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WD\~t%L]'}e60u5 lW*@JԏkO0xV E n$ #4> @+[ 4Hl m`JU6\& {(mA)e@P!H5Z~ T *.RNN)J7`'*(R퇠= Y'.Y9iȀG`,!S(fdMx"qa b>y􂊚1GX@:FE "~&*X|.,2DʭRc(Hg v׊YOHP80HPW*2!KtSEcǎPryb`̒2IHƢԃA!)?@"W 5Q0& ׄj2yl{ o~.&!"x¹XuR _`E DC sBY H_dFD.4dQIgW@eqR?PW|V]2Q~V_F0&$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ /ʤKVIENDB`3 A@@   Dr.Prof. organisationMrselfMsMissMrspg1pg2pg3pg4pg5pg6pg7pg8pg9pg10pg11pg12pg13pg14pg15pg16pg17pg18pg19pg20pg21pg22pg23pg24pg25pg26pg27pg28pg29pg30pg31pg32pg33pg34pg35pg36pg37pg38pg39pg40pg41pg42pg43pg44pg45pg46pg47pg48pg49pg50pg51pg52pg53pg54pg55pg56pg57pg58pg59pg60pg61pg62pg63pg64pg65pg66pg67pg68pg69pg70pg71pg72pg73pg74pg75pg76pg77pg78pg79pg80pg81pg82pg83pg84pg85pg86pg87pg88pg89pg90pg91pg92pg93pg94pg95pg96pg97pg98pg99pg100RepresentatingName of organisationSectionPageCommentBIf you have any problems please enquire by clicking the link belowSubmit CommentsThank you for your inputDetailsPreambleScope of the guidelineRelated guidelines Methodology DisclaimerEndorsing organisations?National Blood Pressure and Vascular Disease Advisory Committee&National Heart Foundation of AustraliaEpidemiology of Blood Pressure-Definition and Classification of HypertensionHypertensive emergencies5Hypertension and Absolute Cardiovascular Disease RiskTable of Contents 7(Evaluation and Diagnosis of HypertensionBlood pressure measurement Blood pressure measuring devices(Blood pressure measurement in the clinic0Blood pressure measurement outside of the clinicMedical history2Physical examination and laboratory investigations1Additional diagnostic tests for selected patients#Treatment of Confirmed HypertensionLifestyle advicePhysical activityWeight controlDietary modificationSmoking cessationModerate alcohol consumptionRelaxation therapies@Practical recommendations to support long-term lifestyle changes!Starting Antihypertensive Therapy Choice of antihypertensive drugs*Treatment strategies and treatment targets*Doses and Safety of Antihypertensive DrugsGuide for Combination TherapyFTreatment Strategies and Treatment Targets for Selected Co-morbiditiesCerebrovascular diseaseChronic kidney diseaseDiabetesMyocardial infarctionChronic heart failurePeripheral arterial disease.Treatment Strategies for Associated Conditions"White-coat and masked hypertension Older persons PregnancyBlood pressure variability Treatment resistant hypertensionObstructive sleep apnoea Strategies to Maximise Adherence*Managing Other Cardiovascular Risk FactorsLipid-lowering drugsAntiplatelet therapy&Monitoring Responses to Drug Treatment'Follow-up of patients with hypertensionWithdrawing drug therapyPatients Perspectives ReferencesGeneral commentOtherEmail (in case of query)PositionKGuideline for the diagnosis and management of hypertension in adults - 2015Consultation submissionpagedrop down listsTitle FirstnameSurnameGiseleRochagisele.rocha@racgp.org.au/Senior Project Officer, eHealth & Quality Care PTo submit your comments click below then save and attach this file to the email.9Royal Australian College of General Practitioners (RACGP)According to the guideline, cardiovascular risk calculator should be moderated by clinical judgement in patients with increased fibrinogen, apolipoprotein B, high-sensitivity C-reactive protein. Calculators include the presence of left ventricular hypertrophy as a risk. The guideline needs to clarify if it is suggesting that these tests be performed or just the subset described in the table 'initial laboratory investigation for all patients' (on page 22). It would be useful to specify why ECG is recommended for all patients as part of the initial checks when hypertension is diagnosed (presumably to detect atrial fibrillation, left ventricular hypertrophy and evidence of previous ischaemic heart disease).  Revise the recommendation for starting antihypertensive therapy. On page 32, the guideline recommends initiating antihypertensive therapy in patients with moderate risk (10-15%) and persistent BP e"140/90. However, the National Vascular Disease Prevention Alliance (NVDPA) guideline recommends treating if BP >160/100, family history of premature CVD, South Asian, Middle Eastern, Maori, Pacific Islander. If not, it recommends monitoring for 3-6 months.hThe table should including other ARBs available in Australia (currently only Candesartan is mentioned). It would be helpful to include a comparison table between recommended relaxed target blood pressures and previous guidelines and an emphasis on out of clinic measurements of blood pressure. It would be helpful to combine the summary table directing choice of antihypertensive medication for co-morbidities and a separate table for BP target in these patients. This section is inconsistent with the NVDPA guideline. It recommends starting combination therapy if BP>20 systolic and >10 diastolic above target. This is despite the lack of evidence to support this and with the major cited benefit being adherence. The RACGP welcomes the publication of the guideline. It is a helpful reference for health professionals across Australia, with clear evidence-based recommendations. We have reviewed the guideline and believe some elements of the document are not in accordance with current recommendations for the diagnosis and management of hypertension. Ease of use can be improved by bringing information together in reader-friendly summary tables. _The guideline has diastolic blood pressure levels to diagnose hypertension and diastolic blood pressure targets. A discussion on the relevance of diastolic blood pressure recording, rather than an alert to search for valvular heart disease, would be beneficial as cardiovascular risk calculators use systolic blood pressure to assign risk estimates. It would be useful to include a one-page summary of the Sharman et al article as an appendix to the guideline (if the article is not published and therefore unable to be referenced by the time the guideline is released). On page 24, the guideline states that primary aldosteronism occurs in up to 10% of untreated patients with hypertension and the plasma aldosterone/renin ratio blood test should be considered. Are the guidelines suggesting that all patients have this test prior to commencing treatment? The guideline should explain the follow up procedures of this test as it may be impractical to refer this number of patients to specialist services. The flow diagram on page 33 has the potential to be used as a  tear out for reference. Rather than a reference to the other section, adding a box about the different cut-offs for ambulatory and home blood pressure monitoring would be useful and make it more user friendly. There needs to be another step after the green  No box. For example, an arrow indicating the start of drug treatment if blood pressure is elevated after 2 months. This indicates that action needs to be undertaken in order to avoid clinical inertia. 1The figure sugg<ests one needs to review antihypertensive treatment every 4-6 weeks continuously. Is the suggestion to perform a review every 4-6 weeks until targets are reached? A box that indicates frequency of reviews once targets are reached to assess for efficacy and other measures would be helpful. There is a discrepancy in the specified treatement targets for older patients <80 years which is <140/80 compared to other parts of the guidelines which state the target is 140/90 for all other patients except those with proteinuria. The lipid lowering paragraph and reference no. 191 reference the 2013 version of the RACGP General practice management of type 2 diabetes. This should be updated to reflect the recommendations of the 2014-15 guidelines.The way this section is currently written might inhibit practitioners from taking into account falls risk, frailty, polypharmacy and advanced multimorbidity. Elderly patients will all be at high risk of cardiovascular events but also many will be at high risk of harms. The section could be expanded to include numbers-needed-to-treat in the elderly to prevent events and where information is available the numbers-needed-to-harm. The guidelines should describe whether cardiovascular risk calculations should use pre-treatment values of cholesterol. 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