Guidelines for hypertension management in primary care: is local adaptation possible?

Hypertension affects more than one billion people worldwide. There has been much discussion about clinical practice guidelines (CPGs) following the proposal of lower thresholds for starting pharmacological treatment. Some smaller groups or institutions could benefit from adapting CPGs to their local context, a process that requires high-quality CPGs with few points of conflict in their recommendations. To address this issue, we have compared high-quality hypertension CPGs and highlighted conflicting recommendations.

CPGs were searched in MEDLINE, Embase, the Cochrane Library, as well as specific websites. Only CPGs published between 2016 and 2019 were included. We defined CPGs as high-quality if the 'rigor of development' and 'editorial independence' AGREE II domains were scored at least 60%. We compared recommendations made by high-quality CPGs and highlighted areas of conflict (defined as disagreements between more than two CPGs).

Nineteen CPGs were identified. The highest scoring domain was 'scope and purpose' (74.3%) and the lowest scoring was 'applicability' (40.0%). Eight CPGs were rated as high quality. Most CPG recommendations on the management of hypertension were consistent. Conflicting recommendations were regarding blood pressure (BP) levels to initiate pharmacotherapy and therapeutic goals, particularly in patients with low cardiovascular risk and older patients.

It is possible to adapt hypertension CPGs once high-quality documents have been identified with agreement between most recommendations. Guideline developers can focus on the adaption process and concentrate efforts on implementation.