9 / 76
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 2, March/April 2017
AFRICA
75
Running clinics that are very busy may also have contributed
to the discordance between knowledge of the enormity of the
hypertension burden and performing routine blood pressure
checks on all adult patients. Our finding is however similar to that
of an earlier survey by Ajuluchukwu
et al
.
11
of general practitioners
in Nigeria where 70% of the PCPs routinely checked the blood
pressure of their patients in consultation. It is however lower than
the 80.5 and 87% reported for Cameroon- and Australia-based
PCPs.
14,15
This practice may largely underlie the high burden of
undiagnosed hypertension and hypertensive target-organ damage
in Nigeria, although factors related to patient and healthcare
systems such as poor health-seeking behaviour and the use of
alternative medical practitioners may also be contributory.
2,8
Symptoms of target-organ damage is what often brings patients
with hypertension to healthcare facilities in Nigeria.
2
The casual measurement of blood pressure varies widely,
hence certain measures are recommended to improve its
reliability.
7,16
This includes making the patients sit comfortably
for some minutes before blood pressure measurement is carried
out, the measurement of blood pressure on both arms during
the patient’s first visit, and subsequently choosing the arm with
higher blood pressure as the reference.
7,12
Only 26.4% of all respondents allowed a rest of 10 minutes or
more, recommended by the IFHA guidelines.
7
This recommended
period appears to be too long for it to be practicable in routine
clinical practice, hence the small proportion of respondents
adhering to it. A shorter duration of rest, the five minutes
recommended by the American JNC 7 guidelines,
17
appears
more practicable in day-to-day clinical practice considering the
workload in primary healthcare facilities.
The small proportion of respondents (16.2%) who measured
blood pressure on both arms during a patient’s first visit may
be due to high patient load or outright ignorance of this
recommended practice. This contrasted sharply with the 55.1% of
India-based PCPs who recorded blood pressure on both arms.
18
PCPs may miss the clues for secondary hypertension by initial
measurement of blood pressure on only one arm. Subjects with
hypertension may be wrongly labelled as normotensive, and
uncontrolled hypertension assessed as being controlled by the
inadvertent use of the arm with a lower blood pressure value
for evaluation. The practice of not identifying the arm with
higher blood pressure and using it as the reference may also be
contributory to the high burden of undiagnosed hypertension,
uncontrolled hypertension and hypertensive target-organ damage
in Nigeria.
2,7,8
The above underscores a comment by Kaplan that
the measurement of blood pressure is the clinical procedure of
greatest importance that is performed in the sloppiest manner.
19
Evaluation of the total cardiovascular risk of hypertensive
individuals is recommended by the guidelines. Apart from
assisting in prognostication, modification of some of these risk
factors is associated with blood pressure reduction.
7,17,20
On the
other hand, failure to adhere to risk-factor modification, such
as weight reduction for obese subjects, may result in resistant
hypertension.
7,17,20
A large majority of the PCPs clinically
evaluated their patients for these risk factors, with the exception
of obesity, which was performed by less than half of the
PCPs. Not paying adequate attention to obesity in individuals
with hypertension may be contributory to the high burden of
uncontrolled hypertension reported globally.
2,11,12
Another evaluation carried out routinely by a minority (41.2%)
of the PCPs was lipograms. This may be predicated on the belief
that it is not an important investigation in sub-Saharan African
blacks because of low levels of cholesterol.
21
However recent
studies have not only shown that lipid abnormalities are common
in Nigerians newly presenting with hypertension, but also that
these abnormalities worsen with the severity of hypertension.
22,23
A very small proportion (5.3%) of respondents examined
the optic fundus of their hypertensive patients. This is lower
than the 18.9 and 56.6% reported for PCPs in Italy and
Slovenia, respectively.
24,25
It is however instructive to note that
optic fundus examination was the least-frequently performed
element of the minimal hypertension diagnostic procedures, not
only in the current study, but also in the Italian and Slovenian
studies.
24,25
Likely reasons for this may include inadequate
medical consultation time and dearth of skills and/or equipment
for optic fundus examination.
Though the approach of the practitioners in private and
government practice to the evaluation of hypertension was
heterogeneous, their overall performance was similar. Out of
the 19 questions asked (excluding questions on awareness of
guidelines) the PCPs in private practice performed better than
those in government practice in their responses to three questions,
and vice versa to three other questions. The performance of the
two groups in the remaining 13 questions was similar. The reason
for this similarity in the overall performance by these two groups
is not apparent in this study, but we dared to postulate that
it may have been due to the effect of PCPs in private practice
having more time to read and adhere to guidelines being offset by
the effect of better exposure to continuing professional education
(practical and theoretical) by PCPs in government practice.
As expected, the PCPs in the guideline-aware group performed
better than those in the unaware group (seven out of 19 responses
vs two out of 19 responses). This shows that hypertension
guideline awareness is associated with better hypertension care
and that awareness of these guidelines should be promoted
among PCPs. In spite of these findings, the general performance
of the guideline-aware PCPs was unsatisfactory. This may have
been due to them not being conversant with the content of the
hypertension guidelines despite being aware of the guidelines.
This scenario was reported among South Africa-based PCPs
by Parker
et al.
where 68.8% of the PCPs were aware of
hypertension guidelines, but only 18.2% of the guideline-aware
PCPs were conversant with the content thereof.
13
A preference
for the use of personal experience that is not evidenced based
over evidence-based recommendations contained in guidelines
has been documented among PCPs in Croatia. A similar
scenario may have played out in our cohort of PCPs. Inadequate
time for medical consultation may also be contributory to the
suboptimal general performance of guideline-aware PCPs.
Limitations of this study include the use of a self-administered
questionnaire, which is limited by the varying abilities of the
participants to recall. This study evaluated the knowledge of the
PCPs, which may not represent their actual practices. Obtaining
data from medical records would have given an excellent picture
of what these PCPs actually do.
Conclusion
Considering the enormity of issues related to hypertension
in terms of the large segment of the population involved, the