Implications for health care
Policy and practice on high blood pressure might best be considered in conjunction with a review of all cardiovascular disease prevention advice to health authorities and general practitioners, as focusing on individual risk factors in isolation is unlikely to produce coherent proposals.
Detection
Standardisation of methods of blood pressure measurement is essential. Use of Korotkov V (disappearance of sounds) should be widely promoted in primary health care. Facilities for the routine maintenance of sphygmomanometers should be available in all health districts.
The British Hypertension Society guidelines on thresholds for starting treatment require review following publication of the New Zealand guidelines and the wider recognition of the importance of absolute disease risk in formulating preventive health care policy.
Evidence to support detection and treatment of high blood pressure in older people is very strong. This evidence should be widely disseminated, and professional barriers to treating older people recognised as unacceptable and not consistent with best practice.
Ambulatory monitoring methods increase the cost and complexity of blood pressure detection without providing any tangible benefits, and should not be promoted in primary health care.
Blood pressure is only one of a number of powerful risk factors which predict the chances of suffering a stroke or ischaemic heart disease. Greater emphasis should be placed on examining risk factor scores (or profiles).
Adherence
Improving professional adherence to best practice in the management of high blood pressure through a range of mechanisms is required. More direct methods such as financial incentives and penalties require investigation as they may prove more effective than educational or clinical guideline approaches.
Evidence is lacking to support any specific approaches to improving patient adherence with antihypertensive drugs or lifestyle changes. Standardisation of methods of measuring and reporting on patient adherence is required. Further research on patient adherence should be linked with the associated question of improving blood pressure control.
Control
The British Hypertension Society's recommended target blood pressures which should be achieved on drug treatment need to be reviewed. Criteria should take into account co-morbidity, age and level of hypertension.
A stepped-care approach to management is supported by American randomised controlled trial evidence, but this is not directly applicable to British practice.
Evidence to support nurse-led compared with doctor-led care as a better option in achieving blood pressure control is very sparse.