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(Circulation. 2005;111:1278-1283.)
© 2005 American Heart Association, Inc.

Hypertension

General Practitioners’ Approach to Hypertension in Urban Pakistan

Disturbing Trends in Practice

Tazeen H. Jafar, MD, MPH; Saleem Jessani, MD; Fahim H. Jafary, MD; Mohammad Ishaq, MD; Raza Orkazai, MD; Sarwar Orkazai, MD; Andrew S. Levey, MD; Nish Chaturvedi, MD, MRCP

From the Section of Nephrology (T.H.J.), Department of Medicine, and the Clinical Epidemiology Unit (T.H.J., S.J., R.O., S.O.), Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan; Division of Nephrology (T.H.J., A.S.L.), Department of Medicine, Tufts-New England Medical Center, Tufts University Medical School, Boston, Mass; Section of Cardiology (F.H.J., M.I.), Department of Medicine, Aga Khan University, Karachi, Pakistan; and Department of Clinical Pharmacology (N.C.), National Heart and Lung Institute, Imperial College London, UK.

Correspondence to Dr Tazeen H. Jafar, Head, Section of Nephrology, Director, Clinical Epidemiology Unit, Associate Professor, Medicine and Community Health Sciences, Aga Khan University, PO Box 3500, Stadium Road, Karachi, 74800, Pakistan. E-mail tazeen.jafar{at}aku.edu

Received September 16, 2004; revision received November 28, 2004; accepted December 14, 2004.

Background— Control of blood pressure (BP) remains suboptimal worldwide. The objective of this study was to determine whether (primary) general practitioners’ (GPs) approach to high BP is in accordance with international guidelines.

Methods and Results— We conducted a cross-sectional survey of 1000 randomly selected GPs from urban areas in Pakistan during 2002. A rigorously developed questionnaire on (1) type of practice and (2) detection, (3) evaluation, (4) treatment, and (5) source of information about high BP was administered by trained medical personnel. A total of 1051 GPs were approached, and 1000 (95%) consented to enroll; 766 were male and 655 had been in practice 10 years. The average number of patients (SD) seen per day was 48.2 (42.7). Overall, 30.6% (29.0% to 32.3%) and 79.7% (78.3% to 81.0%) of GPs used incorrect BP cutoffs to diagnose hypertension in patients <60 and 60 years, respectively. Appropriate therapy for hypertension in the elderly was initiated by only 34.7% (33.0% to 36.3%) of GPs. The use of sedatives either alone (23.8%) or in combination with antihypertensive agents as first-line medication for lowering BP was reported by 45.0% (43.2% to 46.7%). Thiazide diuretics were rarely prescribed (4.2%). Sublingual antihypertensive agents were prescribed by 68.7% (67.1% to 70.3%) of GPs for treating very high levels of BP. The practices of recent graduates from medical school were not better than those of older graduates.

Conclusions— GPs in Pakistan underdiagnose and undertreat high BP, especially in the elderly. Our findings underscore the need for urgent revision of teaching curricula in medical schools with regard to the risks, complications, and management of hypertension, as well as the initiation of widespread and intensive continuing medical education for all physicians involved in the management of patients with hypertension. Particular efforts are needed to encourage the use of low-cost thiazide diuretics as antihypertensive agents in developing countries.

Key Words: hypertension • epidemiology • diagnosis • blood pressure • patients

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