Managing Hypertension: An Audit of Local Practice in A Tertiary Care Hospital

Introduction

Hypertension coupled with an increased risk of cardiovascular disease is one of the most significant modifiable risk factors for morbidity and mortality worldwide. Even though good management of hypertension lessens the worldwide burden of the disease, less than half of those who have it are aware of it. Moreover, those who are aware of their status are either untreated or inadequately treated.^1,2 In Southeast Asia, hypertension is the third most common disease.³ With a prevalence of 29.8% in India, hypertension is a non-communicable disease that needs to be controlled appropriately.³

Because the vast majority of cases are asymptomatic, they go unnoticed and untreated, increasing the risk of end-organ damage which includes coronary artery disease, heart failure, renal failure, cerebrovascular disease, and hypertensive retinopathy.⁴ Hypertension accounts for 57% of deaths due to cerebrovascular disease and 24% of deaths due to coronary heart disease in India.⁵ In 2005, 20.6% of Indian males and 20.9% of Indian females had hypertension.⁶ As per the literature there are geographical disparities in mortality and the frequency of Coronary heart disease (CHD) and stroke in India (the south Indian region has higher CHD mortality rates while eastern India has higher stroke rates).⁷

Early diagnosis, management, and rate retention are the three steps in managing hypertension. The initial diagnosis is based on the number of times the patients attend an outpatient department and have their blood pressure tested by a professional. The classification of hypertension is based on the American Heart Association (AHA) guidelines and essential laboratory investigations. These rule out end-organ damage and distinguish secondary causes of hypertension such as fasting blood sugar / pos-prandial blood sugar (FBS/ PPBS), lipid profile, electrolytes, creatinine, chest X-ray, and an echocardiogram. These factors are all part of the diagnostic process.

The primary support for management is age-appropriate medication and the categorization of hypertension. Continued therapy and follow-up, primarily to monitor for adverse effects and adherence to pharmacotherapy to determine whether to reduce or increase the dosage are included in the retention rate The current study is aimed to audit on local ractices in a tertiary care hospital on the patterns of management of hypertension.

Materials And Methods

Patients treated for hypertension between 1^st January 2022 and 1^st March 2022 were identified by a retrospective chart review using the computerized medical health records of Adichunchanagiri Institute of Medical Sciences, Karnataka, and were compared against the initial audit conducted in May–July 2020. Based on the examination, 486 patients were treated for hypertension and 247 patients were included in the study. Those recently diagnosed with high blood pressure at the Adichunchanagiri Hospital and Research Centre met our inclusion criteria. The other patients were left out because they did not meet the inclusion criteria. They had already been diagnosed with high blood pressure or were being treated somewhere else. Patient records were evaluated based on three criteria. Initial assessment, pharmacotherapy, and treatment results were according to several parameters of the recommendations adapted from the AHA guidelines. A re-audit was performed on April 1,2021, to verify adherence to the proposed recommendations.

Results

Patient’s information was collected from a total of 247 files. There was a 3:1 female: male ratio. The age of the patients ranged from 26 to 84 years, with a mean age of 55 years.

Preliminary audit

The preliminary audit occurred between May and July 2021 (Table 1). These results showed limited compliance with the AHA recommended guidelines for managing hypertension. Standards categories for hypertension are presented in Table 2.

Second audit

Differences were noted when the secondary audit was done six months after the intervention through teaching sessions organized by the Department of Medicine.

Discussion

Hypertension is a common disease in the southern part of India in 29.8% of the population. This noncommunicable disease has high morbidity and mortality rates. Primary/essential hypertension is usually asymptomatic and idiopathic. People rarely get their blood pressure monitored because of the condition being asymptomatic. End-organ damage is frequently the first sign of hypertension, and complications of hypertension include cerebrovascular diseases, heart failure, ischemic heart disease, angina, peripheral artery disease, renal failure, retinopathy leading to blindness, and sexual dysfunction.⁸

The first and most crucial step is to ensure that the blood pressure values are accurate. When blood pressure is examined by a physician or qualified people, the odds of making an error are reduced since they are more likely to be familiar with the Korotkoff sounds. Many processes make it possible to produce a reading with a few mistakes. While checking the blood pressure when the patient is relaxed, the reading is lower than when the patient has not had enough rest. The reading is more accurate when the patient is sitting than in a standing or supine position.

When the arm of the patient is placed at their heart level, it provides a more accurate reading. When the arm is held at a station, the values tend to increase. In contrast, crossed legs tend to give a higher reading. In the reaudit, there was a generalized improvement in all of the above indicators (8%–13%). The size of the cuff plays a crucial role in measuring blood pressure; a smaller cuff increases blood pressure reading, while a more oversized cuff decreases blood pressure reading. The results of the re-audit revealed a significant improvement (32%) pertaining to the compliance with the AHA recommended guidelines for managing hypertension

As per the protocol of study, the standard readings must be confirmed twice, at least 1–4 weeks apart, and taken at least 1 minute to diagnose hypertension. The re-audit results demonstrated a general improvement in this trend (27%). The AHA classification (Table 2) helps to classify and prescribe the required medications. A massive jump in the results was found during the re-audit (99%). Diagnosing and distinguishing primary hypertension from secondary hypertension, which frequently appears as refractory hypertension, despite the prescription of three to four medication classes is a critical step in therapy.⁹ The number of tests requested increased by 7%–44% during the re-audit, including FBS/PPBS, lipid profile, renal function tests, electrocardiogram (ECG), electrolytes, and chest X-ray.

Management of hypertension can be divided into two categories: lifestyle changes and medication. Pharmacotherapy is based on the patient profile and differs from person to person when allocating risk factors and comorbidities, which has seen a 64% increase in reaudit. Regular physical activity and dietary changes such as limiting salt intake, reducing alcohol consumption, reducing saturated fat intake, and following the Dietary Approaches to Stop Hypertension (DASH) diet are all critical steps in managing hypertension. Body weight management and weight loss programs are also valuable in lowering blood pressure. Routine follow-up and monitoring of the patient’s blood pressure is equally important as it leads to efficient management by either increasing the dose or tapering it; if required prescribing another class of drug or removal of one which saw an improvement in the re-audit (48%).

Limitations

Data entry for hypertension was incomplete, and many patients were excluded from the study.

Conclusion

Early diagnosis and management of high blood pressure reduce its progression to systemic complications, thereby, reducing morbidity and mortality rates. Being mainly asymptomatic, it is hard to diagnose this condition when a person is healthy. Promoting regular health checkups and identifying risk factors for this condition are the foremost steps to reduce the disease burden in our country. Audits can help us improve the standard of care and systematically address hypertension, helping us create checklists to maintain a consistent standard of care.

Conflict of interest

Nil

Financial support

Nil.