Al-Ansary-guideline

18 Pages·2012·0.26 MB·English

A Systematic Review of Recent Clinical Practice
Guidelines on the Diagnosis, Assessment and
Management of Hypertension
Lubna A. Al-Ansary1,2*, Andrea C. Tricco3, Yaser Adi2, Ghada Bawazeer2,4, Laure Perrier3,
Mohammed Al-Ghonaim5, Nada AlYousefi1, Mariam Tashkandi6, Sharon E. Straus3,7
1DepartmentofFamilyandCommunityMedicine,CollegeofMedicine,KingSaudUniversity,Riyadh,SaudiArabia,2ShaikhBahamdan’sResearchChairforEvidence-
BasedHealthCareandKnowledgeTranslation,CollegeofMedicine,KingSaudUniversity,Riyadh,SaudiArabia,3LiKaShingKnowledgeInstituteofStMichael’sHospital,
Toronto,Ontario,Canada,4CollegeofPharmacy,KingSaudUniversity,Riyadh,SaudiArabia,5PrinceSalmanBinAbdulazizChairforKidneyDisease,Departmentof
InternalMedicine,CollegeofMedicine,KingSaudUniversity,Riyadh,SaudiArabia,6AppliedHealthResearchCenter,St.Michael’sHospital,Toronto,Ontario,Canada,
7DivisionofGeriatrics,UniversityofToronto,Toronto,Ontario,Canada
Abstract
Background:Despitetheavailabilityofclinicalpracticeguidelines(CPGs),optimalhypertensioncontrolisnotachievedin
many parts of the world; one of the challenges is the volume of guidelines on this topic and their variable quality. To
systematicallyreviewthequality,methodology,andconsistencyofrecommendationsofrecently-developednationalCPGs
onthe diagnosis, assessmentand the managementofhypertension.
Methodology/PrincipalFindings:MEDLINE, EMBASE, guidelines’ websites and Google were searched for CPGs written in
EnglishonthegeneralmanagementofhypertensioninanyclinicalsettingpublishedbetweenJanuary2006andSeptember
2011. Four raters independently appraised each CPG using the AGREE-II instrument and 2 reviewers independently
extractedthedata.Conflictswereresolvedbydiscussionortheinvolvementofanadditionalreviewer.ElevenCPGswere
identified. The overall quality ranged from 2.5 to 6 out of 7 on the AGREE-II tool. The highest scores were for ‘‘clarity of
presentation’’ (44.4% 288.9%) and the lowest were for ‘‘rigour of development’’ (8.3%–30% for 9 CGPs). None of them
clearlyreportedbeingnewlydevelopedoradapted.Onlyonereportedhavingapatientrepresentativeinitsdevelopment
team.Systematicreviewswerenotconsistentlyusedandonly2up-to-dateCochranereviewswerecited.TwoCPGsgraded
somerecommendationsandrelatedthattolevels(butnotquality)ofevidence.TheCPGs’recommendationsonassessment
and non-pharmacological management were fairly consistent. Guidelines varied in the selection of first-line treatment,
adjustmentoftherapyanddrugcombinations.Importantspecificaspectsofcare(e.g.resistanthypertension)wereignored
by 6/11 CPGs. The CPGs varied in methodological quality, suggesting that their implementation might not result in less
variation ofcareorin better health-relatedoutcomes.
Conclusions/Significance:Moreeffortsareneededtopromotetherealisticapproachoflocalizationorlocaladaptationof
existinghigh-quality CPGsto the nationalcontext.
Citation: Al-AnsaryLA, Tricco AC, Adi Y,Bawazeer G, Perrier L,et al. (2013)A Systematic Review of Recent Clinical Practice Guidelines on theDiagnosis,
AssessmentandManagementofHypertension.PLoSONE8(1):e53744.doi:10.1371/journal.pone.0053744
Editor:JamesLoGerfo,UniversityofWashington,UnitedStatesofAmerica
ReceivedMay24,2012;AcceptedDecember3,2012;PublishedJanuary17,2013
Copyright:(cid:2)2013Al-Ansaryetal.Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermits
unrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalauthorandsourcearecredited.
Funding:ThewholeworkwaspartlyfundedthroughresearchtrainingcollaborationbetweenKingSaudUniversityandtheLiKaShingInstituteatStMichael’s
Hospitalbutthesponsorshadnoroleatallinstudydesign,inthedatacollectionandanalysis,interpretationofdata,writingofthearticleorinthedecisionto
submititforpublication.
CompetingInterests:Theauthorshavedeclaredthatnocompetinginterestsexist.
*E-mail:[email protected]
Introduction hypertensioniscost-effective;treatmentwithmedicationresultsin
improved health outcomes (higher quality-adjusted life-years;
Globally,theprevalenceofhypertensionamongadultsaged25
QALYs) [4]. However, awareness of hypertension, its treatment
and over was approximately 40% in 2008 [1] and the total
andcontrolarefarfromadequateworldwide[5–7].Thevariation
economic burden of hypertension in the United States was
in the multiple CPGs on hypertension published between 1997
estimated at $73.4billion in 2009[2].
and2005hasbeenaddressedinanearlierstudy[8]anditisclear
Better hypertension management leads to improved health thatvariationinthequalityofguidelinesexistsforotherconditions
outcomes. A large systematic review of 147 trial reports on the and is not unique to hypertension [9–13]. Of the CPGs used in
management of hypertension has shown that a reduction of 235studiesassessingtheeffectivenessandefficiencydissemination
10mm Hg in systolic blood pressure and 5 mm Hg in diastolic and implementation strategies, only 3% of guidelines used were
wasassociatedwitha20%reductionofcoronaryheartdiseaseand based ongood evidence[14].
32%reductioninstrokeinoneyear[3].And,themanagementof
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Theaimofthissystematicreviewwastoassessthequalityand reviewers. Discrepancies at any stage were resolved by discussion
consistency of recommendations of recently-developed national or theinvolvementof athird reviewer.
and international CPGs on the diagnosis, assessment and the
management of hypertension and, to determine the extent to Data collection process and data items
whichtheseCPGsareinformedbyCochraneandnon-Cochrane A draft data extraction form was developed, piloted, and
systematic reviews. modifiedasnecessary.Tworeviewersindependentlyextractedall
of the data using the standardized data extraction form.
Methods Discrepancies were resolved by discussion or the involvement of
a thirdreviewer.
Thissystematicreviewwascompletedbasedonaprotocolwith
All the relevant documents and websites of the selected CPGs
input from experts in hypertension and systematic review
wereexamined.TheextracteddataincludedCPGcharacteristics
methodology, as recommended in the PRISMA Statement [15]
(e.g., year of dissemination, country/region, development team,
(Table S1). The institutional review board was not obtained
funding organization), recommendations related to the diagnosis
because there was no direct involvement with patients or bodily
and assessment of hypertension, and recommendations related to
samples.
the management of hypertension. The Appraisal of Guidelines
Research and Evaluation (AGREE) II tool [16] was used by 4
Eligibility criteria
reviewers independently to appraise the validity of each included
Multi-disciplinary CPGs endorsed by a national governmental
CPGs. The 4 assessors also provided their judgments on the
or provider organization related to the diagnosis, assessment and
overall assessment, the possible risk of bias and recommendation
managementofhypertensionwereincluded.Allsubgroupsofthe
for future use for each CPG that they appraised. Discrepancies
populationhadtobeexaminedtoensurethattheCPGscaterfor
wereresolvedbydiscussionortheinvolvementofafifthreviewer.
the needs of those with comorbidities in different settings; CPGs
The agreement of the 4 raters in the ‘‘Rigour of Development’’
focused exclusively on hypertension among special groups (e.g.
domainwasexploredusingpercentageofagreement.Tomeasure
pregnancy,children,elderly,blacksordiabetes)orspecificsettings
inter-rater agreement, values for the eight items were collapsed
(e.g. primary care only or emergency management only) were
from7to3valuesasfollows:1,2,3as1torepresent‘‘disagree’’
excluded. To ensure that the most up-to-date CPGs were
and 5, 6 and 7 as 2 to represent ‘‘agree’’ and 4 becomes 3 as
included, inclusion was limited to January 2006 onwards.
‘‘neutral ‘‘. This analysis was conducted using the AgreeStat
Furthermore, onlyCPGs writteninEnglish were included.
software [17].
The reference list of each of the selected CPGs was reviewed
Information sources
and the number of Cochrane and non-Cochrane systematic
Medical Subject Headings and text words related to hyperten- reviews in each was recorded. The end of search date for each
sionandguidelineswereusedtosearchMEDLINEandEMBASE CPGwascheckedtodeterminetheavailableandrelevantreviews
usingtheOVIDinterfacefromJanuary2006toSeptember2011. preparedbytheCochraneHypertensionGroup[18]bythatdate.
The electronic database search was supplemented by searching For CPGs where the end-of-search date was not reported, the
websites and Google, as CPGs are not always cited in such principalauthorwascontacted.Iftherewasnoresponsefromthe
databases. Specifically, the following websites were searched: author, it was assumed that search ended one year prior to
GuidelinesInternationalNetwork(G-I-N;www.g-i-n.net),Nation- publicationoftheCPG.Tworeviewersindependentlyscreenedall
al Guidelines Clearinghouse (www.guideline.gov), Australia Na- theabstractsofthereviewspreparedbytheCochraneHyperten-
tional Health and Medical Research Council (www.nhmrc.gov. sionGrouptoassesstheirrelevancetothegeneralmanagementof
au/guidelines/index.htm), National Institute for Health and primaryhypertension.
ClinicalExcellence(www.nice.org.uk)andScottishIntercollegiate
Guidelines Network (SIGN; www.sign.ac.uk), The word ‘hyper- Synthesis of results
tension’wasenteredintothewebsitesearchutilityandthefirst30
The included CPGs were summarized descriptively according
results were reviewed. Google was also searched using the
to diagnosis, assessment and management recommendations. For
keywords ‘hypertension’ and ‘guideline’ in a similar manner. To
eachitem,wenotedwhethertheCPGrecommendedit,thelevel
ensure all potentially relevant guidelines were identified, targeted
ofevidence(whichisbasedonthestudydesign),andthequalityof
searchingbycountrywasconductedinGoogle,thereferencelists
studies supporting/refuting the recommendation (determined
of included CPGs were scanned, and a list of the included
whenthereviewerscritically appraised thestudies). For diagnosis
guidelineswereemailedtoexpertsinthefieldtoidentifyadditional
and assessment, the following categories were used: identification
CPGs.
of cardiovascular risk factors, blood pressure measurement
methods,medicalhistory,physicalexamination,subclinicalorgan
Search
damage, and laboratory investigations. For management, the
Anexperiencedinformationspecialist(LP)conductedallofthe followingcategorieswereused:lifestylemodifications,initiationof
literature searches. The search strategy for the main electronic therapy, type of therapy, adjustment of therapy, combination
search (MEDLINE) is presented in Box S1; details on the therapy, harms associated with the therapy, consideration of
EMBASE search are available upon request. specialgroups(e.g.,elderly,diabetics,renaldysfunction,pregnan-
cy),follow-up, compliance, andspecialistreferral.
Study selection
Toensurereliability,atrainingexercisewasconductedpriorto Results
commencingthestudyselectionprocessusingarandomsampleof
25 citations. Two reviewers independently screened the search Study selection
results for inclusion using a pre-defined relevance criteria form. Thesearchstrategyretrieved2168citations,ofwhich114were
The full-text article was obtained for potentially relevant CPGs considered for full-text screening and 11 were included in the
and these were subsequently screened by two independent review(Figure1).TwoCPGsweremultinationaleffortstodevelop
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Figure1.FlowchartusingthePRISMAstatementforthesystematicreview.
doi:10.1371/journal.pone.0053744.g001
a unified hypertension CPG (EUR and LAT) [19–21]. The ranged from 5 to 31. Five CPGs (SOA, IND, POL, AUS, CAN)
remaining hypertension CPGs were conducted in South Africa did not refer to reviews from the Cochrane Collaboration
(SOA)[22],India(IND)[23],Poland(POL)[24],Malaysia(MAL) developedbytheHypertensionReviewGroupthatwereavailable
[25],Japan(JAP)[26],Australia(AUS)[27],Canada(CAN)[28], atthetimeofguidelinedevelopment.TheJAP,SAU,MAL,LAT
Saudi Arabia (SAU) [29]andtheUnited Kingdom(NICE) [30]. andNICEcited8,5,3,1and3Cochranereviews,respectively.Of
the reviews from the Cochrane Hypertension Group, one was
Clinical practice guideline characteristics cited by the EUR CPG [31] and 2 were cited by NICE CPG
Table1displaysthecharacteristicsandmethodsrelatedtoCPG [32,33]. Table 1 shows the numbers of available and relevant
development.TwoCPGswerenew(POLandLAT);therestwere reviews from the Hypertension Group for each CPG that could
updates. All CPGs (except the SAU and IND CPGs) were havepotentiallybeenusedbytheguidelines’developmentteams.
retrievedthroughsearchingthemedicalliteraturedatabases.The Someoftheguidelinesclearlyreportedthattheyreferredtoother
SAUandINDCPGswereretrieved through thecountry-specific international guidelines (SAU, LAT and IND) )but noneof them
Google search. reported being an adaptation ofanother CPG.
The affiliation and/or the specialties of the developing group
team members were not described in three CPGs (SOA, IND, AGREE-II appraisal results
LAT); the remaining guidelines provided some or a detailed Ingeneral,theguidelinesreceivedthelowestscoresforrigourof
description of the team. Two CPGs were funded by drug development among all 6 AGREE domains (mean 27%, range:
companies(SAU,MAL),threereportedfundingfromprofessional 8.3%–86.4%), whereas, they scored highest on clarity of presen-
organizations and provided a list of members with their tation (mean 66.8%, range: 44.4%–88.9%). The CAN CPG
declaration of interest (AUS, CAN, NICE), and the remainder scored the highest on rigour of development (Domain 3) and the
didnotdiscloseafundingsource.IntheCANguideline,members NICE CPG scored the highest for the scope and purpose and
with conflict of interest for certain recommendations were editorial independence (Domains 1 and 6; Tables 2–3). The
‘‘recused’’ from voting. The size of the guideline development applicability(Domain5)andstakeholderinvolvement(Domain2)
team varied from 7 to 65 members. Most of the CPGs (7/10) domainswerescoredconsistentlylowacrosstheCPGs(Tables2–
providedinformationontheaffiliationofthesemembersbutonly 3). The overall quality of the CPGs ranged from 2.5 to 6 on a
3(MAL,CANandSAU)providedinformationontheirspecialties. 7 pointscale.WiththeexceptionoftheCANCPG,allguidelines
Except for one CPG (NICE), 10/11 CPGs did not report were either not recommended for use or were recommended for
including patient representatives in their guideline development usewithmodifications.Theriskofbias(judgedbythereviewersas
team. Apart from the AUS, CAN and NICE CPGs, none of the an inverse overall assessment of the rigour of development
guidelinesreportedasearchstrategyintheirmethodssection.All domain) was lower in the CAN and NICE CPG and higher in
CPGs(exceptfortheINDandPOL)citedsomesystematicreviews the SOA, POL, EUR, LAT and the SAU CPGs. The degree of
in the reference section. The number of systematic reviews cited agreement among reviewers was tested using percentage of
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O Table1. Characteristics and Methods UsedForDeveloping the 11Clinical Practice Guidelines.
S
O
N
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| Characteristics SOA2006IND2007POL2007MAL2008 EUR2009 JAP2009LAT2009AUS2010 CAN2011 SAU2011 NICE2011
w
w
w StatusoftheCPG
.plo New No No Yes No No No Yes No No No No
s
on Updated Yes Yes No Yes Yes Yes No Yes Yes Yes Yes
e
.o Levelofdevelopment
rg
National Yes Yes Yes Yes No Yes No Yes Yes Yes Yes
Regional No No No No Yes No Yes No No No No
Organizationbehindtheguideline
Professionalorganization(e.g.Societies) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Government Yes No No Yes No No No No No Yes Yes
Funding/Sponsorship No NR NR Industryeducational NR NR NR ProfessionalGrants Professionalgrants Industry NICE
grant
Developingteamstructure&affiliationdescribed
Numberofmembers 7 33 15 17 32 30 14 14 65 19 15
Affiliationdescribed? No No Yes Yes Yes Yes No Yes Yes Yes Yes
Specialtydescribed? No No No Yes Notclear No No No Yes Yes Yes
Searchingandselectingreferences
4
SearchStrategyDescribed? No No No No No No No Yes Yes No Yes
Totalreferencescited 110 146 4 251 293 742 157 64 56 53 662
Totalsystematicreviewscited 6 0 0 19 19 36 5 6 6 8 12
TotalCochranereviewscited 0 0 0 3 1* 8 1 0 0 0 3
Totalcited/available**relevantCochrane 0/11 0/15 0/15 0/17 Jan-32 0/32 0/32 0/34 0/39*** 0/39*** 2****/39
reviewsfromtheHypertensiongrouponly
Methodsofderivingrecommendations
Evidencelinked,Formalconsensusmethod No No No No No No No No Yes No Yes
Jan Evidence-linked,nodescriptionofmethod No No No Yes No No No Yes No No No
uary Consensusmethod,nodetaileddescription Yes Yes No No No No Yes No No No No Rev
20 Notdescribed No No Yes No Yes Yes No No No Yes No iew
13 Implementationstrategiesdescribed Yes No No No Yes,weak No No Yes Yes Yes Yes of
| R
Volu YtheearCoPfGpublicationofthepreviousversionof2003 2001 - 2002 2007 2004 - 2009 2010 2007 2006 ecen
m t
e NextUpdateoftheCPG 2012 NR NR 2012 NR NR NR NR 2012 NR NR H
y
8 p
e
|Issue NE*TxRhc:eeNllEoeSntHcreeRp).eoartpepdr.aSisOaAl:inSo2u0t0h9Acfirtiecda;oINnDly:1Indreiav;iePwOL(4:Proelvainedw;sMwAeLr:eMcaitleaydsiian;2EU00R7:)E.urope;JAP:Japan;LAT:LatinAmerica;AUS:Australia;CAN:Canada,SAU:SaudiArabiaandNICE(TheUK’sNationalInstituteforHealthandClinical rtensio
n
1 **ProducedbytheHypertensionCochraneReviewGroupcalculatedforuptooneyearbeforethedateofpublicationoftheCPGswhenthesearchdatewasnotreported. G
| ***Thetotalnumberofreviewsavailableatthattimewas41buttworeviewswereexcludedbecausetheywerejudgedasirrelevant. u
e id
537 *d*o*i*:1T0h.e13u7p1d/jaotuerdnavle.prsoionne.0o0f5M37u4rl4o.wt0’0s1reviewwaspublishedin2008butthe2000versionwastheonecited. elin
4 e
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ReviewofRecentHypertensionGuidelines
agreementfortherigourofdevelopmentdomain.Theagreement
v7loa3wr%iea,d7s1a5%c8r,%o6s,s9%5th6,e%6g2,u%5id2e%(SliO,ne5As0,%fJrAo,mP4,6aL%sAhT(Ii,gNhMDaA,sLM8,A8r%eLs,p(eACcUtAivSNe,l,yNP)IOtoCLEa)s,, CE2011 xcellence.
SAU, respectively) NI 83 74 62 55 72 88 alE
Only two guidelines linked their grade of recommendations to nic
the level of evidence (MAL, CAN), yet they did not elaborate on 1 Cli
the quality of studies contributing to the recommendations 201 and
(rTecaobmlem4e)n.daAtgiorneesmweanstnboettowbeseenrvethde.sFeorCePxGams polne, tthheeagdrvaidcee oonf SAU 44 49 30 64 46 38 Health
epxroervcidiseedwtahsegervaiddeedncAeitnabMlesALforanthdeDir rinecComAmNe.nTdhaetioNnIsCaEndCPthGe 2011 utefor
StiAonUsbCuPtGnorneepoorfttehdemtherelpeovertleodftehveidsternecnegtfhorosformeceomremcoemndmaetinodnas-. CAN 75 75 86.4 88.9 59.3 75 alInstit
The other 7 CPGs did not disclose the level of evidence or how on
their recommendationswere decided upon. 10 Nati
0
Clinical practice guideline recommendations AUS2 22.2 38.9 27.1 88.9 59.3 64.6 CE:UK’s
Definition. Most CPGs considered high normal blood NI
d
pressure to range from 120–129 systolic blood pressure (SBP) or n
9 a
80–84fordiastolicbloodpressure(DBP)(Table5).Theexception 00 bia
wastheINDandNICECPGs,whichdefinedhypertensionusing AT 1.1 1.6 5.6 4.4 0.2 5.4 Ara
ahighercutoffpoints.TheCANCPGdidnotusecutoffpoints L 6 4 1 4 3 3 di
u
for hypertension. Sa
hadigd‘‘hWreershseitbdelocuoosdaintgspyrnesdesslrfuo-mrmeeea’w’su(hir.eeen.d,thbmeloepaorsdouprpeedrnessistbuyyrfeoaripnaclt9iine/ni1ct1isantoC)PhwaGvases. AP2009 0.8 8 8.75 2.5 4.6 9.1 nada;SAU:
T(bmhSeyhOetpeaweAserud,tereenMinvnisgAcidoeLisnfbf,eluwoErsoeaUendsdRtmi,pnsarJedeAtssteePisnlu,ifng-rAmesaUol(alnoSnCfi,tfdioCPcreGAii,ndsNgehenaoxwtincmfeeydrepienNtgadtIwneCpsdoEcar)(ti.PaibemTOendhtbLseu,ilndaAasitUso7trihSnyCa))c.vPtiifGonongrs EE-IIInstrument. EUR2009J 36.12 27.71 23.41 69.46 21.81 64.62 US:Australia;CAN:Ca
CaArdllioCvPaGscsurleacromRimskended assessing hypertension in relation to eAGR 2008 erica;A
o(Tthaebrle 5ca).rdiovascular risk factors during patient assessment singth MAL 65.3 45.8 26.5 69.4 42.7 68.75 LatinAm
Family and Clinical history esU 007 LAT:
fSaAmTUihl,yeNhcIilCsintoEicr)ya,lsotarfsoskheesyspm(eINretneDtn,siinoMcnlAu(dLIeN,dDEUa,sRkMi,nAgJLAp,Pa,EtiLUenARtTs,,aJAbAoPUu,StL,tAhaenTidr, Guidelin POL2 25 12.5 8.3 75 16.6 4.1 AP:Japan;
J
S(icInhANqrUuoDin)r,,iicnMdgykAsaildbiLpno,iuedyEtempUrdiReaisv,ei(oaIJNusAesDPc(,oTarMaonbndAlaeLrAy,5UaE)r.SUt)e.ARrylAldallinbsdeuCatPsAeGoU,nhsSee)raeraCctnoPfdamGildmuira(ePebnOaedtneLedds) alPractice IND2007 44.4 13.9 21.8 50 17.7 16.6 EUR:Europe;
rpeecroipmhmereanldaerdterayskdiinsegasaeboanudt preatsitnohpisattohryy. of stroke and existing Clinic 2006 alaysia;
Physical examination searching for subclinical organ he11 SOA 47.2 37.5 13.5 55.5 38.5 39.6 MAL:M
daAmllagCePGs recommended assessing the patient’s body mass %)fort OSE Poland;002
Lie(eacgPnhxxnlaudOcaodAbceemlLoloexpLlssi.)trCnAteaec,aSfTPrtootboioGnirmollCrs,onyiiosodlP.cuandetGrrgAereelgey(salshe.Cld,ttesiirPntmEnaeeiGlcdgCnlaoetGamau,(LsdrsmpiaAdeaossre)Tst,enaias)npdssngser(eTioeddufctaameefsbmiustnlsinenoaadagrnd5ynoidb)fsd.icclaouooAbaormplllideblnypu,egeolmxilenufdcxeiecneicsnpotpeytss(pttTeloeit,cfafokffbaortrhilsrsteteoekitnsn5hptge)fieh.anbycgCOPltsooOiPncforoGalLsdyr,l DomainScores(Table2. DOMAIN1.SCOPEANDPURP DOMAIN2.STAKEHOLDERINVOLVEMENT DOMAIN3.RIGOUROFDEVELOPMENT DOMAIN4.CLARITYOFPRESENTATION DOMAIN5.APPLICABILITY DOMAIN6.EDITORIALINDEPENDENCE SOA:SouthAfrica;IND:India;POL:doi:10.1371/journal.pone.0053744.t
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Table3. Qualityof the11Hypertension Clinical Practice Guidelines forthe sixdomains ofthe AGREE-II Instrument(D1–D6) and the OverallImpression ofthe 4 Assessors.
Riskof RecommendCPG
D1 D2 D3 D4 D5 D6 Overall* Bias** forUse***
Item# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 # 22 23
SOA2006 5 3 4 4 1 5 1 1 1 2 2 2 4 3 5 6 3 3 4 3 3 5 2 3 +++ No
IND2007 4 3 4 2 2 2 2 2 1 1 2 2 5 2 4 5 3 2 2 2 2 3 1 2.5 ++ No
POL2007 2 1 4 3 1 1 1 1 2 1 3 2 1 1 6 6 5 1 2 1 3 1 1 3 +++ No
MAL2008 5 5 5 5 2 5 2 1 1 1 4 4 4 4 5 6 5 3 4 4 4 6 5 3 ++ Unsure
EUR2009 3 3 3 4 1 3 2 3 4 1 4 2 3 1 5 6 5 5 2 2 1 4 6 3.5 +++ No
JAP2009 2 2 3 3 1 2 2 2 2 2 4 3 2 1 4 6 5 2 2 2 1 4 2 4 ++ Unsure
6 LAT2009 6 4 5 3 3 5 2 1 1 2 3 2 3 3 4 4 3 3 2 3 4 4 2 3 +++ Unsure
AUS2010 2 3 3 4 4 2 3 1 1 3 4 2 6 2 6 6 7 5 6 3 5 3 7 4.5 ++ Yes,with
modifications
CAN2011 5 6 6 7 5 6 7 7 6 7 6 6 5 7 7 7 6 4 6 4 4 5 6 6 + Yes
SAU2011 4 4 4 5 3 4 3 3 2 3 3 3 2 4 5 6 4 5 4 3 3 4 3 3.5 +++ No
NICE2011 6 6 6 6 5 6 6 6 6 6 5 5 4 5 6 6 6 5 6 6 6 7 6 6 + Yes,with
modifications
D1:Scope&purpose,D2:Stakeholderinvolvement,D3:Rigorofinvolvement,D4:Clarityofpresentation,D5:Applicability,D6:editorialindependence.
Ja Allthe23itemsoftheAGREE-IIinstrumentareratedona7-pointscalewhereascoreof1isgivenwhenthereisnoinformationthatisrelevanttotheitemoriftheconceptisverypoorlyreported;ascoreof7isgivenifthequality
nuary othferefpuollrctirnitgeriisaeoxrcecpotniosindaelraatniodnws.hSecroertehseinfuclrlecarsiteeraisamanodrecocnristeidreiaraatrieonmseatrtaicnudlacteodnsiindethraetiAoGnsREaEd-dIIrUessseerd’s.MInanouthaelrhawvoerdbse,etnhemheitg;haenrdtahescsocroereb,etthweeebnet2tearntdhe6qisuaaslistiygnoefdthwehCePnGthiteermep.ortingoftheAGREEIIitemdoesnotmeet Rev
2013 S**A*ORlAtihs:koSuoogfuhtbhitahAse:fr+isc+cao+;rIihNnigDgh:is,In+dd+oiani;nePteiOnrLmi:nePtdeoiglaaetnerds,,;+tMhloeAwLn:.uMmablaeyrssiain;EtUhiRs:cEoulruompne;rJeApPr:esJeapntanth;eLAaTv:eLraatginesAomfethriecas;cAoUrinS:gAduosntrealbiay;C4AaNss:eCsasnoarsd.a;SAU:SaudiArabiaandNICE:UK’sNationalInstituteforHealthandClinicalExcellence). iewof
|Volu *d*o*iT:1h0is.1i3s7b1a/jsoeudrnoanl.pthoenes.u0b05je3c7t4iv4e.t0as0s3essmentmadeindividuallybyeachofthe4assessorsinresponseto:‘‘DoyourecommendthisCPGforuse?’’ Recen
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Table4. Strengthofthe recommendationsstated inthe Malaysianand CanadianClinical Practice Guidelines.*
Recommendations Strengthofrecommendation
MAL2008 CAN2011
Recommendationstoattainnormalbodymassindex C B
Anintakeof,100mmolofsodiumdaily A B
Advicetorestrictintakeofalcohol C B
Generaladviceonexercise A D
AdaptinghealthyDASHdiet A B
SmokingCessation C Notgraded
RecommendationstouseACEIinpresenceofmicroalbuminuria A A
UseofARBifACEIisnottolerated A B
Recommendationfordiureticsorcalciumchannelblockersasalternativetherapyindiabetic A A
hypertensivepatients
CombinationofACEIsandARBsinpatientswithhypertensionandnodiabeticrenaldisease A B
*NoneoftheotherCPGsstatedtheirstrengthofrecommendations.
MAL:Malaysia;CAN:Canada.
doi:10.1371/journal.pone.0053744.t004
two CPGs (IND and JAP) recommended assessing C-reactive antiplatelet therapy, statins and/or glycemic control were
protein aspart of theworkup forpatients withhypertension. addressed in 11/11,10/11and3/11CPGs respectively.
Recommendationsforthemanagementofhypertension: Followup,compliance,adherencestrategiesandreferral
Findings from guidelines about the management of hyperten- OnlytwoCPGs (AUSandSAU)addressed howoften patients
sionarepresentedinTable6.Allguidelinesadvocatedsimilarlife shouldbeseenduringthestabilizationphase.TheAUSsuggested
stylechangesasacornerstoneinthemanagementofhypertension. thatthisshouldoccurevery6weeksorasindicated(whichcould
Minor differences included recommendation of dietary supple- befewdaysto2months).TheSAUsuggestedmonthlyvisits.Six
ments, increase of potassium intake, exercise, and stress and CPGssuggestedoneof2plansforfollowupofpatientswithstable
emotional management. BP;eithertofollowallpatientsevery3–6monthsortofollowhigh
All CPGs emphasized the need to stop smoking, maintaining risk (20% risk or higher) patients three monthly and low risk
weight, following nutritional guidelines, lowering sodium intake, patients six monthly. The methods for assessing compliance with
limiting alcohol intake (except for SAU) and lowering fat intake medicationandstrategiestoimproveadherencewerediscussedin
(except forAUS) forhypertensivepatients. 7/11 CPGs. The indications for referral to other specialties were
Most guidelines recommended the same criteria for initiating discussed in 9/11CPGs
drugtherapy;minordifferenceswerenotedregardingtheduration
of a life style modification trial before starting drug therapy. All Discussion
CPGs recommended starting antihypertensive therapy without
Most of the CPGs clearly presented their recommendations.
delayforpatientswithhighbloodpressureorhighcardiovascular
However methodological gaps exist across the guidelines that
risk defined by most guidelines (except for the AUS CPG) as
should be addressed including clarifying the scope and purpose,
$20% risk of developing a cardiovascular event over 10 years.
ensuring representation of all stakeholders including consumers,
TheAUSCPGsdefinedhighriskas$15%riskofdevelopingan
developingguidelineswithscientificrigour,supportingimplemen-
event over5 years.
tation of the recommendations and declaring the presence or
Most CPGs recommended use of any of the 5 classes of
absence of editorial independence. These results are similar to a
antihypertensivedrugs(angiotensinconvertingenzymesinhibitors,
recentreviewof42reviewsofguidelines(atotalof626CPGsona
angiotensin receptor blockers, beta-blocker, calcium channel
varietyoftopics)publishedbetween1980and2007,whichshowed
blockers or diuretics) as first line therapy. However, low-dose
that despite some increase in quality of CPGs over time, the
diuretics were preferred by the IND and SAU CPGs and were
average quality scores as measured with the AGREE Instrument
exclusively recommended by the SOA CPGs. The CPGs also
have remained moderate (43% for ‘Rigour of Development’) to
differed in their strategies of adjustment of therapy. Most
low (35% for ‘Stakeholder Involvement’, 30% for ‘Editorial
recommended adding another drug if the blood pressure is not
Independence’ and20%for‘Applicability’) [34].
adequately controlled (10/11); others suggested substituting with
In general, the recommendations of the CPGs on diagnosis,
another drug (3/11) and/or increasing the dose of the first agent
assessmentandnon-pharmacologicalmanagementwereconsistent
(3/11).Recommendationsaboutdrugcombinationswerevariable
despitescoringpoorlyintheirrigourofdevelopment.Itisdifficult
across guidelines. Selection of therapeutic agents for compelling
to tell whether this happened because there was no evidence to
indications such as established cardiovascular disease or diabetes
guideor because theauthors did not search andmake use ofthe
weresimilar,yetthereweresomedifferencesinrelativeorabsolute
bestavailableevidence.ThisfindingissimilartothatofBurgers,et
contraindication definitions. Only five CPGs discussed managing
al, who reviewed 15 CPGs for patients with diabetes from 13
resistanthypertensionandfiveCPGsdidnotdiscusshypertensive
countries [35]. They found an international consensus in the
emergencies. Controlling associated risk factors by the use of
recommendations despite the variation in cited evidence and
PLOSONE | www.plosone.org 7 January2013 | Volume 8 | Issue 1 | e53744
P
L
O Table5. Recommendationsfrom Clinical Practice Guidelines About Diagnosis andAssessment of Patientswith Hypertension.
S
O
N
E
| ITEM SOA2006 IND2007 POL2007 MAL2008 EUR2009 JAP2009 LAT2009 AUS2010 CAN2011 SAU2011 NICE2011
w
w
w DefinitionofHypertension
.plo Normal:SBP(120–129)or ! SBP,130 ! SBP,120, ! ,125/80 ! ! NR SBP,120and Clinic,140/
so DBP(80–84),ifdifferent, DBP,85 DBP,80 DBP,80 90mmHgor
ne state HBPM/ABPM
.o ,135/85
rg
Highnormal:SBP(130– ! ! ! Pre-HTNSBP120–! ! ! SBP(120–139)or ! Pre-HTN120–139,X
139)orDBP(85–89)if 139mmHg,DBP DBP(80–89) and/or80–89
different,state 80–89mmHg
Mild(G1):SBP(140–159)or! ! ! ! ! ! ! ! X ! Clinic$140/
DBP(90–99) 90mmHgand
HBPM/ABPM
$135/85
Moderate(G2):SBP(160– ! ! ! ! ! ! ! ! X ! Clinic$160/
179)orDBP(100–109) 100mmHgand
ABPM/HBPM
$150/95mmHg
Severe(G3):SBP.180or ! ! ! ! ! ! ! ! X $180and/or ClinicSBP$180/
DBP.110 $110 110mmHg
Isolatedsystolic NR ! ! ! ! ! ! ! NR NR SBP$160mmHg
hypertension:SBP.140
8 andDBP,90ifdifferent,
state
Isolatedsystolic NR ! ! ! ! ! ! ! NR NR NR
hypertension+widened
pulsepressure:SBP.160
andDBP,70
CardiovascularRiskAssessment
Dataelementsrecommendedforcardiovascularriskstratification
SBP/DBP ! NR ! NR ! ! ! ! ! ! !
Jan Smoking ! ! ! ! ! ! ! ! ! ! !
uary Dyslipidaemia ! ! ! ! ! ! ! ! ! ! ! Rev
20 Diabetes ! ! ! ! ! ! ! ! ! ! ! iew
13 Subclinicalorgandamage of
| R
Volum LMViHcrooanlbEuCmGi/nEuCrHiaO:ECR3– !! 1!.2–2mg/dl !Recommended !$2.0mg/mmol !30–300mg/ !Recommended !Recommendedbut !$2.0mg/mmol !Recommendedbut !NR !Albuminuria ecent
e 30mg/mmol butcut-offnot (males)or 24hours butcut-offnot cut-offnotreported (males)or$2.5mg/ cut-offnotreported statedbutnocut- H
y
8 reported $2.5mg/mmol reported mmol(females)on offreported p
e
|Issue (utferesimnteOalsRecsr2)e4oe-nnhionsupgrot stueprsionttaOruyRrian2leb4-ushcmoreuinerning rtensio
1 urinaryalbumin excretionrate n
G
| excretionrate $20mg/minute u
e537 $20mg/minute idelin
4 e
4 s
P
L
O Table5.Cont.
S
O
N
E
| ITEM SOA2006 IND2007 POL2007 MAL2008 EUR2009 JAP2009 LAT2009 AUS2010 CAN2011 SAU2011 NICE2011
w
w
w CKD
.plo Elevatedcreatinine: ! elevated Recommended x ! ! CR.1.3mg/dL X x ! Reportedwithno
so Men115–133,Women serum butnocut-off cut-offstated
ne 107–124mmol/l creatinine
.o 1.2–2.0mg/
rg dl
Proteinureaprotein/ ! x Urinaryalbumin/ Urinaryprotein Albumin- ! x ! ! NR Reportedwithno
creatinineratio$30 creatinineratio .500mg/24hr creatinineratio: cut-offstated
mg/mmolonspot buttheratiois oralbuminto .or=22(M);
urinetestorurine notstated creatinineratio or31(W)mg/g
protein.300mg/day [ACR].30mg/ creatinine
ontimedurinesample mmol
eGFR,60mL/minute/ 6 ! ! ! ! ! eGFR,30 ! ! NR Reportedwithno
1.73m ml/min/1.73m cut-offstated
Subclinicalorgandamage:Vasculardisease
Atheroscleroticplaque Notstated ! ! ! ! ! ! ! ! ! !
(aorta,carotid,coronary, clearly
femoralandiliac
arteries)evidenton
USorradiology
9 Hypertensive ! ! 6 ! ! ! gradeIII/IV ! ! ! !
retinopathy(grade
IIorgreater)
Stratification:Low; normal,high! normal,high ! ! ! low,intermediate Low,Mod, NR ! NR
Moderate;High/Very normal,mild, normal,Grade andhigh High
Highaddedrisk moderate, 1,2and3)
severe
BPmeasurement
Office:140/90 ! ! ! ! ! ! ! ! ! ! !
Ja Home:135/85 ! ! 6 ! ! ! ! 6 ! ! !
n
uary A(mmebaunlantiogrhyt:);12103/57/085 !* !* 6 !* !* ! !* !* ! !* !* Rev
20 (meanday);130/80 iew
13 (24-hour)*Suggested o
| forselectedcases fR
Volum Ranedasosenl(fs-m)foonritHoorimnge Fgororuspeslect FCooratWHhTitne- NR WMohnitietocroinagtHTN WMohnitiet-ocroinagtHDTxN MDxorMeaasckceudrate Mwhasitkee-dcoaantdHTN McoaastkeHdTNanadndwhFUite- FcooartwHhTitNe- WHThNiteM-coonaittoring cwohnitfier-mcodaitagHnToNsis, ecent
e only ofresistantHTN andwhite- andFU Dxofresistant H
y
8 coatHTN HTN p
e
|Issue Listofdevicesprovided ! NR NR ! ! !Iamdhperorevnecse ! NR NR ! !$ rtension
1
G
| Botharms*Firstvisits !* !* NR ! !* NR ! !* !* !* !* u
e537 only idelin
4 e
4 s
P
L
O Table5.Cont.
S
O
N
E
| ITEM SOA2006 IND2007 POL2007 MAL2008 EUR2009 JAP2009 LAT2009 AUS2010 CAN2011 SAU2011 NICE2011
w
w
w FamilyHistory
.plo EarlyCVD:Menaged ! ! ! ! ! ! Notclear ! ! ! !
so ,55yearsandWomen
ne aged,65years
.o
rg Highbloodpressure 6 ! NR ! ! ! NR ! NR ! !
Obesity 6 ! 6 ! 6 ! ! 6 6 ! 6
Stroke 6 ! 6 ! ! ! ! ! 6 ! 6
Dyslipidaemia 6 ! 6 ! ! x 6 ! 6 6 6
Diabetes 6 ! 6 ! ! ! NR ! 6 6 6
ClinicalHistory
CAD ! ! ! ! ! ! ! ! ! ! !
HeartFailure ! ! ! ! ! ! ! ! ! ! !
CKD ! ! ! ! ! ! ! ! ! ! !
StrokeorTIA ! ! NR ! ! ! ! ! ! ! !
Peripheralvascular ! ! NR ! ! ! ! ! ! ! !
disease
1 Retinopathy ! ! NR ! ! ! ! ! ! ! !
0
Aorticdisease 6 ! NR ! ! ! ! ! 6 ! !
Hypercholesterolaemia: ! ! ! ! ! ! 6 ! ! ! !
SerumTC.7.5mmol/L
Previousmedications 6 ! NR ! ! ! ! ! ! ! !
Othersignificant 6 6 NR ! ! ! 6 ! 6 ! !
conditions(asthma,
sleepapnea,COPD)
Modifiablelifestylerisk ! ! ! ! ! ! NR ! ! ! !
Ja factors
n
uary Horisstuogrygeosfthivyepsoykmalpaetommias 6 6 NR ! 6 NR 6 ! ! ! ! Rev
20 Other - Smoking, Smokingand personal, Smoking, - - psychosocial - Growth Symptomsof iew
13 gout, Gout psychosocial dietary, andenviron- retardation identifiablecause o
f
| sexual andenviron- obesity, mentalfactor sofHTN R
Volu dDyiestfuarnyct(iSoanlt,, mentalfactors pexheyrscicisael ecen
m t
e Alcohol, H
8 Caffeine) yp
e
|Issue PCahrydsioicvaalscEuxlaarmination 6 ! ! ! ! ! ! ! ! ! ! rtensio
n
1 ECG ! ! NR ! ! ! ! ! ! ! ! G
| u
e Obesity(Waist-to-hip ! ! ! ! ! ! ! ! ! ! ! id
537 ratioorBMI) elin
4 e
4 s