High Blood Pressure Research Council of Australia

HBPRCA Email Newsletter March-April 2010

Welcome from Geoff Head

We have a great issue this quarter with a feature article from Faline Howes and Mark Nelson on how general practitioners manage hypertensive patients. Lots of other news so read on.

ISH2012 – As you are all aware, the HBPRCA will be hosting ISH2012 in Sydney, 30 September – 3 October. As members of the HBPRCA, we would like you to advertise the Congress, by downloading the slides and including them at the end of your presentations. Please click here to download.

ISH2010 – will be in Vancouver on the 26th-30th September. PowerPoint slides available here.

President’s Message 2010 Annual Scientific Meeting News 2010 Workshop News Student News Membership News Society Liaison News Ambulatory Blood Pressure Monitoring (ABPM) Working Group Initiative Feature Article Upcoming Meetings Articles of interest New Secretariat Contact Details

In This Issue
President’s Message from Stephen Harrap
2010 Annual Scientific Meeting News from Kate Denton
2010 Workshop News
Membership News
Society Liaison News
Ambulatory Blood Pressure Monitoring (ABPM) Working Group Initiative
Feature Article
Upcoming Meetings
Articles of interest
New Secretariat Contact Details

President’s Message from Stephen Harrap

With all the excitement building for ISH 2010 in Vancouver and our own meeting in Melbourne later in the year, it would be easy to overlook World Hypertension Day on May 17.

In previous years the HBPRCA has run some interesting campaigns. My personal favourite involved a previous Howard Government Health Minister stripped to the waist, his Jockeys just peeping above his trousers, resplendent with a hirsute chest and a 24-hour ambulatory BP monitor attached. A sign of things to come. These days it’s Budgie-Smugglers and surfboards.

However, WHD 2010 will be even bigger and of greater impact if things go according to plan. We have been delighted that one of the biggest advertising agencies in the world – Ogilvy – has, through Ogilvy Healthworld in Australia, taken on the HBPRCA as a pro bono client. We owe a debt of thanks to Vicky Stavroulakis from Boehringer-Ingelheim who through contacts with Ibi Szentirmay and Graham Edwards put us in touch with Ogilvy Healthworld.

Ibi and Graham have been absolutely fantastic and expressed a desire to maintain the HBPRCA as a long-term pro bono client and use WHD as the launch pad for a campaign to raise awareness about blood pressure throughout the community. We are in the process of putting the campaign together and we have been astounded by the links throughout the advertising, PR and media world that they hope to bring to the party.

Watch this space!

2010 Annual Scientific Meeting News from Kate Denton

Mark this in your diaries!
Wednesday 1 – Friday 3 December 2010
Crown Conference Centre, Melbourne

The grants are in (hopefully), and now we are making advances with this year’s Annual Scientific Meeting to be held at the Crown Conference Centre, Melbourne in December. Our three main speakers have been invited and they have all accepted; Professor David Harrison, Professor David Celermajer and Dr Anthony Ashton. This year the meeting will commence late Wednesday afternoon with our Austin Doyle lecturer presenting “Voyages in vessels – non-invasive detection of vascular disease” followed by posters, including some moderated prizes, and welcome drinks! A convivial evening of friends and science to get our meeting off to a great start.

RD Wright Lecturer – Professor David Harrison is the Bernard Marcus Professor of Medicine at Emory University. Dr Harrison is also the Director of Cardiology at Emory. His career has been devoted to basic research related to vascular function, the practice of cardiology and the education of young physicians. His work currently focuses on Hypertension, Inflammation and Adaptive Immunity. Dr. Harrison has been an Established Investigator of the American Heart Association and has served on numerous committees for the AHA and editorial boards of multiple journals, including Circulation, Circulation Research, Atherosclerosis Thrombosis and Vascular Biology, the Journal of Clinical Investigation and Hypertension. He has given numerous invited and named lectures related to his research, including, Robert M. Berne Distinguished Lecture to the American Physiology Society and the Sir George Pickering Lecture to British Hypertension Society Annual Scientific Meeting. In 2004, Dr. Harrison received the Novartis Award from the American Heart Association Council on High Blood Pressure, which is the highest award given for hypertension research.

Austin Doyle lecturer – Professor David Celermajer is the Scandrett Professor of Cardiology and Medicine, Central Clinical School and Heart Research Institute. His work encompasses basic, clinical and public health research. His interests lie in the area of early detection and prevention of heart disease. He has won numerous awards and prizes for ongoing contributions in his field including the Commonwealth Health Minister’s Award For Excellence In Health And Medical Research, in 2002 “for outstanding lifetime achievement in health research”. In 2006, Professor Celermajer was elected as a Fellow of the Australian Academy of Science.

Colin Johnston lecturer – Dr Anthony Ashton is an R. Douglas Wright Fellow, NH&MRC, Senior Lecturer, University of Sydney and Scientific Director, Division of Perinatal Research, Royal North Shore Hospital. Anthony is a vascular biologist with significant experience in the manipulation of blood vessel formation. He undertook post-doctoral training at the Albert Einstein College of Medicine in New York. Whilst in New York he published several seminal manuscripts on the regulation of blood vessel formation in cardiovascular disease. In 2006 Anthony was awarded a NHMRC Biomedical Career Development Award to return to the Perinatal group and explore his unique findings examining the role of human-specific genes in complications of pregnancy. In January 2007 he was awarded the positions of Scientific Director of Basic Research and Team Leader of the Program into Vascular Development and Placentation at the Perinatal Research group in the Kolling Institute. His main research interests are in understanding the basis for the formation of new blood vessels, the destruction of existing blood vessels and how these processes are altered to complicate multiple processes, including placental formation and fetal development.

2010 Workshop News

This years annual workshop will be for a half day only in order to give the main meeting more time and allow a less crowded feeling. The theme for the workshop hasn’t yet been finally decided but our working title is ”Better Blood Pressure Measurement” which will focus on issues relating to clinic, ambulatory and home blood pressure measurements and techniques. If you would like to make a contribution to the sessions please feel free to contact me via the Secretariat.

Membership News

March 31st was the annual subscription due date for the HBPRCA. If you have thus far overlooked paying it’s still not too late! Simply go to the HBPRCA website (http://www.hbprca.com.au/) and follow the link on the left for access to the secure payment site or to download a form for return by post. If you don’t have internet access, can’t remember if you have paid, or just need a bit of help, contact the Secretariat by phone, fax or post (details below).

Don’t forget to encourage your graduate students and post docs to take out membership with the Council (free for students!). The special initiatives that have been introduced are specifically intended to benefit student and early career members. And of course participating in the vibrant Annual Scientific Meeting is a tremendous opportunity for you, your post-docs, students and research associates to see and discuss the broad research interests of the council and share your own.

Society Liaison News

Not a great deal to report after the flurry of announcements about the winners of the various HBPRCA awards in the last Update. January is definitely a slow news quarter. I am, however, pleased to tell you that we now have the name of the winner of the Goldblatt Award from the US. Christian Delles from Glasgow will be joining us at our meeting in Melbourne at the end of the year. Fortunately, Michael De Silva, has saved my skin with a very nice report on his trip to the US last year. So I will leave you with that:

“As a recipient of the High Blood Pressure Research Council of Australia Young Investigator Award, I was given the wonderful opportunity to attend the 63rd High Blood Pressure Research Conference held by the American Council for High Blood Pressure Research in Chicago, USA (September 23rd – 26th 2009). The High Blood Pressure Research Council of Australia was extremely generous in providing me with financial assistance to attend this conference, and in organizing the opportunity to present my research as an oral communication.

The conference attracted numerous distinguished scientists in the field of cardiovascular research and the presentations I attended by these researchers were both varied and stimulating. Following the Harry Goldblatt Awards session, which was full of interesting presentations by young post-doctoral researchers, I tried to suppress my nerves as I gave my presentation titled “Defining the Role(s) of Nox2-Containing NADPH Oxidase in the Cerebral Circulation”. This was an immense honour to be able to present my work at this conference and it no doubt increased my exposure to the international scientific community.

In addition to attending the conference, I was fortunate to visit the research laboratories of Professor Frank Faraci at the University of Iowa in Iowa City and Professor Neil Granger at the Louisiana State University Health Sciences Center in Shreveport. These lab visits were extremely beneficial as I was able to meet two highly regarded scientists in the field of cardiovascular research. I was also fortunate to be invited to present a seminar and received many positive comments about my research.

I am extremely grateful to the High Blood Pressure Research Council of Australia for organizing this amazing opportunity. Thank you.”

63rd High Blood Pressure Research Conference Report
T. Michael De Silva
Chicago, Illinois, USA

Ambulatory Blood Pressure Monitoring (ABPM) Working Group Initiative

Members: Geoff Head, Susie Mihailidou, Karen Duggan, Alexandra Bune, James Sharman, Arduino Mangoni, Peter Howe, Narelle Berry, Diane Cowley, Michael Stowasser, Lawrie Beilin, Jonathan Hodgson, John Chalmers, Carla Morey, Mark Nelson, Mark Brown, Barry McGrath and John Ludbrook

We have continued our analysis of the very large dataset we have gathered and this time compared the influence of obesity of setting ambulatory targets for hypertension management. To this end we submitted the abstract below to ISH.

Objective: Although ambulatory blood pressure (ABP) equivalents exist for the diagnosis of hypertension, there are limited ABP equivalents for target blood pressure (BP) in the management of hypertension. Our collaborative initiative has derived reference ABP equivalents for the clinic BP targets used in hypertension diagnosis and management (BMJ, in press). Considering the increasing prevalence of obesity as a risk factor for hypertension, we have since compared these targets in age and gender matched cohorts of obese with body mass index (BMI) >30 and lean subjects (BMI < 25).

Design and Methods: Data obtained from 2023 individuals using validated devices for 24 hour ABPM were collated from multiple centres across Australia. Seated or supine clinic BP was measured by trained non-medical health professionals to minimise white coat effect. Least product linear regression analysis was used to relate clinic BP and ABP values, with the resultant regression equations being used to generate ABP equivalents for the lower limit of grade 1 hypertension (equivalent to 140/90 mmHg) or therapeutic target (130/80 mmHg).

Results: Both groups were 50% female and aged 53.8 years. Obese subjects had average BMI of 34.4 and clinic BP 143/85 mmHg (n=1403). Lean subjects had BMI of 22.6 and clinic BP 140/83 mmHg (n=619). Daytime ABP equivalent for clinic 140/90 mmHg was 132/86 mmHg for lean and 134/83 mmHg for obese. Day ABP equivalents of target clinic BP of 130/80 mmHg values were 126/78 for lean and 126/75 mmHg for obese subjects.

Conclusions: The similarity of clinic BP and daytime ABP readings across a wide BP range in both lean and obese individuals indicates that accepted targets for clinic BP management are also applicable as targets for ABP, regardless of the presence of obesity.

Feature Article – How do general practitioners manage their hypertensive patients? from Faline Howes and Mark Nelson, University of Tasmania

Hypertension is the most frequently managed problem in general practice1. A potential barrier at the level of the individual general practitioner (GP) is clinical or therapeutic inertia: the recognition of a problem and the failure to act. This phenomenon has been described as an issue in the management of patients with asymptomatic chronic illnesses such as hypertension, dyslipidaemia and diabetes2.

We conducted a qualitative study that was presented at the HBPRCA ASM in 2009. Six focus groups were undertaken with 30 GPs and GP registrars in 2008. Common emerging themes were derived by an iterative thematic analysis. Analysis was contemporary and ceased when no new issues emerged suggesting data saturation. The themes developed capture GPs’ descriptions of why it is difficult for them to diagnose and manage hypertension. Barriers to initiating treatment and treating to target were often discussed at the same time, with issues surrounding treatment to target dominating conversation.

Clinical uncertainty about the true blood pressure value and a distrust of the technology used to measure blood pressure

Most participants expressed uncertainty regarding the accuracy and representativeness of individual BP readings taken in the clinic. Participants expressed a lack of confidence in the HBPRCA distributed OMRON HEM-907, questioning their accuracy and reliability. GPs described a process of “mental adjustment” of BP readings. They were adjusted down to ‘better represent’ what was thought to be the patient’s ‘true’ underlying BP. It also involved taking multiple readings and accepting the lowest as the most representative.

Distrust of the evidence underpinning hypertension management
Rather than large gaps in knowledge and awareness of the management of hypertension, there was an element of distrust toward the evidence underpinning it. Participants had seen major changes in the evidence during their own careers, for example, “systolic was previously 100 plus your age”. Questions were raised about the risk-benefit ratio for treating the elderly. Distrust was also reflected in comments such as “targets are continually being revised lower and lower”.

Patient age, gender and co-morbidity
The two extremes of the lifecycle were felt to fall outside the limits of the available evidence. Children and adolescents were seen as a challenge and one that would increase in the future given the obesity epidemic. Participants were reluctant to initiate and treat to target in the elderly due to the witnessing of adverse events. The fear of the consequences of treating a person’s hypertension was far greater than the fear of the consequences of not treating it.

Men were described as difficult particularly if young, busy, overweight, single or heavy consumers of alcohol. In terms of co-morbidity the main groups included: the anxious, those with another disease as the main focus of treatment, and renal patients with lower targets, and difficult to manage side effects and interactions. Culturally and linguistically diverse populations were also seen as challenging.

Perceived patient attitude
Patients were often described as being reluctant or unwilling to both commence anti-hypertensives and to adhere to treatment in the long term. Delay or failure to initiate was attributed to some patients preferring an initial trial of lifestyle modification, reluctance to take an additional medication, patient’s previous experience with side effects, a lack of understanding of risk, and a lack of persuasiveness by the GP.

Particularly with regards to making lifestyle changes, GPs described patients’ as often lacking the motivation to change and being reluctant to take responsibility for their own healthcare. The medical literacy of patients was raised and concern expressed about how the public perceives both the concepts of BP and cardiovascular risk.

Clinical inertia
Clinical inertia was evident in discussions around making a diagnosis, providing advice on lifestyle change and treating to target. Associated issues included a time poor environment, perceived patient attitude and difficulties encountered in a group practice: a few participants described reluctance to initiate treatment in ‘someone else’s patient’ despite repeated high BPs having been recorded.

Most participants’ stated that their knowledge of lifestyle factors and how to manage them was adequate; the overriding problem was the lack of success seen in practice. This led to a lack of motivation.

With regards to reaching target, waning motivation was also described as a ‘mental slowing down’. This was related to how close to target the patient’s BP was, the number of comorbidities they had, and the degree of polypharmacy. Failure to reach target was further justified by discussing BP as a continuum, with small improvements viewed as a therapeutic success.

Patient-centred care
The GPs described a comprehensive, holistic approach to patient care. Participants stated they individualised the approach to hypertension management. Biomedical information was integrated with patient concerns and context.

Cost was viewed as a major barrier for some patients, particularly those who did not qualify for government healthcare benefits. One practice located in a socioeconomically disadvantaged area, described financial costs and the role of stress in their patients’ lives as a major contributor to their decision-making.

Systems issues
Systems issues included a lack of resources and a lack of time. To monitor therapy more accurately, more automated machines for home monitoring and greater access to ambulatory BP monitoring were considered of need. Hypertension was viewed as a general practice area of speciality rather than a specialist area of care. However, practitioners found it difficult to identify specialists with a primary interest in hypertension management to refer to and identified timely access to specialists and allied health practitioners as an issue.

Time was raised as an issue. The lack of time in consultations related to the complexity of managing hypertension concurrently with other chronic disease and it related to competing demands where doctor and patient agendas may not harmonise.

Addressing these concerns
Further research is required into the process of care to further develop the evidence base for hypertension management strategies. The HBPRCA is funding us to conduct further qualitative research to address the barriers to the uptake of evidence-based care.

REFERENCES
1. Britt H, Miller GC, Charles J, Henderson J, et al. General practice activity in Australia 2007-08. General practice series no. 22. Cat. no. GEP 22 Canberra: AIHW; 2008.
2. Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, et al. Clinical inertia. Ann Intern Med 2001; 135(9):825-34.

Upcoming Meetings

The 23rd Scientific Meeting of the International Society of Hypertension

Register now!
Click here to register. The one-year Countdown to the 23rd Scientific Meeting of the International Society of Hypertension (ISH 2010) to be held September 26 – 30, 2010 in beautiful Vancouver, British Columbia, Canada is on! This important International Meeting, focussing on Global Cardiovascular Risk Reduction will be at the forefront of new concepts in basic, clinical and population science.

Online abstract submission
ISH 2010 is already accepting abstract submissions. Early decisions on acceptance of abstracts will give participants who require travel visas a longer lead time for applications. The three major program tracts are Basic Science, Clinical Science, and Population Health / Public Policy. The target audience includes Basic Scientists, Clinicians (Cardiology, Endocrinology, General Medicine, Neurology, Nephrology, Primary Care Physicians, Nurses, Nutritionists and Pharmacists), and Population Health and Public Policy specialists and is inclusive of all individuals interested in cardiovascular health. Complete guidelines and directions on how to submit an abstract can be found on the ISH 2010 website.

Meeting objectives
The ISH 2010 theme, Global Cardiovascular Risk Reduction, will capture the newest information in the field of hypertension and will also focus on all aspects of cardiovascular risk. Future perspectives, new research, treatment and prevention will be showcased over four days of invited plenary talks and oral and poster presentations. Special Symposium initiatives include an Alaskan Cruise and several high profile Summits to discuss priority needs and actions for non-communicable disease prevention. The meeting will provide a forum for scientific exchange, global interaction and global initiatives with the objective of a legacy of new initiatives in Global Cardiovascular Risk Reduction.

Accommodation & optional tour and social event program
ISH 2010 has arranged for a selection of hotels close to the Meeting venue that will meet everyone’s budget. The Meeting has also arranged a fabulous optional Tour and Social Event program exclusively for ISH 2010 attendees. Accommodation as well as Tours and Social Events can be booked conveniently during the online registration process, or you may update your registration with Accommodation and/or Tour and Social Event Participation once your travel arrangements are made.

Everything at your fingertips
Visit the ISH 2010 website for detailed information on the Meeting including Scientific Program, Registration, Abstract Submission, Accommodation, Tours and Social Events. The Main Announcement is available on the website as a pdf download to review at your leisure.

HBPRCA younger members able to apply for FHBPR travel grant

Articles of interest

Australian Division of World Action on Salt and Health (AWASH) Response to Government Salt Targets (Bruce Neal quoted)

AWASH congratulates the Australian government on yesterday’s announcement of salt targets for bread and breakfast cereals and keenly anticipates hearing the salt targets for other food categories. … read more

If you have been quoted in the media, please email us the link to hbprca@meetingsfirst.com.au

Acknowledgements

HBPRCA would like to acknowledge the support of the following companies:

Corporate Members

Corporate Sponsors

Meetings in 2010

6th International Congress of Pathophysiology
22 – 25 September 2010
Montreal
Click here for meeting website
3rd International Conference on Fixed Combination in the Treatment of Hypertension, Dyslipidemia and Diabetes Mellitus
18 – 20 November 2010
Brisbane
Click here for meeting website

Meetings in 2011

8th Asian-Pacific Congress of Hypertension 2011 (8th APCH 2011)
24 – 27 November 2011
Taipei International Convention Center (TICC), Taiwan
Click here for meeting website

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