Article type
Abstract
Background: Blood pressure (BP) targets play a crucial role in hypertension management. Significant variation is observed across international guidelines and the last national guideline on hypertension in Singapore was published in 2017, highlighting the need for updated recommendations.
Objective: To develop an ACE Clinical Guidance (ACG) on management of hypertension, including setting BP targets for patients attending primary or generalist care in Singapore.
Methods: A systematic and robust methodology was employed to identify high-quality international guidelines on hypertension (AGREE-II) and appraise their underlying evidence and rationale for recommendations (GRADE), including their impact on the healthcare system. Inputs from a multidisciplinary group of healthcare professionals were incorporated through the RAND/UCLA appropriateness rating methodology for consensus. There was no consumer involvement.
Results: Local data findings revealed 75% of patients with hypertension achieved BP control, defined as a BP target of <140/90 mmHg based on the 2017 guideline. However, a concerning trend of increasing hypertension prevalence coupled with heart and renal conditions prompted the consideration of cardiovascular (CV) risk as key determinant for BP target setting, with more stringent cut-offs. For patients without relevant CV conditions, the recalibrated Singapore-modified Framingham Risk Score was used to determine CV risk. On the backdrop of evidence reporting favourable outcomes (such as decreased risk of cardiovascular events and death) with more intensive BP lowering, expert consensus was reached to recommend a BP target of <130/80 mmHg for patients at high CV risk – encouraging this also for those at lower risk, as tolerated. Nevertheless, the ACG discusses the importance of individualised BP targets to cater to the diverse patient population in primary care, with the flexibility to tailor BP targets as needed, such as for the elderly or frail.
Conclusion: Local data used in synergy with international evidence enabled informed deliberation by experts on hypertension BP targets for the local setting, based on CV risk. The broader impact of lower BP targets extends to the larger population without existing CV disease, presenting an opportunity to influence long-term BP control, which may not be fully evident in relatively shorter trials spanning 3 to 5 years of follow-up.
Objective: To develop an ACE Clinical Guidance (ACG) on management of hypertension, including setting BP targets for patients attending primary or generalist care in Singapore.
Methods: A systematic and robust methodology was employed to identify high-quality international guidelines on hypertension (AGREE-II) and appraise their underlying evidence and rationale for recommendations (GRADE), including their impact on the healthcare system. Inputs from a multidisciplinary group of healthcare professionals were incorporated through the RAND/UCLA appropriateness rating methodology for consensus. There was no consumer involvement.
Results: Local data findings revealed 75% of patients with hypertension achieved BP control, defined as a BP target of <140/90 mmHg based on the 2017 guideline. However, a concerning trend of increasing hypertension prevalence coupled with heart and renal conditions prompted the consideration of cardiovascular (CV) risk as key determinant for BP target setting, with more stringent cut-offs. For patients without relevant CV conditions, the recalibrated Singapore-modified Framingham Risk Score was used to determine CV risk. On the backdrop of evidence reporting favourable outcomes (such as decreased risk of cardiovascular events and death) with more intensive BP lowering, expert consensus was reached to recommend a BP target of <130/80 mmHg for patients at high CV risk – encouraging this also for those at lower risk, as tolerated. Nevertheless, the ACG discusses the importance of individualised BP targets to cater to the diverse patient population in primary care, with the flexibility to tailor BP targets as needed, such as for the elderly or frail.
Conclusion: Local data used in synergy with international evidence enabled informed deliberation by experts on hypertension BP targets for the local setting, based on CV risk. The broader impact of lower BP targets extends to the larger population without existing CV disease, presenting an opportunity to influence long-term BP control, which may not be fully evident in relatively shorter trials spanning 3 to 5 years of follow-up.