A study of the consistency between

hypertension medications prescribed by general

practitioners and 2018 ESC/ESH
guidelines for the management of
hypertension
32
Un estudio de la consistencia entre los medicamentos para la hipertensión prescritos por los médicos generales y
las pautas de la ESC/ESH de 2018 para el tratamiento de la hipertensión
Stafa Bijani1*, Ali Asghar Khaleghi2, Mahmood Hatami3, Hojatolah Najafi4, Aboutaleb Haghshenas5
Assistant Professor, Department of Medical Surgical Nursing, Fasa University of Medical Sciences, Fasa, Iran.
1

2
Assistant Professor, Non Communicable Diseases Research Center (NCDC), Fasa University of Medical Sciences, Fasa, Iran.
3
Fasa University of Medical Sciences, Fasa, Iran.
4
PhD candidate, Health Human Resources Research Center, Department of Health in Disasters and Emergencies, School of Management and Information Sciences,
Shiraz University of Medical Sciences, Shiraz, Iran.
5
M.sc, MSN. Department of Nursing, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran.
*Corresponding Author: Mostafa Bijani, Assistant Professor, Department of Medical Surgical Nursing, Fasa University of Medical Sciences, Fasa, Iran.
Email: [email protected]

Introduction: Prescription of the right antihypertensive Results: The participants ranged from 37 to 59 years of
Abstract

drug plays a key role in treatment and prevention of se- age with an average age of 47.23±15.1 years. 60% of
rious side effects for patients. The present study aims to the patients studied had stage 1, 30% stage 2, and 10%
identify the types of hypertension medications prescribed had stage 3 hypertension. Beta blockers were found to
by general practitioners and the degree to which they be the medications most frequently prescribed by the ge-
agree with 2018 ESC (European Society of Cardiology) neral practitioners. Most of the patients with cardiac di-
and ESH (European Society of Hypertension) Guidelines sorders, diabetes, and kidney failure had been prescribed
for the management of hypertension in the health centers beta blockers, which was not in accordance with the new
of villages near a city in the province of Fars, south of Iran. hypertension guidelines.

Materials and Methods: The present study is a des- Conclusion: Medications prescribed for patients with hy-
criptive, cross-sectional work where 300 individuals with pertension are usually not consistent with hypertension
hypertension were selected from 30 villages according to guidelines. It is recommended that general practitioners’
the cluster sampling method. Data were collected using awareness of hypertension guidelines be raised through
a checklist which addressed the respondent’s demogra- workshops in order to decrease or prevent the serious
phics, underlying disease, and type of hypertension medi- consequences of hypertension in patients by treating
cation. Subsequently, the extent of consistency between them correctly.
the prescribed medications and the hypertension guide-
lines were examined. The collected data were analyzed Keywords: Hypertension, Prescription Drugs, Hyperten-
using SPSS-23. sion Guidelines.

Introducción: la prescripción del fármaco antihiperten- Materiales y métodos: El presente estudio es

Resumen

sivo correcto juega un papel clave en el tratamiento y la un trabajo descriptivo y transversal en el que
prevención de los efectos secundarios graves para los pa- se seleccionaron 300
cientes. El presente estudio tiene como objetivo identificar
los tipos de medicamentos para la hipertensión prescri-
tos por los médicos generales y el grado en que están de
acuerdo con 2018 ESC (Sociedad Europea de Cardiología)
y ESH (Sociedad Europea de Hipertensión) para el manejo
de la hipertensión en los centros de salud de Pueblos cerca
de una ciudad en la provincia de Fars, al sur de Irán.
individuos con hipertensión de 30 aldeas según el mé- todo de
muestreo por grupos. Los datos se recopilaron mediante una lista
de verificación que abordaba los da- tos demográficos, la
enfermedad subyacente y el tipo de medicamento para la
hipertensión del encuestado. Pos- teriormente, se examinó el grado
de coherencia entre los medicamentos prescritos y las pautas de
hipertensión. Los datos recolectados fueron analizados utilizando
SPSS-23.

Resultados: Los participantes oscilaron entre los 37 y los 59 años

de edad, con una edad promedio de 47.23
± 15.1 años. El 60% de los pacientes estudiados tenían estadio 1,
30% estadio 2 y 10% hipertensión estadio 3.
 www.revhipertension.com Revista Latinoamericana de Hipertensión. Vol. 14 - Nº 1, 2019
Se encontró que los bloqueadores beta son los medica- the risks of stroke, heart attack, and cardiac disorders
mentos más frecuentemente recetados por los médicos by 30%, 20%, and 50% respectively11. The greatness
generales. A la mayoría de los pacientes con trastornos of the variety of hypertension medications with different
cardíacos, diabetes e insuficiencia renal se les habían rece- mechanisms of action, patients’ various responses to di-
tado bloqueadores beta, lo que no estaba de acuerdo con fferent categories of medications, and the variety of pri-
las nuevas pautas de hipertensión. ces have caused12. Physicians to occasionally select and
prescribe medications based on personal taste Moreover,
Conclusión: los medicamentos recetados para pacientes general practitioners’ unfamiliarity with new hyperten-
con hipertensión generalmente no son compatibles con sion guidelines has occasionally led to their prescribing
las pautas de hipertensión. Se recomienda aumentar la the wrong medication13.
concienciación de los médicos generales sobre las pautas
de hipertensión a través de talleres para disminuir o pre- Different types of medications are prescribed in different
venir las graves consecuencias de la hipertensión en los countries for treatment of hypertension; for example, in
pacientes al tratarlos correctamente. the U.S. and Canada, angiotensin-converting-enzyme in- 33
hibitors (ACEI) and calcium channel blockers are usually
Palabras clave: Hipertensión, medicamentos recetados, prescribed, while in Germany and England, physicians
pautas de hipertensión. prefer beta blockers and diuretics14.

A study reports that the chances of success of a single-

medication treatment plan for average hypertension are
Introduction

between 50% and 60%, while the probability of success

of a combination therapy is 80% to 90%15. According
to the study of Pasty et al., the majority of hypertension
patients (60%) use only one type of medication for their
condition and only 30% of patients are given a combina-
ypertension is a dangerous and life-threa-
tion therapy16. According to the study of, Taddei (2015)
tening disease that often doesn’t have
the chances of success of a combination therapy are consi-
any clinical signs1. Hypertension is a major
derably higher than those of single-medication treatment.
medical and general health issue which is becoming in-
This approach should improve BP (Blood pressure) control
creasingly prevalent2. Prevention of and controlling hyper-
and provide better cardiovascular protection17.
tension is a primary challenge to general health in many
countries3. Hypertension is known as a silent killer with As the prescription of suitable medications is essential to
multiple clinical, economic, and social consequences4. Hy- treating and controlling the consequences of hyperten-
pertension is the leading preventable contributor to car- sion and physicians’ awareness of hypertension guidelines
dio- vascular morbidity and mortality, affecting 1 billion can help them choose the right medication, the present
people and linked to more than 9 million deaths globally5. study was conducted to identify the types of hyperten-
sion medications prescribed by general practitioners and
According to World Health Organization (WHO), hyper-
the degree to which they are consistent with 2018 ESC/
tension accounts for 47% of strokes and 37% of ischemic
ESH Guidelines for the management of hypertension in
heart diseases6. 50% of the total medical costs is spent on
the health centers of villages near a city in the province of
treatment of hypertension in patients with cardiovascular
Fars, south of Iran.
diseases; thus, treatment of and controlling the condition
can lead to a reduction in medical costs and fewer disabi-
lities and fatalities7.
Materials and methods

Studies show that less than 50% of patients with hyper-

tension are aware of their condition, 25% are undergoing

he present study is a descriptive, cross-sectio-

their disease8. The purpose of treating hypertension is
prevention of injury to vital organs (brain, heart, kidneys, nal work conducted in 2018 on 300 patients
etc.). According to studies, reduction of systolic blood- aged over 30 who were undergoing treatment
pressure (SBP) by 10 mmHg and diastolic blood pressure for hypertension in health centers. Sampling was execu-
(DBP) by 5 mmHg decreases the risks of cardiovascular ted in two stages: initially, 30 villages were selected ac-
diseases and brain strokes by 20% and 32% respectively9. cording to the cluster sampling approach; subsequently,
random sampling was applied to select patients from the
Prescription of the correct hypertension medication is the villages. As most of the available research on hyperten-
most important part of a hypertension treatment plan and sion in Iran has been conducted in urban areas, the sub-
is key to recovery and controlling the consequences of the jects for the present study were selected from rural areas.
disease10. The results of various studies show that effec- Having acquired written permission from the department
tive treatment of hypertension by medication decreases of health, the researcher visited the health centers of the
 villages under study. For ethical considerations, the sub- Table 3: The type of prescription medication used in un-
jects were shown the researcher’s introduction papers, derlying diseases
informed that participation was on a voluntary basis, and Calcium
assured of their anonymity and confidentiality in the stu- Diuretics ACE inhi- Beta-
ARBs Channel Diseases
(thiazides) bitors blockers
dy. Data were collected using a checklist which addressed Blocker
the patients’ demographics and the types of hypertension % n % n % n % n % n Myocardial
medications prescribed by their general practitioners. Sub- 3.84 5 5.38 7 6.15 8 23.10 30 61.53 80 infarction
sequently, the extent of consistency between the prescri-
% n % n % n % n % n Chronic kidney
bed medications and the 2018 ESC/ESH Guidelines for the
20 2 10 1 10 1 20 2 40 4 disease
management of hypertension was measured. Descriptive
statistics and SPSS-23 were employed for data analysis. % n % n % n % n % n
Heart failure
15 6 10 4 12.5 5 25 10 37.5 15
Results

% n % n % n % n % n
Diabetes
34 6.68 2 10 3 16.66 5 20 6 46.66 14

Discussion
he participants were aged between 35 and 59
years old, with the mean being 47.23±15.1
years; 120 were male and 180 were female. 90 ypertension is an increasingly prevalent
(30%) of the patients did not have a history of a primary and serious issue in healthcare in most
disease. Among 210 (70 %) the patients with a history of countries. Correct choice of treatment ac-
an underlying disease, 130 (61/9%) had a history of myo- cording to the new hypertension guidelines can play a key
cardial infarction, 10 (4/76 %) had a history of a chronic role in controlling and preventing the acute and chronic
kidney disease, 40 (19.04%) had a history of heart failure, consequences of hypertension. The results of the present
and 30 (14/38%) had diabetes. 60% of the participants study showed that beta blockers were the general practi-
had stag 1 hypertension, 30% stage 2 and 10% had sta- tioners’ first choice for treatment of hypertension. Hyper-
ge 3 hypertension (Table 1). tension guidelines suggest that thiazide diuretics and beta
blockers should be the first-line medications for hyperten-
Table 1: Classifications of high blood pressure: ESH/ESC 2018 sion, which is relatively consistent with the findings of the
Optimal SBP [mmHg] <120 DBP [mmHg] <80 present study. Here, however, atenolol was the most com-
Normal 120–129 <80 monly prescribed beta blocker to the exclusion of other
Upper range of normal 130–139 80–89 beta blockers. Also, thiazide diuretics were found to be
Grade I hypertension 140–159 90–99
rarely prescribed. According to the 2000 study of Wright
et al., beta blockers were the most common group of me-
Grade II hypertension 160–179 100–109
dications taken by 48% of patients18. A study of 3777
Grade III hypertension ≥ 180 ≥ 110 patients in the U.S. over 18 months showed that 60% of
patients were on a single medication and the most fre-
The most frequently prescribed medications for stage 1
quently prescribed medications were beta blockers and
were found to be beta blockers (Atenolol), and the most
ACE inhibitors19. In their study of 128 family doctors in
frequently prescribed medications for stage 2 were ACE
the state of Iowa in 1988, Carter et al. discovered that for
inhibitors and thiazide diuretics. The majority of the pa-
79% of patients with stage 1 hypertension, beta blockers
tients with the underlying conditions of heart disorders
were prescribed as the first-line treatment, which is similar
and diabetes had been prescribed beta blockers (Ateno-
to the findings of the present study20. In another study in
lol). Beta blockers were found to be the most frequently
the U.S. where physicians’ prescriptions written between
prescribed medications. 60% of the patients were taking
1992 and 1995 were collected and examined, the results
beta blockers (Table 2-3).
showed that calcium channel blockers were the most fre-
quently prescribed medications in the first-line treatment,
Table 2: Distribution of type of antihypertensive drugs in hyper-
tensive patients which is not consistent with the findings of the present
21
Percentage Number Drug study . In 1999, Collin et al. studied 37000 patients with
60 180 Beta-blockers
hypertension for 5 years and found beta blockers and
25 75 Calcium Channel
thiazide diuretics to be the medications most frequently
Blocker
prescribed for them. Their results showed that the afore-
6 18 ACE inhibitors
mentioned medications resulted in an average decrease
4 12 ARBs in diastolic blood pressure by 5-6 mmHg22. According to
5 15 Diuretics (thiazides) 2018 ESC/ESH Guidelines for the management of hyper-
100 300 Overall tension, beta blockers are recommended for patients with
hypertension who have had myocardial infarction (MI)23.
www.revhipertension.com Revista Latinoamericana de Hipertensión. Vol. 14 - Nº 1, 2019
In the present study, the results showed that the guideline

Conclusions
was being followed (in 61% of the cases, beta blockers
had been prescribed). For patients with heart failure (HF),
use of beta blockers (atenolol) following serious left ventri-
cular dysfunction can aggravate the patients’ condition. In
the present study, beta blockers (atenolol) had been pres- he findings of the present study show that
cribed for 40% of patients with cardiac disorders, which the medications prescribed for treatment of
was not consistent with the new guidelines23. Moreover, hypertension are not consistent with hyperten-
according to the new hypertension guidelines, in the case sion guidelines. Thus, it is recommended that workshops
of patients with heart failure, administration of selective be planned to introduce general practitioners to new
beta blockers, like Carvedilol, is preferred to atenolol. The treatment plans which bring about more satisfactory results
new guidelines state that ACE inhibitors and angioten- in treatment of hypertension.
sin receptor blockers (ARBs) can significantly control hy-
pertension and prevent acute left ventricular dysfunction Acknowledgement: The researchers are grateful to all the 35
in patients with heart failure24. In the present study, the individuals who cooperated with them in the present study.
most frequently prescribed hypertension medications for
Conflict of interest: The authors declare that they have no
patients with diabetes were beta blockers (46%)25. Con-
conflict of interest.
sidering the side effects of beta blockers (restricting hor-
monal responses and masking the clinical symptoms of Funding: This research did not receive any specific grant
hypoglycemia), they are usually not selected as the first- from funding agencies in the public, commercial, or not
line treatment for hypertension26. In a study comparing for profit sectors.
the effects of ACE inhibitors and ARBs on one hand with
those of other common hypertension medications (beta
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