Doctors, Nurses and Patients

ABSTRACTS

Doctors, Nurses and Patients: 2nd International Satellite Meeting of the 17th Scientiﬁc Meeting of the International Society of Hypertension Glasgow, 5 June 1998 (Convenor; Dr J Curzio)

Journal of Human Hypertension, 1998, Volume 12

 1998 Stockton Press ISSN 0950–9240

Recent developments in hypertension DG Beevers

University Department of Medicine, City Hospital, Birmingham, UK

There have been many important developments in however, remain some anxiety on the use of short- hypertension since the last multidisciplinary confer- acting calcium channel blockers in patients with ence in 1996. We now know more about the value existing coronary heart disease. of antihypertensive treatment and have increasing The angiotensin receptor antagonists have proved evidence in favour of both the calcium channel immensely successful and in March 1997 the first blockers and the ACE inhibitors. long term trial of losartan was published (the ELITE In September 1997 the final results of the SYST- study). This showed that losartan was as good as or EUR trial were published. These showed that blood slightly better than captopril in the management of pressure lowering with the calcium channel blocker, elderly patients with heart failure. It is significant nitrendipine, was associated with a significant that a great many other drugs in this class are being reduction of strokes and an impressive but non-sig- developed by other drug companies. There is nificant reduction in coronary heart disease. There increasing evidence that blocking the renin-angio- was no excess mortality in the treated patients from tensin system has added benefits over other drug cancer or haemorrhagic events. therapies in delaying the progression of renal failure The SYST-EUR trial is almost the last of the pla- in both diabetics and non-diabetics with nephro- cebo controlled trials and the next generation of pathy and also in reducing left ventricular hypertro- trials will be comparing different treatment regimes. phy. There is also one interesting study which sug- Since 1995 there have been considerable anxieties gests that the ACE inhibitors delay the development on the safety of calcium channel blockers in the light of retinopathy in diabetic patients. of a series of papers from the United States. Most of A great many trials are now being established to these studies were relatively weak case-controlled investigate the benefits of the ‘new’ versus the ‘old’ studies and many commentators thought that the drugs in hypertension. In particular the Anglo-Scan- results were improbable. The results of the SYST- dinavian Cardiac Outcome Trial (ASCOT) is ending EUR trial largely reassured us that calcium channel its pilot phase. There will however be relatively blockers are not associated with any excessive mor- little new information on the treatment of hyperten- tality from non-cardiovascular disease. There must, sion until well into the next century.

Mercury poisoning RE Ferner

West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham, UK

A ruling by the European Union heralds the demise such as dimethylmercury, which are very fat sol- of those useful clinical instruments, the mercury uble; and metallic mercury, which is only absorbed thermometer and the mercury sphygmomanometer. into the body as the vapour. The new laws have been passed because of worries Inorganic mercury salts are water soluble, irritate about mercury poisoning. Yet you can drink met- the gut, and can cause severe kidney damage. allic mercury and come to no harm. What does it Organic mercury compounds, which are fat soluble, all mean? cross from the blood into the brain, and cause intel- There are three forms of mercury from the toxico- lectual impairment, damage to the optic nerves, and logical point of view: inorganic mercury salts such ataxia. There can also be peripheral nerve damage. as mercuric chloride; organic mercury compounds, Mercury metal poses two dangers. It can be vapor- Doctors, nurses and patients — Abstracts

768 ised: the vapour pressure (the amount of vapour is turned into organic mercury, for example by bac- ‘given off’) at room temperature is about 100 times teria in the sludge at the bottom of lakes. The bac- the safe amount. As mercury metal is heated, it teria concentrate the organic mercury, and are eaten evaporates more readily, and the vapour pressure by marine creatures that are themselves eaten by fish doubles for every 10°C rise in temperature. This higher up the chain, until the fish are eaten by makes heating mercury, especially in a confined humans. Environmental contamination by metallic space, very dangerous. Even at room temperature, mercury from chemical plants, its subsequent organ- poisoning can occur if mercury metal is spilled into ification, and the concentration of poisonous organic crevices or cracks in the floorboards of a poorly ven- mercury in fish, lead to the Japanese tragedy at Mini- tilated room. Dentists are occasionally poisoned in mata Bay in the late 1950s when over 800 people this way. Mercury vapour, being fat soluble, easily were poisoned. A number were children in utero. crosses into the brain, and causes tremor, It is the need to reduce mercury contamination of depression, and a behavioural disturbance called the environment which should encourage us to cut erethism. In addition, the vapour causes mouth the usage of metallic mercury. However, much more ulcers and salivation. metallic mercury is spilled as waste by the chemical A second danger from metallic mercury is that it industry than is dropped on the floor in the clinic.

Validated patient self-measurement of blood pressure veriﬁes hypertension and optimises its management RS Armstrong, JP Taylor, M Stowasser and RD Gordon

Hypertension Unit, Greenslopes Private Hospital, Brisbane, Australia

Patient self-measurement of blood pressure period of time. Self-measurement verifies hyperten- optimises management through providing compre- sion by excluding white coat hypertension and hensive, accurate information and by promoting quantifying the white coat effect. Patients can take patient compliance and involvement in the manage- frequent measurements at times not normally read- ment of their condition. Self-measurement also ily obtainable and thus contribute more comprehen- enables the progress of geographically remote sive information with regard to 24-h control and patients to be followed. Assessment, education and optimal distribution of medication. continuing follow-up however are essential to pro- Management is optimised by patient self-measure- vide valid, standardised measurements and reason- ment because the measurement is more consistent ably ensure user and device accuracy. and accurate than what is provided by many health Patients view an instructional video either on the professionals. Because the patient feels more in con- hospital video system or at the Hypertension Nur- trol, compliance is improved. By excluding the se’s office. Viewing is followed by demonstration white coat effect, lower doses can be administered and practice with the nurse instructor using a dual with confidence with fewer side effects and a better or three way stethoscope. Accuracy is confirmed quality of life. The chronotherapuetic approach to prior to leaving and patients take home written management using self-measured blood pressures instructions and a simplified checklist. A 2-week can facilitate optimal use of medication and result later follow-up visit to ensure proper technique and in reduced cost for individual and health budgets. promote patient confidence is arranged and further Patient self-measurement, because of its repeat- 6-monthly checks of device and patient technique ability without aid of health professional staff for are encouraged. Aneroid gauges are checked by comparing ran- each period of measurement, is more cost effective domly selected points on the gauge against the mer- than office blood pressure measurement or 24 h cury column. Electronic devices are connected with ambulatory monitoring. a Y piece to the mercury and a series of six simul- In these days of accountability and cost valued taneous same arm measurements are taken on the ahead of outcome by government agencies, the person who uses the device for self-measurement. reduced cost to the patient and the community at Validity is also promoted by obtaining multiple the same time as patient care is improved, must be readings under standardised conditions over a short almost unique.

Knowledge-base of blood pressure measurement—do guidelines help? D Wingﬁeld, M Pierce and M Feher

Dept of Primary Healthcare and General Practice, Imperial College School of Medicine, London University, London, UK

The measurement of blood pressure (BP) is a crucial questionnaire survey was conducted of 831 com- part of clinical assessment and hypertension man- munity-based practitioners (550 general prac- agement and is commonly performed inaccurately titioners and 281 practice nurses) in north west Lon- despite the publication of national and international don. consensus guidelines for its measurement. A postal The response rate was 61%. Overall the nurses (n Doctors, nurses and patients — Abstracts

769 = 196) had a greater knowledge base than the GPs the nearest 2 mm mercury (GP 53%, nurse 67%) and (n = 320) and both community groups had a greater correctly reporting the rate of fall of the mercury col- knowledge for key questions than hospital prac- umn (GP 27%, nurse 55%). Most said they had titioners from two previous surveys. Nurse prac- access to a large cuff (GP 98%, nurse 93%), but sig- titioners (n = 17) and GPs involved in teaching in niﬁcant numbers had not used it in the past 4 weeks postgraduate education programmes (n = 69) had (GP 33%, nurse 24%) and few knew the correct better knowledge than their respective peer groups. coverage of the upper arm circumference (GP 27%, The nurse practitioners scored best overall. Knowl- nurse 32%). Only 12% of the GPs and 19% of the edge of a guideline source was associated with nurses were able to name the source of the pub- improved self-reported BP technique. lished guidelines on BP measurement. Previous education in BP measurement was These results show that there are important differ- recorded in 87% of the GPs and 95% of the nurses ences in the knowledge-base of BP measurement which is higher than surveys of hospital prac- between different community practitioners. The titioners. Precision factors recorded for the GPs and proportion who can name a source of BP measure- nurses respectively included routine use of diastolic ment guidelines is disappointingly low but these phase V (GP 60%, nurse 66%), reading the BP to practitioners do have a better knowledge-base.

Joint National Committee on Prevention, Detection, Evaulation and Treatment of High Blood Pressure (JNC VI) MN Hill

Johns Hopkins University School of Nursing, Baltimore, MD, USA

The National High Blood Pressure Education Pro- pressure, the role of managed care in the treatment gram (NHBPEP), co-ordinated by the National Heart, of high blood pressure, the introduction of new com- Lung, and Blood Institute (NHLBI)1,2 of the National bination antihypertensive medications and angio- Institutes of Health, is succeeding in its mission of tensin II receptor blockers, and strategies for increasing awareness, prevention, treatment, and improving adherence to treatment. control of hypertension. The most recent national The prevention and treatment of hypertension data, however, indicate disturbing decreases in rates represent major public health challenges for the of hypertension awareness, prevention, treatment United States as we enter the new millennium. The and control. new challenges identified are: The purpose of the Sixth Report of the Joint • to prevent the rise of blood pressure with age; National Committee on Prevention, Detection, • decrease the existing prevalence of hypertension; Evaluation, and Treatment of High Blood Pressure • increase hypertension awareness and detection; (JNC VI) is to provide guidance for primary care clin- • improve control of hypertension, reduce cardio- icians. Using evidence-based medicine and consen- vascular risks; sus, the report updates contemporary approaches to • increase recognition of the importance of con- hypertension control for use by primary care phys- trolled isolated systolic hypertension; icians. The JNC VI report places more emphasis than • improve recognition of the importance of high– earlier reports on absolute risk and benefit and uses normal blood pressure; risk stratification as part of the treatment strategy. • reduce ethnic, socio-economic, and regional vari- This report strongly encourages lifestyle modifi- ations in hypertension; cation to prevent blood pressure, as definitive ther- • improve opportunities for treatment; and apy for some, and as adjunctive therapy for all per- • enhance community programmes. sons with hypertension. In addition, the major emphasis is placed on selection of appropriate phar- macologic therapy. References Among other issues briefly covered are the cost 1 NHLBI website at www.nhlbi.nih.gov/nhlbi/nhlbi.htn of health care, the use of self-measurement of blood 2 NHLBI Information Center at 1–800–575–9355

Joint National Guidelines on Coronary Heart Disease Prevention in the UK: implications for hypertension NR Poulter

Cardiovascular Studies Unit, Department of Clinical Pharmacology & Therapeutics, Imperial College School of Medicine, London, UK

In 1994 the European Societies of Cardiology, encourage national societies to follow suit and pro- Atherosclerosis and Hypertension published rec- duce locally relevant guidelines. Hence the British ommendations on the prevention of coronary heart Cardiac Society, British Hyperlipidaemia Associ- disease in clinical practice. This collaboration ation and the British Hypertension Society decided between professional societies was intended to in 1996 to produce Joint British Recommendations Doctors, nurses and patients — Abstracts

770 on Prevention of Coronary Heart Disease in Clinical Practice. This document will be finalised in the summer of 1998 and is expected to appear as a sup- plement to Heart later this year. A much shorter, more easily digested version will be produced later in 1998 and distributed by the British Heart Foun- dation. The objective of the document was simply to encourage a unified approach towards the reduction of first time or further cardiac events and reduce overall morality. The document prioritises preven- tive efforts to: (1) patients with established CHD; (2) patients with other major atherosclerotic disease; (3) patients with various risk factors (eg, hypertension) which put them at high risk of multifactorial approach to the management of each developing CHD or other atherosclerotic disease. risk factor including hypertension. In the context of primary prevention it rec- It was felt necessary to produce such a document ommends that a level of absolute risk is calculated because of increasing trial evidence in recent years for high risk patients on the basis of a risk score, which has strengthened our understanding of the based largely on the Framingham Study. The score effectiveness of various therapeutic interventions for includes: age; sex; systolic blood pressure (SBP); preventing CHD, and because hitherto there has diastolic blood pressure (DBP); total cholesterol; been a strong tendency for professional isolation in HDL-cholesterol; diabetes (yes/no); smoking clinical practice whereby a patient with angina may (yes/no); and ECG-LVH. A computerised disc to cal- well be under the care of specialists in cardiology, culate coronary heart disease (CHD) risk in the next hypertension, lipids and diabetes all in the same 10 years is provided with the recommendations, but hospital. Each of the specialists tends to deal with for those not wishing to use a computer, a chart their own risk factor in isolation of the others and similar to that produced in the New Zealand Guide- by doing so overlooks the other major determinants lines will be produced. of a patient’s progress. The treatment algorithm for hypertension is sum- The document therefore recommends a broader marised in the figure.

The peaks and troughs of trough:peak ratios HL Elliott

Department of Medicine and Therapeutics, Western Inﬁrmary, Glasgow, UK

There are very few drugs, if any, which produce an to the time of the next dose being taken and it will absolutely consistent antihypertensive response be 24 h post-dose with a once daily regimen and such that the magnitude of the blood pressure (BP) 12 h post-dose with a twice daily regimen. reduction is wholly consistent throughout the full The concept of the trough:peak ratio was derived 24 hours. Instead, at some time after dosing there from FDA guidelines which were concerned not will be a period of maximum pharmacological only about the suitability of antihypertensive drugs activity and thereby a period of maximal BP for their recommended dosage intervals but also reduction which will typically occur at 2 or 4 or 6 h about patient safety if excessive BP reductions were post-dose. To identify and quantify this ‘peak’ effect produced. Thus, the administration of high doses it is therefore necessary to take account of the level sufﬁcient to cause hypotensive effects at peak was of BP which would be present if no antihypertensive not permissible if the sole aim was the prolongation drug had been administered, ie, following placebo of the antihypertensive effect to the end of the dos- administration. Thus, it is necessary to have an age interval. assessment of the BP under placebo conditions There are additional practical considerations in across the dosing interval, which may be 12 or 24 h terms of a high trough:peak ratio. The FDA set a in routine practice, to directly compare the meas- minimum requirement to 50–66% but the closer the ured BP response on active treatment and to then value approaches 100% then the greater is the con- subtract this value from the BP values obtained sistency of the antihypertensive response throughout its dose interval: ie, across 24 h with a once with placebo. daily drug. The timing of the trough BP measurement, in con- trast to the more variable timing of the peak BP response, is strictly deﬁned as the end of the dosage Conclusions The trough:peak ratio (if appropri- interval. This obviously will be immediately prior ately characterised) provides information about the Doctors, nurses and patients — Abstracts

771 suitability of an antihypertensive drug for its rec- quently: values approximating to 100% indicate a ommended dosage interval (ideally 24 h). Values satisfactory and consistent (ie, non-ﬂuctuating) anti- which do not consistently reach 50–66% indicate hypertensive effect throughout the whole 24 hours. that the drug should be administered more fre-

ANBP2: from protocol to practice A Bruce on behalf of ANBP2 Management Committee, High Blood Pressure Research Council, Australia

The Second National Australian Blood Pressure population across Australian cities and rural Study (ANBP2) is a cardiovascular outcome trial of centres? the treatment of hypertension in the elderly. Six ANBP2’s research nurses are involved in all stages thousand hypertensive patients aged between 65–84 of the project from GP recruitment to subject ran- years will be randomised to receive treatment based domisations. Once the GP has registered it falls to on an angiotensin-converting enzyme (ACE) inhibi- the research nurse to foster a collaborative environ- tor or a diuretic-based regimen and monitored for ment within each practice enabling successful sub- total cardiovascular events over a 5-year period. ject recruitment. The study is being conducted entirely in general There are 102 nurses registered with ANBP2 and practice in and around five Australian capital cities. by 30 June 1998 approximately 55000 subjects will At the onset there were several areas which required have been screened yielding 6000 randomised consideration if this study was to be successful. patients. This has been possible through the partici- The first challenge in implementing ANBP2 was pation of 1938 general practitioners working within to identify general practitioners willing to take part 962 practices throughout Australian city and rural and therefore willing to allow access to patient files centres. and also willing to have hypertensive patients with- Already the subject monitoring process is drawn from antihypertensive therapy for a period of underway and it is expected that December 2001 time prior to recommencement of therapy according will see the completion of this second phase. to the study protocol. The role of the research nurse has been pivotal Second, would patients be willing to participate to the successful establishment and conduct of this in such a study and finally could we realistically nationwide project and I would like to further dis- hope to implement this protocol in the general practice setting while maintaining high quality of data cuss specific protocol issues in consideration of the collection, given the enormous variability of prac- general practice setting and its general practice tice environments and cultures and the spread of clientele.

The British Regional Heart Study: a prospective study of cardiovascular disease in 24 towns M Walker

Department of Primary Care & Population Sciences, Royal Free Hospital School of Medicine, London, UK

The British Regional Heart Study aims to explain the found in the mean blood pressure measurements regional variation in ischaemic heart disease and made on Mondays compared with Fridays. stroke rates which have a 2 to 3-fold range across The geographic variation in town mean blood Great Britain, highest in the north-west and lowest pressure is consistent with the geographic variation in the south-east. in cardiovascular mortality rates. An increase in In 1978–1980, 7735 men aged 40–59 years were mean blood pressure of 1 mm Hg produces an recruited from GP age–sex registers in 24 towns and approximate 2% increase in the prevalence of examined by a team of three nurses to obtain a full hypertensives (systolic blood pressure [SBP] Ͼ160 cardiovascular risk factor proﬁle. All men have been mm Hg). Factors which contribute to raising blood followed up through their GP for CVD morbidity and pressure, such as age, alcohol consumption, body through the National Health Service Central Regis- mass index (BMI), and social class only partially ters for mortality. explain these town variations. Blood pressure was measured using the London Heart attacks occur twice as often in men with a School of Hygiene sphygmomanometer and each SBP Ͼ148 mm Hg compared with those whose SBP nurse carried out one-third of each of the procedures is less than 148 mm Hg. Whereas strokes occur four in each town. Despite the use of training tapes, inter- times more often in men with SBPs above 160 observer variation occurred and this has been mm Hg. adjusted for in the analyses. A marked increase was Contrary to widespread belief smoking status does Doctors, nurses and patients — Abstracts

772 not raise blood pressure, but increases CVD risk by From a later study of treatment practice, in a a factor of two. The independent effects of smoking national sample of GPs, it was found that they are and hypertension interact to increase stroke risk by failing to treat the older age groups adequately in 12-fold, compared with non-smoking normotensives. line with British Hypertension Society guidelines. Physical activity appears to have a modest ben- The study continues to follow the 6000 survivors eﬁcial effect on blood pressure, apart from a small and is currently re-examining them 20 years after increase in levels in the very vigorously active men. their baseline measurements. Response rates at re- Moderate daily physical activity reduces the risk of screening so far range between 75–86% in the heart attacks and strokes by 50%, but hypertensive towns. men who are vigorously active incur a slightly higher risk of heart attacks.

Western Australian longitudinal study of heart health DL Dunbar, V Burke, LJ Beilin and R Milligan

University of Western Australia, Department of Medicine, Royal Perth Hospital and the Western Australian Heart Research Institute, Perth, Australia

Objectives To study the influence of diet, demo- tivity were particularly associated with lower socio- graphic factors, body mass and physical fitness on economic status in girls. Longitudinal analysis blood pressure (BP) levels in children from the gen- showed that BP was greater in boys with hyperten- eral community and to relate changes in BP to data sive fathers and that BP increased more rapidly in recorded over an extended period. this group. Children of overweight parents had lower levels of fitness throughout the period of the Design and methods This is a longitudinal study surveys, ate less fibre and more saturated fat. In commenced in 1985 with a cohort of 1565 children longitudinal models, body mass index (BMI) from aged 9 years resurveyed every 3 years. Measure- the age of 9 to 18 years was consistently greater in ments included BP, height, weight, total cholesterol, offspring of overweight parents and BMI in 18 years anthropometry, fitness testing and questionnaires olds was significantly predicted additively by relating to diet, lifestyle, attitudes and health beliefs, father’s and mother’s BMI. The study has also high- family history and physical activity. DNA samples lighted associations between adverse health behav- were obtained in the most recent survey. Parents iours with smoking as a key indicator of clustering were invited to attend in 1996–1998 for BP measure- of risk behaviours. ments to validate previous family history question- Conclusions These observations have important naires. implications for health promotion in young people. There is potential for identifying, at an early age, Results Of the 1565 eligible participants 1066 were individual children and groups of children who are seen in 1985, 1311 in 1988, 694 in 1991 and 669 most at risk of becoming hypertensive adults. Par- in 1994. Cardiovascular risk factors were related to ental hypertension and overweight should alert health behaviours of individuals and differed within health professionals to the potential risk for chil- families. Systolic blood pressure (SBP) was posi- dren, indicating the need to improve health behav- tively related to weight, smoking and alcohol intake iours in families although genetic factors may con- and negatively to energy intake, fitness and tribute. Our data suggest that recognition of children birthweight. Total cholesterol was positively asso- at risk can lead to reduction in levels of risk factors ciated with waist–hip ratio and negatively with fit- during childhood and adolescence and through to ness. Adverse dietary patterns and physical inac- adulthood.

The detection and treatment of hypertension in paediatric practice GYH Lip1, M Beevers1, M J Dillon2 and DG Beevers1

1University Department of Medicine, City Hospital, Birmingham; and 2Institute of Child Health, Great Ormond Street Hospital, London, UK

The management of hypertension in children has patient. The majority measured blood pressures been rather neglected, with only limited information whilst the child is sitting (57.6%) or supine (17.6%), on the current clinical practice. To investigate this usually with a mercury sphygmomanometer further, we conducted a postal survey of 1500 paedi- (81.4%); only 13.2% used ambulatory blood press- atricians in the United Kingdom, of whom 706 ure devices. When measuring diastolic blood press- (47.1%) provided analysable replies. Only 50.7% of ures, 49.3% used Korotkof phase IV, whilst 30.2% respondents routinely measured out-patient blood used phase V: 10.8% would consider a child as pressures themselves: 16.7% measured blood press- hypertensive if the blood pressure was Ͼ90th per- ures from birth, 11.6% from age 1, 21.7% from age centile, 34.8% used the 95th percentile and 37.8% 3, 11.3% from age 7 and 3.3% from age 13; 29.6% used the 97.5th percentile. Most would perform urea did not routinely measure blood pressure in an out- and electrolytes (91.6%), urinalysis (92.5%) and full Doctors, nurses and patients — Abstracts

773 blood count (81.2%) as basic or initial tests in a blockers (33.8%), diuretics (26.6%) or calcium hypertensive child, although Ͼ65% would check antagonists (7.6%). urate levels, an ECG or perform a renal ultrasound. This survey provides an insight into blood press- A total of 59.2% routinely referred to blood pressure ure management amongst British paediatricians, and charts/normograms in the interpretation of blood suggests a wide variation in treatment strategies and pressure results, usually that from the 2nd Task prescribing habits. Further guidelines are needed to Force on Blood Pressure Control in Children achieve a consensus strategy for such patients. (30.6%). The ﬁrst-line drugs of choice were beta-

Blood pressure levels in England and Scotland: a comparison using data from the Scottish Health Survey and the Health Survey for England A McMunn, L Bost, P Primatesta, Wei Dong, H Colhoun and M Marmot

University College London Medical School, Department of Epidemiology and Public Health, London, UK

Background Because mortality tends to be higher Scotland had been given treatment, compared with in Scotland than in England for cancer, coronary 63% in England. heart disease and stroke, the Scottish Office com- missioned the Scottish Health Survey (SHS) to be Controlling hypertension In terms of how success- modelled on the Health Survey for England (HSE) ful each country had been in actually controlling for comparison. The SHS was conducted in 1995 by hypertension with treatment, in Scotland, 75% of the same unit that conducts the HSE. The following men and 86% of women who were being treated for analysis is based on 1995 SHS and 1994 HSE data. hypertension had SBP of less than 160 mm Hg and Nearly all questionnaires were identical for the DBP of less than 95 mm Hg compared with 71% of two surveys. men and 74% of women in England. Other risk factors Both men and women in Scot- Blood pressure levels While the prevalence of any land were more likely to be current cigarette smok- cardiovascular disorder was higher in Scotland than ers than those in England, with most of the differ- in England for both men and women aged 45–64 ence concentrated in those aged 45–64 years. Also, years, blood pressure levels appear to be lower. Both both male and female smokers in Scotland were mean systolic blood pressure (SBP) and mean dias- more likely than those in England to report smoking tolic blood pressure (DBP) were lower in Scotland 20 or more cigarettes a day. than in England across all age groups for both men A larger proportion of respondents in Scotland and women. One reason for this may be differences reported doing no moderate or vigorous activity in in treatment and control rates for hypertension the past week, and respondents in Scotland gener- between the two countries. ally reported eating a less healthy diet than those in England. Geometric mean fibrinogen was much higher in Treatment for hypertension High blood pressure Scotland than in England for all age groups and was in both the SHS and the HSE was defined as hyper- у у statistically significant for both men and women tensives (SBP 160 or DBP 95 mm Hg), either after adjusting for age. Higher levels of fibrinogen in treated or untreated, and normotensives (SBP Ͻ160 Ͻ Scotland were not altered when cigarette smoking and DBP 95) who had been treated. Looking at the status was adjusted for. proportion of those with survey-defined high blood pressure who had been treated, 64% of men with Conclusion Unless the high prevalence of cardio- high blood pressure in Scotland had been given vascular disease in Scotland begins to drop due to treatment, compared with 52% in England. Seventy- effective control of hypertension, the effect of four percent of women with high blood pressure in fibrinogen warrants further examination.

The Health Survey for England as a monitoring tool P Primatesta, Wei Dong and L Bost

University College London Medical School, London, UK

This presentation will illustrate the use of the The HSE is an annual survey that covers the popu- Health Survey for England (HSE) as a monitoring lation living in private households; data collection tool which, together with investigating the determi- includes a visit by an interviewer, and a subsequent nants of health in the population, is one of the aims nurse visit, where details of prescribed medications of the HSE. are collected, BP and a number of other measure- The distribution of adults’ blood pressure (BP), ments taken. the prevalence of high BP using data from the latest BP is measured using an automated device, the available survey (1996), and trends over time since Dinamap 8100 monitor. Three BP readings are taken 1991 will be examined. under standardised conditions on the right arm with Doctors, nurses and patients — Abstracts

774 the informant in a seated position after 5 min rest. ward trend in mean SBP. The 1995 and 1996 surveys The data analysed are based on the mean of the have not recorded any further downward move- second and third measurements made on respon- ment. Nevertheless, age-adjusted mean SBP level in dents with three recordings completed. 1996 was significantly below that observed in 1991 Adult informants are classified in one of four in both sexes. There is no evidence of a trend in the groups on the basis of their systolic and diastolic prevalence of high BP. BP (SBP/DBP) and current use of antihypertensive As in previous years of the Health Survey since medication. Normotensive treated, hypertensive 1993, the treatment rate was defined as the pro- treated and hypertensive untreated are referred to portion of those with survey defined high BP who as ‘hypertensive’. were taking antihypertensive medication. The con- SBP and DBP generally increased with age, and trol rate was defined as the proportion of those tak- were higher in men than in women. The prevalence ing antihypertensive medication who had SBP less of high BP also increased with age, and was higher than 160 mm Hg and DBP less than 95 mmHg. in men than in women up to age 45–54, while in Among all adults with high BP, the treatment rate the older age groups, the opposite was true. increased. A similar increase in the treatment rate One of the primary aims of the survey is to exam- was seen for men and women separately. For the ine any changes in mean SBP and high BP over time. control rate there was no clear trend. Previous surveys from 1991 to 1994 noted a down-

A critical analysis of patient information leaﬂets on hypertension J Adams, D Fitzmaurice, A Riaz and The Birmingham Clinical Effectiveness Group

Department of General Practice, University of Birmingham, Birmingham, UK

Aim To assess the quality of currently available 9 leaﬂets were dated, all were produced since 1992. leaﬂets against recognised criteria.1

Conclusion Leaflets are available that contain good Methods A comprehensive search for leaflets was information, and are designed as recommended by performed and leaflets obtained from a variety of educational experts. However this is not always the sources including voluntary organisations, pharma- case and health care professionals should be aware ceutical companies and the Internet. Leaflets were of what constitutes good and bad information for randomly allocated to three pairs of doctors from the patients and be familiar with the resources that they Birmingham Clinical Effectiveness Group and are using to complement their verbal advice. scored independently. A random selection of the Most of the leaflets should be readable to most of leaflets was given to a fourth pair with previous the adult population, and give basic definitions. experience. A scoring system was devised using However, two-thirds failed to put hypertension in recognised criteria and marks allocated for content, the context of overall cardiovascular risk, an writing style, design and readability (FOG score). approach that is increasingly encouraged. The quality of the Internet sites is more variable and tends to be less comprehensive. There is a need Results 61 leaflets were obtained (42 Internet, 19 for more UK-based sites. non-Internet). Range of median ‘overall scores’; There was variation in the scores allocated to indi- 30.0 (3.5)–70.0 (5.0)/84, Non-Internet vidual leaflets, however, this was least for leaflets 28.0 (13.2)–67.0 (4.0)/84, Internet that were clearly good or clearly inadequate. The variation may reflect the inherent subjectivity in Sub analysis of 19 non-Internet leaflets: interpreting information and its presentation, and Range of median ‘content’ scores; 18.0 (6.0)–42.0 the resultant difficulty in devising materials that (3.0)/48 have to appeal to a wide range of people. Ideally, 17 mentioned that hypertension is usually asympto- the opinions of a range of potential users are needed, matic. and this will be the subject of further study. 14 explained lifestyle factors that may contribute to hypertension. 12 made it clear that treatment is long term. 6 put hypertension in the context of overall cardio- References vascular risk. 13 leaflets had a mean score of 11.5 or less (2 leaflets 1 Department of Trade and Industry. Instructions for Con- could not be scored because the text was not sumer Products. HMSO: London, 1989. continuous). Doctors, nurses and patients — Abstracts

Nurse counselling in general practice for lifestyle modiﬁcation 775 J Woollard

Department of Medicine, Royal Perth Hospital, Perth, Australia

Counselling can be described as ‘providing advice’ behavioural model will be presented. This research or as ‘an exchange of opinions to decide or plan targeted weight reduction, smoking cessation, something’. Using either description many ‘lay reduction of dietary fat and salt, increasing daily lei- counsellors’ have derived the basis for their coun- sure time physical activity, and reducing alcohol selling on myths or traditions. Whereas in the field intake to recommended guidelines. Results enabled of hypertension, patient counselling is based on the a grant to be obtained to pursue further investigation results of systematic evidence obtained from clinical with high risk groups. The model focused on coun- trials. Evidence-based medicine has also proven the selling skills and used simple tools and strategies value of focusing on high risk groups to achieve the which were included in a patient manual developed early detection and treatment of high blood press- to strengthen the counselling approach. A structured ure. Additionally it is postulated that if we are pro- framework for counselling was developed based on active in modifying lifestyles rather than reactively the concepts of self efficacy, motivational inter- responding to disease outcomes the normal distri- viewing and Prochaska and DiClemente’s Stage of bution of blood pressure (BP) could be universally Change Model. With the move of nursing education shifted downward to decrease the epidemic. Given to the tertiary sector nurses are better able to con- the high percentage of the population who visit their duct or collaborate in qualitative or quantitative general practitioner each year it is suggested that research activities. A cognitive behavioural registered nurses working in or attached to general approach to lifestyle modification includes verbal practice settings are ideally based to target lifestyle and non-verbal communication skills. With time, modification. Early research into lifestyle modifi- resources and training nurses can be assisted to cation for patients with high BP using a cognitive work as effective counsellors.