected group of hospitalized patients. METHODS: The study included 639 patients who were admitted to the hospital with a broad range of medical conditions. Two independent investigators reviewed the medical charts of the patients. Routine blood pressure values were abstracted from the patient charts and evaluated with respect to the occurrence of adverse clinical events in the study group. Changes in blood pressure between the last measurement just before adverse clinical events and the mean blood pressure values 72 hours before the adverse events were calculated and compared with mean normal day-to-day variations in blood pressure. RESULTS: In every patient, a mean of 1.6 +/- 0.6 routine blood pressure measurements per day were performed. Of the 639 patients in the study, 122 (19%) had clinical complications. The most commonly occurring complications were gastrointestinal bleeding (n = 15), falls (n = 13), other bleeding (n = 12) and pneumonia (n = 8). In patients who experienced clinical complications, pre-event systolic and diastolic blood pressure changes of at least 10 mm Hg occurred in 41% and 24% of the group, respectively, but this was not different from the normal day-to-day variations observed in patients who had no clinical complications. The results also were similar for patients who died or who had a severe adverse event that required admission to an intensive care unit. CONCLUSION: Routine blood pressure measurements in a general hospital patient population do not predict clinical adverse events.

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.