Cardiologia Croatica. 2017;12(11-12)

Bojan Jelaković

The goal of guidelines for diagnosing arterial hypertension (1) is to make them practical and useful in everyday work, which was not the case with many of the previously published guidelines that now remain only as an academic monument of one moment in the field of clinical medicine. These guidelines are based on recent guidelines from international professional societies, and their authors have conducted a detailed review of the literature, noting the levels of significance and evidence. We do not list the levels of significance or levels of evidence in this document; instead, based on international, relevant, and recent guidelines, we clearly indicate which diagnostic tests should be performed in specific situations and which physicians at what level of healthcare have the responsibility to perform a specific range of tests. In this way, we reduce the amount of distracting information, and those who are interested in the level of significance or evidence can always check that information in the references to international guidelines or documents cited at the end of the guidelines. Neither do we list the hundreds of references which provided the basis for the preparation of the international guidelines, and thus these guidelines as well; we only note the basic references which will direct anyone interested to the original references. This has allowed us to reduce the size of the guidelines by tens of pages. These guidelines emphasize concrete procedures and data with clearly specified border values. Most data is shown in tables and flowcharts with clear explanations. Since the goal of these guidelines is not only to direct and facilitate decisions in everyday clinical practice, but to educate as well, texts explaining elements of basic knowledge are presented in blue background next to the flowcharts. Some of this is intentionally repeated several times – because of its importance but also to facilitate memorization and later application. Such is the case, for instance, with blood pressure and heart frequency measurements, instructions on taking an exhaustive medical history and performing a clinical examination, and so on. There are several completely novel elements in the guidelines. For the first time, clear instructions are provided for heart frequency, the location and role of measuring central arterial pressure and pulse wave frequency is mentioned, and the evaluation of the kidney function is emphasized as one of the independent cardiovascular risk factors. Information technology is also mentioned for the first time, i.e. home-based blood pressure telemonitoring and the use of verified smartphone applications as a new potential tool in establishing the correct diagnosis. This will be expanded in more detail in the second part of the guidelines, which will address increasing compliance and improving control. A few appendices have been added at the end of the guidelines, which can be of use in everyday clinical practice – sleep apnea questionnaires, a questionnaire on erectile and sexual dysfunction, a questionnaire on cognitive dysfunction, and others. These questionnaires are also accompanied by precise instructions on who to apply and interpret them. Furthermore, peripheral arterial disease has been singled out for the first time, which is very common in hypertonic patients but is still not widely acknowledged as an issue that should be considered in clinical work. The Edinburg questionnaire and a clear flowchart have been added as well. The diagnostics of subclinical heart failure are also a commonly unrecognized problem, so the current flowchart for heart failure diagnostics has been added as well. During the diagnostic procedure, hypertonic patients are often exposed to frequent radiological tests and thus also to the risk of contrast-induced nephropathy; therefore, the appendix also contains a flowchart on the diagnosis and prevention of contrast-induced nephropathy. In these guidelines, we wanted to be practical, precise, and realistic given the circumstances in our health care setting. The goal was to gather and encompass as many procedures and as much data in a single resource that will be useful in practice, so that the physician does not have to lose time in finding this information either in the guidelines themselves or in the literature. The guidelines contain only the essentials, but direct the readers to further reading and searches. As with all guidelines, they should not be seen as prescriptive, but rather as a document that provides useful information and advice which the physician should apply individually with every particular patient. What sets them apart from others is that they contain accurate and concrete facts and precise information and data, which can further facilitate clinical thinking and help make the diagnostic procedure as accurate and as rational as possible. This is the first part of the guidelines on the treatment of hypertonic patients being prepared by professional societies. The second part will contain practical guidelines for the treatment of patients with arterial hypertension and practical guidelines for the diagnostics and treatment of hypertension in children and adolescents.

Bojan Jelaković, Maja Baretić, Maja Čikeš, Živka Dika, Margareta Fištrek-Prlić, Ana Jelaković, Jelena Kos, Ivana Kraljević, Mario Laganović, Robert Likić, Martina Lovrić-Benčić, Draško Pavlović, Darko Počanić, Hrvoje Tiljak, Majda Vrkić-Kirhmajer, Tajana Željković-Vrkić, Željko Reiner, Davor Miličić

Arterial hypertension is the main independent risk factor for cardiovascular morbidity and mortality. The prevalence of hypertension is increasing in most countries. Despite the availability of all classes of antihypertensive drugs, the rate control in hypertension treatment is insufficient, for which there are abundant explanations. One of the main reasons is the gap between evidence-based guidelines and their applicability in practice, a gap which leads to poor rate control in hypertension and increases the number of premature cardiovascular events and death. The first step in the management of a hypertensive patient is rational diagnosis, i.e., to avoid increasing the expenses of treating this mass chronic disease by unnecessary tests and to minimize errors. The aim of these practical guidelines for diagnosis of hypertension is for them to be practical and useful in everyday practice. There is an emphasis on particular procedures and data with exact cut-off values. The aim of these guidelines is not only to guide and simplify our decision-making process in everyday work, but also to educate. We thus provide reminders on some fundamental knowledge. There are some novel elements (instructions of heart rate, place and role of central blood pressure and pulse wave velocity measurement, estimation of renal function, IT e.g. telemonitoring, and the use of smartphone apps). At the end of the guidelines, we provide several appendices which could be useful in everyday clinical work, such as questionnaires for sleep apnea syndrome, questionnaires for erectile and sexual dysfunction, cognitive dysfunction questionnaires, and others. In these guidelines, we wanted to be practical, precise, and realistic given the options available in our work setting. The objective was to show and cover as many specific facts and procedures as possible that we find useful in everyday work, so that the clinician does not have to waste time searching the guidelines or literature.