Evaluation of Clinical Practice Guideline

Evaluation of Clinical Practice Guideline

Healthcare Problem: Hypertension

Hypertension is a continuous elevation in blood pressure. Blood pressure is described in terms of systolic blood pressure and diastolic blood pressure. It is written as a fraction, with the numerator being the systolic pressure and the denominator being the diastolic pressure. Systolic pressure represents the blood pressure when the heart is contracting. Diastolic pressure represents the blood pressure when the heart is relaxing. Hypertension occurs when either or both of the pressures are elevated.

The International Society of Hypertension groups or classifies blood pressure into four classes. The first class is normal pressure, a blood pressure of less than 130/85mmHg (Nugroho et al., 2022). The second class is high-normal, which is blood pressure ranging between 130/85mmHg and 139/89mmHg. The third class is grade 1 hypertension, which is blood pressure ranging between 140/90mmHg and 159/99mmHg. Finally, the fourth class is grade 2 hypertension, a blood pressure equal to or greater than 160/100 mmHg.

Morbidity, Mortality, and Epidemiology

Cases of hypertension have been rising extensively and rapidly. The most common principal diagnosis in the United States of America is hypertension (Rivera, Martin & Landry, 2019). It is also the largest risk factor for mortality and morbidity worldwide and a major preventable cause of cardiovascular illnesses such as myocardial infection, stroke, and chronic renal disease (Mills, Stefanescu, & He, 2020). Approximately 1.4 billion adults worldwide suffer from hypertension, and the prevalence continues to rise. Notably, awareness of the disease and the use of antihypertensive medications is relatively low. Only 45.6% of the population suffering from hypertension were aware that they had the illness. Only 36.9% of those with the illness were using antihypertensive medication. It has been well-established that there is a difference in the prevalence of hypertension between men and women. The prevalence is higher in men, at 24.5%, than in women, at 21.9% (Song et al., 2020).

Pathophysiology

Normal blood pressure is a balance between systemic vascular resistance and cardiac output. This balance involves physiological mechanisms such as chemoreceptors, baroreceptors, the renin-angiotensin-aldosterone-system, and hormones such as atrial natriuretic peptides, mineralocorticoids, and glucocorticoids. All these mechanisms work together to constrict and dilate blood vessels. They also influence the retention and excretion of fluids and electrolytes, thus maintaining a balance between systemic vascular resistance and cardiac output. Derangement in any of these mechanisms leads to a change in function (Harrison, Coffman & Wilcox, 2021). Elevated systemic vascular resistance or elevated cardiac output causes elevated blood pressure.

The risk factors for functional derangement can either be modifiable or non-modifiable. Non-modifiable risk factors cannot be changed by any means. They include gender, ethnicity, age, and heredity. The male gender suffers more from hypertension compared to the female gender (Song et al., 2020). The risk of suffering from hypertension increases with advancing age, usually above 65 years, and the disease is more prevalent among the black communities (Spruill et al., 2019). Furthermore, an individual is more likely to suffer from hypertension if they have a first-degree relative who developed elevated blood pressure at an early age, for instance, above the age of 55 years.

Modifiable risk factors are those which can be prevented or controlled by various measures. They include physical activity, dietary intake, stress, and socioeconomic status (Jagannathan et al., 2019). Minimal physical activity predisposes an individual to increased body weight. Accordingly, increasing physical activity and maintaining a healthy body weight decreases the chances of suffering from hypertension. Dietary intake also predisposes individuals to hypertension. Excessive salt intake, consumption of high-calorie diets, and low fibre intake can cause hypertension. Consumption of a balanced diet rich in fibre and an adequate quantity of fats, carbohydrates, and proteins lowers the risk of acquiring hypertension. Alcohol consumption and cigarette smoking should also be modified to reduce the risk of suffering from highly elevated blood pressure.

Clinical Practice Guideline

The “Practice Guidelines for the Management of Hypertension” were released in May 2020 by the International Society of Hypertension (ISH). The ISH 2020 guidelines were created based on scientific evidence. The guidelines were meant to be applicable on an international level and suitable for use in low-middle-income and high-income countries. Furthermore, the guidelines were expected to be brief, easy to understand, and accessible to nurses and community health workers as necessary. The stated goal was to follow the available data and create a fair proposal for international usage in keeping with the ISH mission.

The Clinical Practice Guideline and Addressing the Health Problem

The ISH 2020 practice guidelines adequately address hypertension. Blood pressures have been clearly defined, the time of starting hypertension therapy has been clearly stated, and the assessment of comorbidities and cardiovascular risk factors in those with the disease has been discussed (Nugroho et al., 2022). The guidelines additionally discuss the pharmacological treatment of choice, opinions on beta-blockers as a choice of medication, and therapy options for resistant hypertension. The use of out-of-office blood pressure measurements, blood pressure targets, and re-evaluation are also discussed. Hypertension in the African population is mentioned.

ISH guidelines describe blood pressure as normal, high normal, grade 1, or grade 2 hypertension. Ideally, a patient is diagnosed with hypertension after multiple office visits. The diagnosis can be supported by out-of-office blood pressure measurements. Out-of-office measurements are done by the patients themselves or by ambulatory blood pressure monitoring.

Patients suspected to have hypertension undergo a thorough medical examination. They are evaluated for risk factors such as obesity, dyslipidemia, stroke, ischemic heart disease, chronic renal disease, dietary salt and caloric intake, diabetes mellitus, smoking, and alcohol drinking habits. Family history of elevated blood pressure, dyslipidemias, cardiovascular diseases, and diabetes mellitus are also evaluated. A complete physical examination and laboratory and radiological investigations are also conducted.

Initiation of therapy and treatment of choice depends on the stage of the disease. Lifestyle changes are the first-line treatment choice in managing elevated blood pressure. Treatment with pharmacological options is considered when there is a failure to maintain normal blood pressure with lifestyle changes. Pharmacological treatment is started when blood pressure is at 140/90 mmHg. ISH guidelines recommend a combination of drugs with different mechanisms of action to achieve better treatment outcomes. The use of beta-blockers is recommended in patients with cardiovascular diseases.

The target blood pressure for an individual receiving treatment is less than 130/80 mmHg but more than 120/70 mmHg. This target is expected to be achieved within three months after the initiation of pharmacological treatment. Optimal therapeutic dosages should be provided, and patient medication compliance should be observed to achieve this target. If treatment failure occurs or the patient has resistant hypertension, they are referred to centres that are well-equipped to deal with their condition.

Basis of the Practice Guideline on Current Evidence

The ISH practice guidelines were set in 2020. Systematic reviews were used to make evidence-based recommendations that informed the management of elevated blood pressure (Beany et al., 2019). A systematic literature review was conducted after defining clinical questions to find data that answers these issues. The evidence was then compiled, graded to reflect the quality of its methodology, and presented. Evidence-based recommendations raised the standard of patient care by encouraging beneficial interventions.

Adequacy of Direction for Healthcare Providers

The ISH 2020 practical guidelines for the management of hypertension adequately direct the healthcare provider in the management of patients with hypertension. The guideline clearly defines hypertension and describes how to make a diagnosis. It states the risk factors that the healthcare provider should ask about in the medical and family history. It then continues to mention signs and symptoms that the patients are likely to present. Relevant laboratory and radiological investigations are also listed. The guideline then describes the non-pharmacological and pharmacological treatment options for hypertension. It describes target blood pressure levels with treatment and what to do if the target pressures are not achieved.

Effectiveness of the Clinical Guideline

The ISH 2020 guidelines for the management of hypertension are very effective in the management of patients. They address multiple issues associated with hypertension, such as assessment of comorbidities, the association of African race with hypertension, evaluation of blood pressure during treatment, compliance to medication, and treatment failure (Unger et al., 2020). All these factors affect the outcome of treatment. Considering all these factors while managing elevated blood pressure improves the treatment outcome. It also reduces the incidence and prevalence of cases of high blood pressure. The effectiveness of this guideline when managing a patient can be assessed by the ability to achieve target blood pressures within a certain period during treatment. It can also be measured by assessing patients’ compliance with medication.

Analysis

The Need for Revision of the Clinical Guideline

The ISH 2020 practical guidelines for the management of hypertension may need to be reviewed. A significant flaw is its formulation of the different BP objectives concerning age, target organ damage, and concurrent disease. This could make it harder for healthcare providers to remember these crucial components of the guidelines, making it more challenging to implement them into clinical practice (Sorato et al., 2022). Additionally, the idea of strict “safety boundaries” (low BP values not to be exceeded out of concern for low-BP-induced undesirable outcomes) and differentiated BP aims are only weakly supported by findings from randomized clinical trials and meta-analyses.

The guidelines also need to include the management of elevated blood pressure in patients with COVID-19. The necessity of evidence-based care is emphasized in the 2020 guideline to reduce the widespread mortality and morbidity caused by HTN and cardiovascular diseases associated with it. The acute and long-term effects of COVID-19 may also affect how people with hypertension are treated, necessitating more research (Akpek, 2020). Due to the worldwide medical, economic, and psychological repercussions, COVID-19-linked morbidity and death, including individuals with underlying hypertension, are anticipated to have a significant impact for several decades. Though current COVID-19 pandemic requirements for out-of-office medical treatment and the use of telehealth technology imply benefits, these developing approaches will be used more to control hypertension.

Changes to the Clinical Practice Guideline

If I were to revise the clinical practice guideline, I would include guidelines on the management of hypertension for patients suffering from COVID-19. It has been hypothesized that hypertension plays a role in the COVID-19 pathogenesis due to the interaction between SARS-CoV-2 and angiotensin-converting enzyme-2 (Schiffrin et al., 2020). It does this by contributing to a deterioration in the illness course, marked by acute respiratory distress syndrome, systemic inflammatory response syndrome, and multiple organ dysfunction, or by acting directly as a pre-existing clinical indicator of disease severity.

The revised guidelines would include the definition of hypertension in COVID-19 patients and how to diagnose the disease. It would also consist of important questions to ask about the past medical history or family and social history. Additionally, it would have signs to look out for on examination and the relevant laboratory and radiological investigations that need to be conducted. Lastly, the guidelines would describe the suitable means of treatment depending on the patient and the appropriate action to take when treatment failure occurs.

How Changes May Affect Revised Guidelines

Changes in US demographics and healthcare reforms will require that guidelines be continually updated. Constant updates ensure that the guideline provides evidence-based treatment suitable for a certain demographic. Up-to-date treatment guidelines are easily understood and applied by healthcare providers. All groups of patients are cared for depending on their health requirements. The administration of optimized healthcare services improves treatment outcomes and the general quality of patients’ lives and even that of society.

Strategies to Increase the Likelihood of Adoption of a New Clinical Practice Guideline

I would carry out a systematic review to make evidence-based recommendations that will guide the management of elevated blood pressure in COVID-19 patients. I would also conduct a systematic literature review after defining clinical questions to find data that answers issues on hypertension in patients with COVID-19. The evidence will then be compiled, ranked to reflect the quality of its methodology, and presented. Evidence-based recommendations will be made to raise the standard of patient care by presenting and encouraging the implementation of advantageous interventions.

Evaluation

Steps To Evaluate the Efficiency of Revised Guidelines

First, I would assess the relevance of the guideline. The guideline would be effective if it is relevant to COVID-19 patients with hypertension.

Next, I would assess its consistency with other guidelines. The guideline would be effective if it is consistent with other COVID-19 and hypertension guidelines.

I would then analyze the goals it has achieved. The guideline would achieve the goal of diagnosing and treating COVID-19 patients with hypertension.

I would also assess the extent to which the guideline is being used. An effective guideline would apply to all COVID-19 patients with hypertension.

Finally, I would assess the impact of the guidelines. The guideline would be effective if it improves the outcome of patients with COVID-19 and hypertension.

Learning Points

Hypertension is the most common principal diagnosis in the United States of America. It is also the largest risk factor for mortality and morbidity worldwide and a major preventable cause of cardiovascular illnesses such as myocardial infection, stroke, and chronic renal disease.

The current guidelines on the management of hypertension need to be updated to treat more individuals suffering from hypertension and improve treatment outcomes.

Evidence-based practice optimizes the administration of drugs to patients and ensures that each patient is treated according to their health requirements.

References

Akpek, M. (2022). Does COVID-19 cause hypertension? Angiology, 73(7), 682-687. https://doi.org/10.1177%2F00033197211053903.

Beaney, T., Schutte, A. E., Stergiou, G. S., Borghi, C., Burger, D., Charchar, F., & MMM Investigators*. (2020). May Measurement Month 2019: the global blood pressure screening campaign of the International Society of Hypertension. Hypertension, 76(2), 333-341. https://doi.org/10.1161/HYPERTENSIONAHA.120.14874.

Harrison, D. G., Coffman, T. M., & Wilcox, C. S. (2021). Pathophysiology of hypertension: the mosaic theory and beyond. Circulation Research, 128(7), 847-863. https://doi.org/10.1161/CIRCRESAHA.121.318082.

Jagannathan, R., Patel, S., Ali, M., & Narayan, K. (2019). Global Updates on Cardiovascular Disease Mortality Trends and Attribution of Traditional Risk Factors. Current Diabetes Reports, 19(7). https://doi.org/10.1007/s11892-019-1161-2.

Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223-237. https://doi.org/10.1038/s41581-019-0244-2.

Nugroho, P., Andrew, H., Kohar, K., Noor, C. A., & Sutranto, A. L. (2022). Comparison between the world health organization (WHO) and international society of hypertension (ISH) guidelines for hypertension. Annals of Medicine, 54(1), 837-845. https://doi.org/10.1080/07853890.2022.2044510.

Rivera, S. L., Martin, J., & Landry, J. (2019). Acute and chronic hypertension: What clinicians need to know for diagnosis and management. Critical Care Nursing Clinics, 31(1), 97-108. https://doi.org/10.1016/j.cnc.2018.11.008.

Schiffrin, E. L., Flack, J. M., Ito, S., Muntner, P., & Webb, R. C. (2020). Hypertension and COVID-19. American journal of hypertension, 33(5), 373-374. https://doi.org/10.1093/ajh/hpaa057.

Song, J. J., Ma, Z., Wang, J., Chen, L. X., & Zhong, J. C. (2020). Gender differences in hypertension. Journal of cardiovascular translational research, 13(1), 47-54. https://doi.org/10.1007/s12265-019-09888-z.

Sorato, M. M., Davari, M., Kebriaeezadeh, A., Sarrafzadegan, N., & Shibru, T. (2022). Antihypertensive prescribing pattern, prescriber adherence to ISH 2020 guidelines, and implication of outpatient drug price on blood pressure control at selected hospitals in Southern Ethiopia. European Journal of Clinical Pharmacology, 1-16. https://doi.org/10.1007/s00228-022-03352-9.

Spruill, T. M., Butler, M. J., Thomas, S. J., Tajeu, G. S., Kalinowski, J., Castañeda, S. F., & Shimbo, D. (2019). Association between high perceived stress over time and incident hypertension in black adults: findings from the Jackson heart study. Journal of the American Heart Association, 8(21), e012139. https://doi.org/10.1161/JAHA.119.012139.

Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., & Schutte, A. E. (2020). 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension, 75(6), 1334-1357. https://doi.org/10.1161/HYPERTENSIONAHA.120.15026.

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The purpose of this assignment is to identify a clinical practice guideline in your speciality area. You will be challenged to evaluate this guideline and discuss its use in clinical practice.
Choose a health problem that you may commonly see in primary care nurse practitioner practice. Describe the health problem and recommend medical management for it. Research published clinical practice guidelines and evaluated the practice guideline you have selected based on the components listed in the Clinical Practice Guideline Template below.

Clinical Practice Guideline Prompts:

HEALTHCARE PROBLEM IDENTIFIED: Briefly describe the health problem you have identified. Include a discussion of morbidity, mortality, epidemiology and pathophysiology related to this health problem.

PRACTICE GUIDELINE: Describe the clinical practice guideline used for this problem. Reflect on the questions included. Expand on your answer using support from the evidence.

Does the clinical practice guideline adequately address the health problem? Describe.
Is this practice guideline based on current evidence (within 5 years)? What is the strength of this evidence?
Does this clinical practice guideline adequately direct the healthcare provider in the management of a patient with this problem?
How effective is this clinical guideline in the management of patients with this healthcare problem? Think about how you would assess the effectiveness of patient management.
ANALYSIS: Think about the future healthcare needs of patients with this problem, changing demographics, and changes in healthcare policies. Address these questions.

Does this clinical practice guideline need revision(s)? Please explain your answer in detail.
If you were going to revise this clinical practice guideline, what would you change? What evidence would you use to base your changes on?
How might changes in US demographics and healthcare reform affect this clinical practice guideline?
What strategies would you use to increase the likelihood that a new or modified clinical practice guideline would be adopted and used in clinical practice?
EVALUATION How would you determine the effectiveness of this revised clinical practice guideline in directing care for patients with the identified health problem? Outline the steps you might employ.

LEARNING POINTS (3-5 bullet points outlining key learning in this case.)

REFERENCES (APA formatting, current within past 5 years.)
I CHOOSING STROKE OR HYPERTENSION
The attachment is a sample. Thanks