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Screening for Hypertension

Guideline Panel Members


Saudi Expert Panel
Dr. Abdullah Alkhenizan
Dr. Ayman Afify
Dr. Mohammed Al-Ateeq
Dr. Rajaa Al-Raddadi
Dr. Saad Albattal
Dr. Amro Alomran
Dr. Mostafa Alshamiri
Dr. Mohammad Kurdi
Dr. Ihab Suliman

McMaster University Working Group


Romina Brignardello-Petersen, DDM, Nancy Santesso, MLIS PhD, Reem Mustafa, MD MPH
PhD, Bram Rochwerg, MD Msc, Jan Brozek, MD PhD, and Holger Schnemann, MD PhD, on
behalf of the McMaster Guideline Working Group

Acknowledgements
We acknowledge Dr. Ahmed Al-Awwad and Dr. Abdulkarim Alsuwaida for their contribu-
tions to the question prioritization survey and to the discussion prior to the final workshop
in March 2015.

We gratefully acknowledge Prof. Lubna Al Ansary from King Saud University for peer
reviewing this final report.

Disclosure of potential conflict of interest:

Mohammad Kurdi has acted as a consultant for AstraZeneca, Sanofi, Medtronic and B-
Braun. He has also received non-monetary and monetary support (sponsorship and hono-
raria to attend meetings). All these activities have been performed as a specialist and are
not directly related to the topic of this guideline.

Other co-authors had no conflicts of interest to declare.

Funding:
This clinical practice guideline was funded by the Ministry of Health, Saudi Arabia.

Address for correspondence:


Saudi Center for Evidence Based Health Care
E-mail: ebhc@moh.gov.sa. Web: http://www.moh.gov.sa/endepts/Proofs/Pages/home.aspx
Screening for Hypertension
ii

Abbreviations

ABPM Ambulatory Blood Pressure Measurement


CBPM Clinic Blood Pressure Measurement
DBP Diastolic Blood Pressure
GRADE Grading of Recommendations, Assessment, Development and Evaluation
HBPM Home Blood Pressure Measurement
HTN Hypertension
KSA Kingdom of Saudi Arabia
MoH Ministry of Health
RCT Randomized Controlled Trial
SBP Systolic Blood Pressure
WHO World Health Organization
Screening for Hypertension
iii

Contents
The Saudi Center for Evidence Based Health Care (EBHC) ..................................................................... v
Executive Summary................................................................................................................................. 1
Introduction ........................................................................................................................................ 1
Methodology....................................................................................................................................... 1
How to use these guidelines ............................................................................................................... 1
Key questions ...................................................................................................................................... 2
Recommendations .............................................................................................................................. 2
Scope and purpose.................................................................................................................................. 4
Introduction ............................................................................................................................................ 4
Methodology........................................................................................................................................... 4
How to use these guidelines ................................................................................................................... 6
Key questions .......................................................................................................................................... 6
Recommendations .................................................................................................................................. 7
Question 1: Should we screen for hypertension in patients 55 years old, who are going to a
physician?............................................................................................................................................ 7
Question 2: Should we screen for hypertension in patients 25 and 54 years old, who are going
to a physician? .................................................................................................................................... 8
Question 3: Should we screen for hypertension in patients 15 and 24 years old, who are going
to a physician? .................................................................................................................................... 9
Question 4: Should we screen for hypertension in patients <15 years old, who are going to a
physician?.......................................................................................................................................... 10
Question 5: Should we screen for hypertension in patients at high risk of hypertension, who are
going to a physician?......................................................................................................................... 11
Question 6: Should we use a cut-off point of systolic blood pressure of 140 mm Hg versus a higher
cut-off point to confirm a diagnosis of hypertension? ..................................................................... 11
Question 7: Should we use a cut-off point of diastolic blood pressure of 90 mm Hg versus another
cut-off point to confirm a diagnosis of hypertension? ..................................................................... 12
Question 8: Should we use a cut-off point of systolic blood pressure of 120 mm Hg versus another
cut-off point (130 mm Hg) to confirm a diagnosis of hypertension? ............................................... 13
Question 9: Should we use a cut-off point of diastolic blood pressure of 80 mm Hg versus a higher
cut-off point to confirm a diagnosis of hypertension? ..................................................................... 14
Question 10: Should ambulatory blood pressure measurement (ABPM) be used as an alternative
to clinic blood pressure measurement (CBPM) for screening for hypertension in patients who
underwent screening and were normotensive? ............................................................................... 15
Question 11: Should home blood pressure measurement (HBPM) be used as an alternative to
clinic blood pressure measurement (CBPM) for screening for hypertension in patients who
underwent screening and were normotensive? ............................................................................... 15
Question 12: Should we use an interval of 1 year versus 2 years to re-screen patients who were
not diagnosed with hypertension after screening? .......................................................................... 16
References ............................................................................................................................................ 18
Appendices............................................................................................................................................ 21
Appendix 1: Evidence to Decision Frameworks ................................................................................ 22
Guideline Question 1: Should we screen for hypertension in patients 55 years old who are
going to a physician? ..................................................................................................................... 22
Screening for Hypertension
iv

Guideline Question 2: Should we screen for hypertension in patients 25 and 54 years old,
who are going to a physician ........................................................................................................ 27
Guideline Question 3: Should we screen for hypertension in patients 15 and 24 years old,
who are going to a physician ........................................................................................................ 32
Guideline Question 4: Should we screen for hypertension in patients < 15 years old, who are
going to a physician? ..................................................................................................................... 37
Guideline Question 5: Should we screen for hypertension in patients at high risk of
hypertension, who are going to a physician? ............................................................................... 42
Guideline Question 6: Should we use a cut-off point of systolic blood pressure of 140 mm Hg
versus a higher cut-off point to confirm a diagnosis of hypertension? ........................................ 47
Guideline Question 7: Should we use a cut-off point of diastolic blood pressure of 90 mm Hg
versus another cut-off point to confirm a diagnosis of hypertension? ........................................ 52
Guideline Question 8: Should we use a cut-off point of systolic blood pressure of 120 mm Hg
versus another cut-off point (130 mm Hg) to rule-out a diagnosis of hypertension?.................. 57
Guideline Question 9: Should we use a cut-off point of diastolic blood pressure of 80 mm Hg
versus a higher to rule-out a diagnosis of hypertension?............................................................. 62
Guideline Question 10: Should ambulatory blood pressure measurement (ABPM) be used as an
alternative to clinic blood pressure measurement (CBPM) for screening for hypertension in
patients who underwent screening and were normotensive?..................................................... 69
Guideline Question 11: Should home blood pressure measurement (HBPM) be used as an
alternative to clinic blood pressure measurement (CBPM) for screening for hypertension in
patients who underwent screening and were normotensive?..................................................... 75
Guideline Question 12: Should we use an interval of 1 year versus 2 years to re-screen patients
who were not diagnosed with hypertension after screening? ..................................................... 81
Appendix 2: Search Strategies and Results ....................................................................................... 86
Appendix 3: Clinical pathway for screening for HTN ........................................................................ 91
Appendix 4: Blood pressure measurement protocol ........................................................................ 92
Screening for Hypertension
v

The Saudi Center for Evidence Based Health Care (EBHC)

The Saudi Centre for Evidence Based Health Care has managed and supported the coordination of
the process of clinical practice guideline (CPG) development between the methodological team from
McMaster University and the local clinical expert panel members in Saudi Arabia.

The EBHC staff members recruited local clinical experts through contacting Saudi specialist societies
and also independent experts interested in developing reliable and most up-to-date CPGs to harmo-
nize the treatment and provide the highest quality of health care in the kingdom of Saudi Arabia.
These experts were health care professionals of multidisciplinary backgrounds. As much as possible,
patients representatives were also included in panels.

In an effort to make national recommendations, the participating experts were professionals from
the Ministry of Health (MoH), National Guard Hospitals, King Faisal Specialist Hospital and Research
Centre (KFSHRC), University Hospitals, Security Forces Hospitals, Prince Sultan Military Medical City
(PSMMC) and from some private hospitals.

Based on a preselection of available evidence syntheses, the EBHC provided a list of potential topics
to be addressed in CPGs after thorough consultations with the local stakeholders. These topics were
further discussed with the McMaster team for important selection criteria and agreed on 12 topics
for wave 2.

The guideline panel meetings were held in Riyadh on 15th-18th March 2015 where about 96 local ex-
perts working in Saudi Arabia participated with the methodological support from 20 experts from
McMaster University and its partners from the American University of Beirut, Lebanon, and the Uni-
versity of Freiburg, Germany, in providing high quality recommendations for common and important
clinical conditions in the Kingdom.

The Saudi Centre for EBHC supports the efforts for dissemination of the CPGs by publishing online
the full reports of the CPGs, facilitates writing concise versions of the CPGs for publication in peer
reviewed medical journals, sending hard copies to hospitals and health care centers. Finally, a mo-
bile App has been introduced in KSA to facilitate the dissemination efforts of the completed practice
guidelines.

The staff members at the Saudi Centre for EBHC:


Dr Zulfa Al Rayess, Consultant Family Medicine, Head of Saudi Center for EBHC
Dr Yaser Adi, Scientific Advisor for the Saudi Centre for EBHC
Miss Nourah Al Moufarreh, Project Manager, Saudi Center for EBHC
Screening for Hypertension
1

that was required to develop full guidelines


Executive Summary for the KSA, including searches for infor-
mation about patients values and prefer-
Introduction ences, and costs and resource use specific to
the Saudi context. Based on the systematic
Hypertension has been recognized as an im- reviews we prepared summaries of available
portant risk factor of cardiovascular diseases, evidence supporting each recommendation
with consequences such as myocardial infarc- following the GRADE (Grading of Recommen-
tion, stroke, and death. It has also been linked dations, Assessment, Development and Evalu-
to chronic kidney disease, heart failure, and ation) approach.13 We used this information
dementia.1-4 In Saudi Arabia, the prevalence to prepare GRADE evidence-to-decision
of hypertension has been estimated to be frameworks that served the guideline panel to
24% across all ages.5 Studies have also report- follow the structured consensus process and
ed that among people aged 15 years or transparently document all decisions made
greater who are hypertensive, 57.8% are during the meeting (see Appendix 1). The
undiagnosed.6 guideline panel met in Riyadh on March 17 &
18, 2015 and formulated all recommendations
Clinical research supports the effectiveness of during this meeting. Potential conflicts of in-
lowering blood pressure levels for preventing, terests of all panel members were managed
decreasing and delaying the consequences of according to the World Health Organization
hypertension.7,8 Therefore, screening for hy- (WHO) rules.14
pertension could lead to an early detection
and treatment of this condition, which could As a quality measure prior to publication, the
potentially reduce its results. final report has been externally peer reviewed
by a methodological expert who has not been
Given the importance of this topic, the Minis- involved in this guideline development.
try of Health of the Kingdom of Saudi Arabia
with the support of the McMaster University Authors have tried as much as they could to
working group produced practice guidelines include the suggested changes in this report,
to assist health care providers in evidence- but that does not mean that all the advised
based decision-making on the Screening for points have been added.
Hypertension.
How to use these guidelines
Methodology
The guideline working group developed and
This practice guideline is a part of the larger graded the recommendations and assessed
initiative of the Ministry of Health of the King- the quality of the supporting evidence accord-
dom of Saudi Arabia (KSA) to establish a pro- ing to the GRADE approach.15 Quality of evi-
gram of rigorous development of guidelines. dence (confidence in the effect estimates) is
The ultimate goals are to provide guidance for categorized as: high, moderate, low, or very
clinicians and other healthcare decision mak- low based on consideration of risk of bias,
ers and reduce unnecessary variability in clini- indirectness, inconsistency, imprecision of and
cal practice across the Kingdom. publication bias of the estimates as well as
factors that lead to upgrading the quality of
The Saudi expert guideline panel selected the the evidence. High quality evidence indicates
topic of this guideline and all healthcare ques- that we are very confident that the true effect
tions addressed herein using a formal prioriti- lies close to that of the estimate of the effect.
zation process. For all selected questions we Moderate quality evidence indicates moder-
updated existing systematic reviews on ate confidence, and that the true effect is like-
Screening for Hypertension9-12. We also con- ly close to the estimate of the effect, but
ducted systematic searches for information there is a possibility that it is substantially dif-
Screening for Hypertension
2

ferent. Low quality evidence indicates that


our confidence in the effect estimate is lim- The strength of recommendations is ex-
ited, and that the true effect may be substan- pressed as either strong (guideline panel rec-
tially different. Finally, very low quality evi- ommends) or conditional (guideline panel
dence indicates that the estimate of effect of suggests) and has explicit implications (see
interventions is very uncertain, the true effect Table 1).16 Understanding the interpretation
is likely to be substantially different from the of these two grades is essential for sagacious
effect estimate and further research is likely clinical decision making.
to have important potential for reducing the
uncertainty.

Table 1: Interpretation of strong and conditional (weak) recommendations

Implications Strong recommendation Conditional (weak) recommendation


For patients Most individuals in this situation The majority of individuals in this situa-
would want the recommended tion would want the suggested course
course of action and only a small of action, but many would not.
proportion would not. Formal deci-
sion aids are not likely to be needed
to help individuals make decisions
consistent with their values and pref-
erences.
For clinicians Most individuals should receive the Recognize that different choices will be
intervention. Adherence to this rec- appropriate for individual patients and
ommendation according to the that you must help each patient arrive
guideline could be used as a quality at a management decision consistent
criterion or performance indicator. with his or her values and preferences.
Decision aids may be useful helping
individuals making decisions consistent
with their values and preferences.
For policy makers The recommendation can be adapted Policy making will require substantial
as policy in most situations debate and involvement of various
stakeholders.

Key questions 6. Should we use a cut-off point of sys-


tolic blood pressure of 140 mm Hg
1. Should we screen for hypertension in versus a higher cut-off point to con-
patients 55 years old, who are going firm a diagnosis of hypertension?
to a physician?
2. Should we screen for hypertension in 7. Should we use a cut-off point of dias-
patients 25 and 54 years old, who tolic blood pressure of 90 mm Hg ver-
are going to a physician? sus another cut-off point to confirm a
3. Should we screen for hypertension in diagnosis of hypertension?
patients 15 and 24 years old, who 8. Should we use a cut-off point of sys-
are going to a physician? tolic blood pressure of 120 mm Hg
4. Should we screen for hypertension in versus another cut-off point to rule-
patients <15 years old, who are going out a diagnosis of hypertension?
to a physician? 9. Should we use a cut-off point of dias-
5. Should we screen for hypertension in tolic blood pressure of 80 mm Hg ver-
patients at high risk of hypertension, sus a higher cut-off point to rule-out a
who are going to a physician? diagnosis of hypertension?
Screening for Hypertension
2

10. Should ambulatory blood pressure Recommendation 5:


measurement be used as an alterna- The panel recommends screening for hyper-
tive to clinic blood pressure meas- tension in patients at high risk of hyperten-
urement for screening for hyperten- sion, who are going to a physician. (strong
sion in patients who underwent recommendation, moderate quality evidence)
screening and were diagnosed as
normotensive? Recommendation 6:
The panel suggests using a cut-off point of
11. Should home blood pressure meas- systolic blood pressure of 140 mm Hg over a
urement be used as an alternative to higher cut-off point to diagnose hypertension
clinic blood pressure measurement in patients who are screened at a physicians
for screening for hypertension in pa- office. (conditional recommendation, very low
tients who underwent screening and quality evidence)
were diagnosed as normotensive?
12. Should we use an interval of 1 year Recommendation 7:
versus 2 years to re-screen patients The panel suggests using a cut-off point of
who were not declared hypertensive diastolic blood pressure of 90 mm Hg over a
after screening? higher or lower cut-off point to diagnose hy-
pertension in patients who are screened at a
Recommendations physicians office. (conditional recommenda-
tion, very low quality evidence)
Recommendation 1:
The panel recommends screening for hyper- Recommendation 8:
tension in adults 55 years old who are going The panel suggests using a cut-off point of
to a physician. (strong recommendation, systolic blood pressure of 120 mm Hg over a
moderate quality evidence) cut-off point of 130 mm Hg to rule-out hyper-
tension in patients who are screened at a phy-
Recommendation 2: sicians office. (conditional recommendation,
The panel recommends screening for hyper- very low quality evidence)
tension in adults 25 and 54 years old who
are going to a physician. (strong recommen- Remarks:
dation, moderate quality evidence) This cut-off point may be particularly
useful in patients with other risk fac-
Recommendation 3: tors for hypertension
The panel recommends screening for hyper-
tension in adults 15 and 24 years old who Recommendation 9:
are going to a physician. (strong recommen- The panel suggests using a cut-off point of
dation, moderate quality evidence) diastolic blood pressure of 80 mm Hg over a
higher cut-off point to rule-out hypertension
Recommendation 4: in patients who are screened at a physicians
The panel suggests screening for hypertension office. (conditional recommendation, very low
in patients <15 years old who are going to a quality evidence)
physician. (conditional recommendation, very
low quality evidence) Recommendation 10:
The panel suggests using ambulatory blood
Remarks: pressure measurement (ABPM) as an alterna-
This recommendation is applicable tive to clinic blood pressure measurement
mainly to children > 6 years old (CBPM) for screening for hypertension in pa-
tients who underwent screening and were
normotensive. (conditional recommendation,
very low quality evidence)
Screening for Hypertension
3

Remarks:
ABPM could be used as an alternative Recommendation 12:
to CBPM, not be preferred over The panel suggests using an interval of 1 year
CBPM to re-screen patients who had systolic blood
pressure < 140 mm Hg or diastolic blood pres-
Recommendation 11: sure < 90 mm Hg during the first screening.
The panel suggests using home blood pres- (conditional recommendation, low quality
sure measurement (HBPM) as an alternative evidence)
to clinic blood pressure measurement (CBPM)
for screening for hypertension in patients who Recommendation 13:
underwent screening and were normotensive. The panel suggests using an interval of 2 year
(conditional recommendation, very low quali- to re-screen patients who had systolic blood
ty evidence) pressure < 120 mm Hg or diastolic blood pres-
sure < 80 mm Hg during the first screening.
Remarks: (conditional recommendation, low quality
HBPM could be used as an alternative evidence)
to CBPM, not be preferred over
CBPM
Screening for Hypertension
4

people from 55 to 64 years old, the preva-


Scope and purpose lence of hypertension has been estimated to
be 51%; while in people from 15 to 54 years
The purpose of this document is to provide old the prevalence is 22%.20 Studies have also
guidance about the Screening for Hyperten- reported that among people aged 15 years or
sion. The target audience of these guidelines greater who are hypertensive, 57.8% are
includes physicians, nurses, healthcare per- undiagnosed.6
sonnel and patients who attend to the prima-
ry healthcare centers and hospitals at the Clinical research supports the effectiveness of
Ministry of Health, and healthcare centers in lowering blood pressure levels for preventing,
the private sector in the Kingdom of Saudi decreasing and delaying the consequences of
Arabia (KSA). Other health care professionals hypertension.7,8 Therefore, screening for hy-
and policy makers may also benefit from the- pertension could lead to an early detection
se guidelines. and treatment of this condition, which could
potentially reduce its results. Even more, the
Given the importance of this topic, the Minis- lack of a healthcare system that it is able to
try of Health (MoH) of Saudi Arabia with the identify and provide periodical follow-up to
methodological support of the McMaster Uni- people who are at a high risk of HTN and car-
versity working group produced practice diovascular diseases has been identified as
guidelines to assist health care providers in one of the main barriers to the implementa-
evidence-based decision-making. This practice tion of programs for the control and treat-
guideline is a part of the larger initiative of the ment of HTN.21
Ministry of Health of Saudi Arabia to establish
a program of rigorous adaptation and de novo Given the importance of this topic, the Minis-
development of guidelines in the Kingdom; try of Health of the Kingdom of Saudi Arabia
the ultimate goal being to provide guidance with the support of the McMaster University
for clinicians and other healthcare decision working group produced practice guidelines
makers and reduce unnecessary variability in to assist health care providers in evidence-
clinical practice across the Kingdom. based decision-making on the Screening for
Hypertension.
Introduction
Methodology
Hypertension (HTN) has been recognized as
an important risk factor of cardiovascular dis- To facilitate the interpretation of these guide-
eases, with consequences such as myocardial lines; we briefly describe the methodology we
infarction, stroke, and death. It has also been used to develop and grade recommendations
linked to chronic kidney disease, heart failure, and quality of the supporting evidence.
and dementia.1-4 The World Health Organisa-
tion estimates that hypertension is responsi- Question selection
ble of 13% of deaths, 51% of deaths from The Saudi expert guideline panel selected the
stroke and 45% of deaths for ischemic heart topic of this guideline and all healthcare ques-
disease globally.17 In addition, high blood tions addressed herein using a formal process.
pressure has been identified as the leading Since the process of screening for hyperten-
single risk factor for global burden of diseas- sion involves a series of inter-related steps,
es.18,19 from the first screening to the confirmation of
the diagnosis in some patients, the panel was
In Saudi Arabia, the prevalence of hyperten- presented with a clinical pathway that includ-
sion has been estimated to be 24% across all ed all these steps, and provided feedback re-
ages (adding all, isolated systolic hyperten- garding the applicability and pertinence of this
sion, isolated diastolic hypertension and com- pathway to the Saudi context. The clinical
bined systolic and diastolic hypertension).5 In pathway was designed based on the process
Screening for Hypertension
5

of screening and diagnosing hypertension, and Evaluation) approach and shared them
including the follow-up of those patients with the panel members (see Appendix 1).13,22
whose diagnosis was neither confirmed nor The guideline panel was invited to provide
discarded during the screening. Panel mem- additional information, particularly when pub-
bers also prioritized the sub-populations of lished evidence was lacking.
patients to address in the guidelines. After
this process, a final list with all the questions Moving from evidence to decisions (formulat-
to inform the clinical pathway was created. ing the recommendations)
The final step consisted of an in-person meet-
Evidence synthesis ing of the guideline panel in Riyadh on March
For the selected questions we updated exist- 17 & 18, 2015 to formulate the final recom-
ing systematic reviews on screening for hyper- mendations. We used the GRADE evidence-to-
tension9-12. For each question, the McMaster decision frameworks to follow a structured
guideline working group updated the search consensus process and transparently docu-
strategy to identify new studies and/or new ment all decisions made during the meeting.
systematic reviews. When relevant, the meta- Potential conflicts of interests of all panel
analyses were updated. We also conducted members were managed according to the
systematic searches to identify studies report- World Health Organization (WHO) rules.14
ing information regarding the risk and preva-
lence of hypertension and hypertension relat- Based on the recommendation, we construct-
ed outcomes in the Saudi population. We ed the clinical pathway proposed to the panel
used this information with 2 main purposes: in the prioritization stage (see Appendix 3).
1) estimating the risk of hypertension and hy-
pertension related outcomes when comparing Grading of the quality of evidence
patients who are screened to those who are The GRADE working group defines the quality
not, and 2) estimating the risk of hypertension of evidence as the extent of our confidence
related outcomes at different blood pressure that the estimate of an effect is adequate to
levels. This was done using a simple modelling support a particular decision or recommenda-
process, in which the baseline risk or preva- tion.15 We assessed the quality of evidence
lence of the outcome was combined with the using the GRADE approach.
estimate of screening for HTN. For example, if
the risk of having an acute myocardial infarc- Quality of evidence is classified as high,
tion in a specific population of patients in KSA moderate, low, or very low based on
was 273.82 per 100,000 , and the relative risk decisions about methodological characteris-
of this outcome comparing patients who are tics of the available evidence for a specific
screened for HTN versus those who are not health care problem. The definition of each
screened was 0.89, we would estimate that category is as follows:
the risk of acute myocardial infarction in KSA
population who are screened was High: We are very confident that the
273.82/100,000 x 0.89: that is, 243.70. Finally, true effect lies close to that of the es-
we also conducted systematic searches for timate of the effect.
information that was required to develop full Moderate: We are moderately confi-
guidelines for the KSA, including searches for dent in the effect estimate: The true
information about patients values and pref- effect is likely to be close to the esti-
erences, and costs and resource use specific mate of the effect, but there is a pos-
to the Saudi context (see Appendix 2). sibility that it is substantially different.
Low: Our confidence in the effect es-
Next, we developed for each question an evi- timate is limited: The true effect may
dence table and an evidence-to-decision (EtD) be substantially different from the es-
table following the GRADE (Grading of Rec- timate of the effect.
ommendations, Assessment, Development
Screening for Hypertension
6

Very low: We have very little confi-


dence in the effect estimate: The true Statements about the underlying values and
effect is likely to be substantially dif- preferences, resources, feasibility, equity, ac-
ferent from the estimate of effect. ceptability as well as other qualifying remarks
accompanying each recommendation are its
Grading of the strength of recommendations integral parts and serve to facilitate an accu-
The GRADE working group defines the rate interpretation. They should never be
strength of recommendation as the extent to omitted when quoting or translating recom-
which we can be confident that desirable ef- mendations from these guidelines if they in-
fects of an intervention outweigh undesirable fluence the strength or direction of the rec-
effects. According to the GRADE approach, ommendation.
the strength of a recommendation is either
strong or conditional (also known as or called
weak) and has explicit implications.16 Under- Key questions
standing the interpretation of these two
grades either strong or conditional of the The following is a list of the clinical questions
strength of recommendations is essential for selected by the Saudi expert panel and ad-
sagacious clinical decision-making. (see Table dressed in this guideline.
1)
1. Should we screen for hypertension in
As a quality measure prior to publication, the patients 55 years old, who are going
final report has been externally peer reviewed to a physician?
by a methodological expert who has not been 2. Should we screen for hypertension in
involved in this guideline development. patients 25 and 54 years old, who
are going to a physician?
Authors have tried as much as they could to 3. Should we screen for hypertension in
include the suggested changes in this report, patients 15 and 24 years old, who
but that does not mean that all the advised are going to a physician?
points have been added. 4. Should we screen for hypertension in
patients <15 years old, who are going
to a physician?
How to use these guide- 5. Should we screen for hypertension in
patients at high risk of hypertension,
lines who are going to a physician?
6. Should we use a cut-off point of sys-
The Ministry of Health of Saudi Arabia and tolic blood pressure of 140 mm Hg
McMaster University Practice Guidelines pro- versus a higher cut-off point to con-
vide clinicians and their patients with a basis firm a diagnosis of hypertension?
for rational decisions about the Screening for 7. Should we use a cut-off point of dias-
Hypertension. Clinicians, patients, third-party tolic blood pressure of 90 mm Hg ver-
payers, institutional review committees, other sus another cut-off point to confirm a
stakeholders, or the courts should never view diagnosis of hypertension?
these recommendations as dictates. As de- 8. Should we use a cut-off point of sys-
scribed in other guidelines following the tolic blood pressure of 120 mm Hg
GRADE approach, no guideline or recommen- versus another cut-off point to rule-
dation can take into account all of the often- out a diagnosis of hypertension?
compelling unique features of individual clini- 9. Should we use a cut-off point of dias-
cal circumstances. Therefore, no one charged tolic blood pressure of 80 mm Hg ver-
with evaluating clinicians actions should at- sus a higher cut-off point to rule-out a
tempt to apply the recommendations from diagnosis of hypertension?
these guidelines by rote or in a blanket fash- 10.Should ambulatory blood pressure
ion. measurement be used as an alterna-
Screening for Hypertension
7

tive to clinic blood pressure meas- Harms of the Option: There were no harms
urement for screening for hyperten- reported. The panel discussed the potential
sion in patients who underwent increase in anxiety levels (outcome rated as
screening and were normotensive? not important).

11.Should home blood pressure meas- Values and Preferences: Although there is no
urement be used as an alternative to research evidence, most patients would agree
clinic blood pressure measurement that the outcomes considered are relevant.
for screening for hypertension in pa-
tients who underwent screening and Acceptability: The MoH, private healthcare
were normotensive? providers, hospital administrators, physicians,
12.Should we use an interval of 1 year patients and family are likely to see this op-
versus 2 years to re-screen patients tion as acceptable.
who were not declared hypertensive
after screening? Feasibility: This is an intervention that it is
already routinely performed in many
healthcare centers, and therefore feasibility of
Recommendations the implementation is likely ensured.

Question 1: Should we screen for hyperten- Resource Use: There are no large costs associ-
sion in patients 55 years old, who are going ated with this intervention.
to a physician?
Balance between desirable and undesirable
Summary of Findings: There is moderate qual- consequences: There is moderate quality evi-
ity evidence from a cluster RCT conducted in dence suggesting a net benefit on long-term
Canada.23 In this trial, communities were ran- outcomes in patients who undergo screening
domized to either a HTN prevention program for hypertension. Patients values and prefer-
that included screening for HTN or no inter- ences are likely to have low variability regard-
vention. The researchers assessed patient- ing the importance of these health outcomes.
important outcomes after 1 year of imple- The incremental cost relative to the net bene-
menting the program. The relative effect es- fits is small, and this is an intervention ac-
timates were combined with the prevalence ceptable to key stakeholders and feasible to
of HTN6,20 and the risk of the outcomes in implement. Most of the consequences of
Saudi Arabia.20,24-28 The quality of the evidence screening for hypertension are desirable, and
was downgraded due to imprecision and indi- the desirable consequences clearly outweigh
rectness, and upgraded due to the availability the undesirable consequences.
of a large body of evidence from observation-
al studies that suggest a large benefit of Recommendation 1:
screening and early treatment of HTN.
The panel recommends to screen for hyper-
Benefits of the Option: Screening for HTN tension in adults 55 years old who are go-
probably reduces all-cause mortality (RR 0.98, ing to a physician. (strong recommendation,
95% CI 0.92; 1.03), death from cardiovascular moderate quality evidence)
disease (RR 0.86, 95% CI 0.73; 1.01), conges-
tive heart failure (RR 0.97, 95% CI 0.87; 1.08) Implementation Considerations and Monitor-
and acute myocardial infarction (RR 0.89, 95% ing: The panel believes it is necessary to de-
CI 0.79; 0.99). This would result on 15 fewer velop guidelines for the implementation of
deaths, 51 fewer cardiovascular deaths, 2 this recommendation. These guidelines would
fewer episodes of congestive heart failure and include benchmarks for a target proportion of
30 fewer acute myocardial infarctions, per patients who are actually receiving the inter-
100 000 patients, per year. vention.
Screening for Hypertension
8

Another aspect to consider is the need of Values and Preferences: Although there is no
standardizing the methods and equipment to research evidence, most patients would agree
screen for HTN. that the outcomes considered are relevant.

Research Priorities: Well-designed RCTs focus- Acceptability: The MoH, private healthcare
ing with a longer follow-up period and other providers, hospital administrators, physicians,
outcomes would help supporting this recom- patients and family are likely to see this op-
mendation. tion as acceptable.

Question 2: Should we screen for hyperten- Feasibility: This is an intervention that it is


sion in patients 25 and 54 years old, who already routinely performed in many
are going to a physician? healthcare centers, and therefore feasibility of
the implementation is likely ensured.
Summary of Findings: There is moderate qual-
ity evidence from a cluster RCT conducted in Resource Use: There are no large costs associ-
Canada.23 In this trial, communities were ran- ated with this intervention.
domized to either a HTN prevention program
that included screening for HTN or no inter- Balance between desirable and undesirable
vention. The researchers assessed patient- consequences: There is moderate quality evi-
important outcomes after 1 year of imple- dence suggesting a net benefit on long-term
menting the program. The relative effect es- outcomes in patients who undergo screening
timates were combined with the prevalence for hypertension. Patients values and prefer-
of HTN6,20 and the risk of the outcomes in ences are likely to have low variability regard-
Saudi Arabia.20,24-28 The quality of the evidence ing the importance of these health outcomes.
was downgraded due to imprecision and indi- The incremental cost relative to the net bene-
rectness (the results reported were for an fits is small, and this is an intervention ac-
older age group, yet we assumed the relative ceptable to key stakeholders and feasible to
effect estimate was constant across popula- implement. Most of the consequences of
tions), and upgraded due to the availability of screening for hypertension are desirable, and
a large body of evidence from observational the desirable consequences clearly outweigh
studies that suggest a large benefit of screen- the undesirable consequences.
ing and early treatment of HTN.
Recommendation 2:
Benefits of the Option: Screening for HTN
probably reduces all-cause mortality (RR 0.98, The panel recommends to screen for hyper-
95% CI 0.92; 1.03), death from cardiovascular tension in adults 25 and 54 years old
disease (RR 0.86, 95% CI 0.73; 1.01), conges- who are going to a physician. (strong rec-
tive heart failure (RR 0.97, 95% CI 0.87; 1.08) ommendation, moderate quality evidence)
and acute myocardial infarction (RR 0.89, 95%
CI 0.79; 0.99). This would result on 3 fewer Implementation Considerations and Monitor-
deaths, 4 fewer cardiovascular deaths, 5 few- ing: The panel believes it is necessary to de-
er episodes of congestive heart failure and 30 velop guidelines for the implementation of
fewer acute myocardial infarctions, per 100 this recommendation. These guidelines would
000 patients, per year. include benchmarks for a target proportion of
patients who are actually receiving the inter-
Harms of the Option: There were no harms vention.
reported. The panel discussed the potential Another aspect to consider is the need of
increase in anxiety levels (outcome rated as standardizing the methods and equipment to
not important). screen for HTN.
Screening for Hypertension
9

Research Priorities: Well-designed RCTs focus- Values and Preferences: Although there is no
ing with a longer follow-up period and other research evidence, most patients would agree
outcomes would help supporting this recom- that the outcomes considered are relevant.
mendation.
Acceptability: The MoH, private healthcare
providers, hospital administrators, physicians,
Question 3: Should we screen for hyperten- patients and family are likely to see this op-
sion in patients 15 and 24 years old, who tion as acceptable.
are going to a physician?
Feasibility: This is an intervention that it is
Summary of Findings: There is moderate qual- already routinely performed in many
ity evidence from a cluster RCT conducted in healthcare centers, and therefore feasibility of
Canada.23 In this trial, communities were ran- the implementation is likely ensured.
domized to either a HTN prevention program
that included screening for HTN or no inter- Resource Use: There are no large costs associ-
vention. The researchers assessed patient- ated with this intervention.
important outcomes after 1 year of imple-
menting the program. The relative effect es- Balance between desirable and undesirable
timates were combined with the prevalence consequences: There is moderate quality evi-
of HTN6,20 and the risk of the outcomes in dence suggesting a net benefit on long-term
Saudi Arabia.20,24-28 The quality of the evidence outcomes in patients who undergo screening
was downgraded due to imprecision and indi- for hypertension. Patients values and prefer-
rectness (the results reported were for an ences are likely to have low variability regard-
older age group, yet we assumed the relative ing the importance of these health outcomes.
effect estimate was constant across popula- The incremental cost relative to the net bene-
tions), and upgraded due to the availability of fits is small, and this is an intervention ac-
a large body of evidence from observational ceptable to key stakeholders and feasible to
studies that suggest a large benefit of screen- implement. Most of the consequences of
ing and early treatment of HTN. screening for hypertension are desirable, and
the desirable consequences clearly outweigh
Benefits of the Option: Screening for HTN the undesirable consequences.
probably reduces all-cause mortality (RR 0.98,
95% CI 0.92; 1.03), death from cardiovascular Recommendation 3:
disease (RR 0.86, 95% CI 0.73; 1.01), conges-
tive heart failure (RR 0.97, 95% CI 0.87; 1.08) The panel recommends to screen for hyper-
and acute myocardial infarction (RR 0.89, 95% tension in adults 15 and 24 years old
CI 0.79; 0.99). Considering the baseline risk of who are going to a physician. (strong rec-
this population, this would result on 30 fewer ommendation, moderate quality evidence)
acute myocardial infarctions, per 100 000 pa-
tients, per year. However, the benefits were Implementation Considerations and Monitor-
considered to be probably large, because the ing: The panel believes it is necessary to de-
estimations represent a year of follow-up, velop guidelines for the implementation of
while in this population the effects would be this recommendation. These guidelines would
seen on the long-term. include benchmarks for a target proportion of
patients who are actually receiving the inter-
Harms of the Option: There were no harms vention.
reported. The panel discussed the potential Another aspect to consider is the need of
increase in anxiety levels (outcome rated as standardizing the methods and equipment to
not important). screen for HTN.
Screening for Hypertension
10

Research Priorities: Well-designed RCTs focus- healthcare centers, and therefore feasibility of
ing with a longer follow-up period and other the implementation is likely ensured.
outcomes would help supporting this recom-
mendation. Resource Use: There are no large costs associ-
ated with this intervention.
Question 4: Should we screen for hyperten-
sion in patients <15 years old, who are going Balance between desirable and undesirable
to a physician? consequences: There is very low quality evi-
dence suggesting an association between ele-
Summary of Findings: There is very low quality vated blood pressure levels in childhood and
evidence from a systematic review of obser- hypertension in adulthood. Patients values
vational studies.11 In this systematic review and preferences are likely to have low varia-
the authors assessed the association between bility regarding the importance of preventing
the presence of elevated blood pressure lev- hypertension and its associated consequences
els in childhood and hypertension in child- in adulthood. There is no evidence available in
hood and adulthood and included 5 observa- children < 6 years old. The incremental cost
tional studies. The results of these studies relative to the net benefits is small, and this is
could not be pooled due to clinical heteroge- an intervention feasible to implement. How-
neity of the studies. The quality of the evi- ever, there may be some issues regarding the
dence was downgraded due to limitations in acceptability of the intervention. The desira-
study design. There were no studies reporting ble consequences probably outweigh the un-
on the association between screening for hy- desirable consequences.
pertension, or elevated blood pressure levels
in childhood, and long-term cardiovascular Recommendation 4:
outcomes.
The panel suggests to screen for hyperten-
Benefits of the Option: The studies reported a sion in patients <15 years old who are going
positive association between elevated blood to a physician. (conditional recommenda-
pressure in childhood and HTN in adulthood. tion, very low quality evidence)
ORs ranged from 1.1 to 4.5 and RRs ranged
from 1.5 to 9. Remarks:
This recommendation is applicable mainly
Harms of the Option: One study reported a to children > 6 years old
non-statistically significant difference in
school absenteeism when children had been Implementation Considerations and Monitor-
screened versus not. ing: The panel believes it is necessary to de-
velop guidelines for the implementation of
Values and Preferences: Although there is no this recommendation. These guidelines would
research evidence, most patients would agree include benchmarks for a target proportion of
that the outcomes considered are relevant. patients who are actually receiving the inter-
vention.
Acceptability: Although the MoH, private Another aspect to consider is the need of
healthcare providers, hospital administrators, standardizing the methods and equipment to
physicians, patients and family are likely to screen for HTN.
see this option as acceptable, there could be
some concerns regarding screening for HTN in Research Priorities: Well-designed RCTs focus-
children, especially from the care-givers per- ing with a longer follow-up period and other
spective. outcomes would help supporting this recom-
mendation.
Feasibility: This is an intervention that it is
already routinely performed in many
Screening for Hypertension
11

comes in patients who undergo screening for


Question 5: Should we screen for hyperten- hypertension would be large. Patients values
sion in patients at high risk of hypertension, and preferences are likely to have low varia-
who are going to a physician? bility regarding the importance of these
health outcomes. The incremental cost rela-
Summary of Findings: There is moderate qual- tive to the net benefits is small, and this is an
ity evidence from an observational study that intervention acceptable to key stakeholders
suggest an association between the presence and feasible to implement.
of many risk factors and hypertension in Saudi
Arabia.6 The quality of the evidence was up- Recommendation 5:
graded due to a large association and a high
confidence in the large effect of the treat- The panel recommends to screen for hyper-
ment of HTN on long-term outcomes in this tension in patients at high risk of hyperten-
population. sion, who are going to a physician. (strong
recommendation, moderate quality evi-
Benefits of the Option: People with risk factors dence)
are at higher risk of hypertension. Odds ra-
tions range from 1.28 to 2.24, depending on Implementation Considerations and Monitor-
the risk factor considered. Since these pa- ing: The panel believes it is necessary to de-
tients have a higher baseline risk of long-term velop guidelines for the implementation of
cardiovascular disease associated outcomes, this recommendation. These guidelines would
the benefits of screening for HTN would be include benchmarks for a target proportion of
even higher than in adults >55 years old. patients who are actually receiving the inter-
vention.
Harms of the Option: There were no harms Another aspect to consider is the need of
reported. The panel discussed the potential standardizing the methods and equipment to
increase in anxiety levels (outcome rated as screen for HTN.
not important).
Research Priorities: Well-designed RCTs focus-
Values and Preferences: Although there is no ing with a longer follow-up period and other
research evidence, most patients would agree outcomes would help supporting this recom-
that the outcomes considered are relevant. mendation.

Acceptability: The MoH, private healthcare Question 6: Should we use a cut-off point of
providers, hospital administrators, physicians, systolic blood pressure of 140 mm Hg versus
patients and family are likely to see this op- a higher cut-off point to confirm a diagnosis
tion as acceptable. of hypertension?

Feasibility: This is an intervention that it is Summary of Findings: There is very low quality
already routinely performed in many evidence from a systematic review of obser-
healthcare centers, and therefore feasibility of vational studies.7 The quality of the evidence
the implementation is likely ensured. was downgraded due to limitations in the
study design. In this systematic review the
Resource Use: There are no large costs associ- authors reported the risk of long-term out-
ated with this intervention. comes per increments of 10 mm Hg of blood
pressure, information that was combined with
Balance between desirable and undesirable the baseline risk of the outcomes to estimate
consequences: There is moderate quality evi- their risk over time (See Evidence Table 1).
dence suggesting an association between risk
factors and the presence of hypertension. Benefits of the Option: In patients with
Even more, the net benefit on long-term out- SBP=140 mm Hg, the predicted all-cause mor-
Screening for Hypertension
12

tality, stroke and coronary heart failure are


744, 36 and 125, respectively. Raising the cut- Research Priorities: There is a need of RCTs
off point to SBP= 150 mm Hg would result in comparing the benefits and harms of using
failing to predict (and potentially prevent) 121 different cut-off points of SBP for diagnosing
deaths, 20 strokes, and 46 episodes of coro- HTN.
nary artery disease.
Question 7: Should we use a cut-off point of
Harms of the Option: The only potential harm diastolic blood pressure of 90 mm Hg versus
is treating more patients than those who need another cut-off point to confirm a diagnosis
treatment, which was considered very small of hypertension?
when compared to the potential benefits of
treating patients with high blood pressure Summary of Findings: There is very low quality
levels. evidence from a systematic review of obser-
vational studies.7 The quality of the evidence
Values and Preferences: Although there is no was downgraded due to limitations in the
research evidence, most patients would agree study design. In this systematic review the
that the outcomes considered are relevant. authors reported the risk of long-term out-
comes per increments of 10 mm Hg of blood
Acceptability: The current standard in Saudi pressure, information that was combined with
Arabia is to use 140 mm Hg, and therefore the baseline risk of the outcomes to estimate
using this cut-off point would be more ac- their risk over time (See Evidence Table 2).
ceptable to stakeholders.
Benefits of the Option: In patients with
Feasibility: Keeping the cut-off of DBP at 140 DBP=90 mm Hg, the predicted all-cause mor-
mm Hg is very feasible, because this is already tality, stroke and coronary heart failure are
implemented. 755, 38 and 129, respectively. Lowering the
cut-off point to DBP= 85 mm Hg would result
Resource Use: There are no large costs associ- in predicting (and potentially preventing) 105
ated with this intervention. extra deaths, 14 strokes and 35 episodes of
coronary heart disease. Raising the cut-off
Balance between desirable and undesirable point to DBP= 95 mm Hg would result in fail-
consequences: There is very low quality evi- ing to predict (and potentially prevent) 123
dence regarding the benefits of using differ- deaths, 21 strokes, and 47 episodes of coro-
ent cut-off points for diagnosing HTN; howev- nary artery disease.
er, when balancing the potential prevention in
HTN associated cardiovascular events with the Harms of the Option: The only potential harm
potential harms of treating extra patients, the of lowering the cut-off point is over diagnos-
panel considered that the benefits of using a ing and treating more patients than those
cut-off point of 140 mm Hg outweighed the who need treatment, which was considered
harms. According to the panels judgment, very small when compared to the potential
this option was also more acceptable and fea- benefits of treating patients with high blood
sible to implement. pressure levels. The harms of raising the cut-
off points are not offering treatment to pa-
Recommendation 6: tients who need it.

The panel suggests to use a cut-off point of Values and Preferences: Although there is no
systolic blood pressure of 140 mm Hg over a research evidence, most patients would agree
higher cut-off point to diagnose hyperten- that the outcomes considered are relevant.
sion in patients who are screened at a phy-
sicians office. (conditional recommenda- Acceptability: The current standard in Saudi
tion, very low quality evidence) Arabia is to use 90 mm Hg, and therefore us-
Screening for Hypertension
13

ing this cut-off point would be more accepta- the baseline risk of the outcomes to estimate
ble to stakeholders. their risk over time (See Evidence Table 1).

Feasibility: Keeping the cut-off of SBP at 90 Benefits of the Option: In patients with
mm Hg is very feasible, because this is already SBP=120 mm Hg, the predicted all-cause mor-
implemented. tality, stroke and coronary heart failure are
550, 15 and 67, respectively. Raising the cut-
Resource Use: There are no large costs associ- off point to SBP= 130 mm Hg would result in
ated with this intervention. predicting (and potentially preventing) 90 ex-
tra deaths, 8 strokes and 24 episodes of coro-
Balance between desirable and undesirable nary heart disease. Other benefits of using
consequences: There is very low quality evi- 120 mm Hg as the cut-off point, such as the
dence regarding the benefits of using differ- health-promotion activities that would be
ent cut-off points for diagnosing HTN; howev- done in those patients with blood pressure
er, when balancing the potential prevention in levels between 120-130 mm Hg, and the po-
HTN associated cardiovascular events with the tential to follow-up more closely to those pa-
potential harms of treating extra patients, the tients with higher risk.
panel considered that the benefits of using a
cut-off point of 90 mm Hg outweighed the Harms of the Option: There is a potential
harms. According to the panels judgment, overtreatment to patients who have a blood
this option was also more acceptable and fea- pressure between 120 and 130 mm Hg if a
sible to implement. cut-off point of 120 mm Hg is used. This
would also result in stigmatizing patients in
Recommendation 7: this range of blood pressure, who are other-
wise living a healthy life.
The panel suggests to use a cut-off point of
diastolic blood pressure of 90 mm Hg over a Values and Preferences: Although there is no
higher or lower cut-off point to diagnose research evidence, most patients would agree
hypertension in patients who are screened that the outcomes considered are relevant.
at a physicians office. (conditional recom-
mendation, very low quality evidence) Acceptability: There may be acceptability is-
sues, as some clinicians would consider this a
Research Priorities: There is a need of RCTs very low cut-off value.
comparing the benefits and harms of using
different cut-off points of SBP for diagnosing Feasibility: There may be feasibility issues
HTN. since most clinicians use a cut-off point of 130
mm Hg.

Question 8: Should we use a cut-off point of Resource Use: Using a cut-off point of 120 mm
systolic blood pressure of 120 mm Hg versus Hg would lead to more resource use to do
another cut-off point (130 mm Hg) to confirm interventions and follow-up in these patients,
a diagnosis of hypertension? there is uncertainty regarding the incremental
cost relative to the net benefit.
Summary of Findings: There is very low quality
evidence from a systematic review of obser- Balance between desirable and undesirable
vational studies.7 The quality of the evidence consequences: There is very low quality evi-
was downgraded due to limitations in the dence regarding the benefits of using differ-
study design. In this systematic review the ent cut-off points for diagnosing HTN: howev-
authors reported the risk of long-term out- er, when balancing the potential prevention in
comes per increments of 10 mm Hg of blood HTN associated cardiovascular events by do-
pressure, information that was combined with ing lifestyle interventions and health promo-
Screening for Hypertension
14

tion, with the potential harms of treating less mm Hg as the cut-off point include health-
patients, the panel considered that the bene- promotion activities that would be done in
fits of using a cut-off point of 120 mm Hg those patients with blood pressure levels be-
probably outweighed the harms. Some unde- tween 80- 85 mm Hg, and the potential to
sirable consequences of this option may be follow-up more closely to those patients with
applicability and feasibility issues. higher risk.

Recommendation 8: Harms of the Option: There is a potential


overtreatment to patients who have a blood
The panel suggests to use a cut-off point of pressure between 80 and 85 mm Hg if a cut-
systolic blood pressure of 120 mm Hg over a off point of 80 mm Hg is used.
cut-off point of 130 mm Hg to rule-out hy-
pertension in patients who are screened at Values and Preferences: Although there is no
a physicians office. (conditional recom- research evidence, most patients would agree
mendation, very low quality evidence) that the outcomes considered are relevant.

Remarks: Acceptability: There are no acceptability is-


This cut-off point may be particularly useful sues.
in patients with other risk factors for hyper-
tension Feasibility: There are no feasibility issues.

Research Priorities: There is a need of RCTs Resource Use: Using a cut-off point of 80 mm
comparing the benefits and harms of using Hg would lead to more resource use to do
different cut-off points of SBP for diagnosing interventions and follow-up in these patients;
HTN. however, the incremental cost is probably
small compared to the benefits.

Question 9: Should we use a cut-off point of Balance between desirable and undesirable
diastolic blood pressure of 80 mm Hg versus consequences: There is very low quality evi-
a higher cut-off point to confirm a diagnosis dence regarding the benefits of using differ-
of hypertension? ent cut-off points for diagnosing or ruling-out
HTN; however, when balancing the potential
Summary of Findings: There is very low quality prevention in HTN associated cardiovascular
evidence from a systematic review of obser- events by doing lifestyle interventions and
vational studies.7 The quality of the evidence health promotion, with the extra resources
was downgraded due to limitations in the required, the panel considered that the bene-
study design. In this systematic review the fits of using a cut-off point of 80 mm Hg prob-
authors reported the risk of long-term out- ably outweighed the harms. There are no is-
comes per increments of 10 mm Hg of blood sues of acceptability and feasibility.
pressure, information that was combined with
the baseline risk of the outcomes to estimate Recommendation 9:
their risk over time (See Evidence Table 1).
The panel suggests to use a cut-off point of
Benefits of the Option: In patients with diastolic blood pressure of 80 mm Hg over a
DBP=80 mm Hg, the predicted all-cause mor- higher cut-off point to rule-out HTN in pa-
tality, stroke and coronary heart failure are tients who are screened at a physicians of-
559, 16 and 69, respectively. Raising the cut- fice (conditional recommendation, very low
off point to DBP= 85 mm Hg would result in quality evidence)
predicting (and potentially preventing) 91 ex-
tra deaths, 8 strokes and 25 episodes of coro- Research Priorities: There is a need of RCTs
nary heart disease. Other benefits of using 80 comparing the benefits and harms of using
Screening for Hypertension
15

different cut-off points of SBP for diagnosing Balance between desirable and undesirable
HTN. consequences: There is very low quality evi-
dence suggesting little or no benefit of ABPM
Question 10: Should ambulatory blood pres- for predicting long-term cardiovascular out-
sure measurement (ABPM) be used as an comes. The resources required are large, and
alternative to clinic blood pressure meas- probably worth it only on those setting where
urement (CBPM) for screening for hyperten- the option is available already. There are no
sion in patients who underwent screening major concerns regarding the acceptability
and were normotensive? and feasibility of implementing this option.

Summary of Findings: There is very low quality Recommendation 10:


evidence from a systematic review of obser-
vational studies.10 The quality of the evidence The panel suggests to use ambulatory blood
was downgraded due to limitations in the pressure measurement (ABPM) as an alter-
study design. In this systematic review the native to clinic blood pressure measure-
authors reported the risk of long-term out- ment (CBPM) for screening for hypertension
comes per increments of 10 mm Hg of blood in patients who underwent screening and
pressure, information that was combined with were normotensive (conditional recom-
the baseline risk of the outcomes to estimate mendation, very low quality evidence)
their risk over time (See Evidence Table 3).
Due to clinical heterogeneity, the results of Remarks:
the studies could not be pooled. The table ABPM could be used as an alternative to
shows the point estimates and confidence CBPM, not be preferred over CBPM
intervals for the ability of ABPM and CBPM
increments to predict cardiovascular associat-
ed outcomes. Question 11: Should home blood pressure
measurement (HBPM) be used as an alterna-
Benefits of the Option: The evidence suggests tive to clinic blood pressure measurement
that there is little to no benefit of using (CBPM) for screening for hypertension in pa-
ABPM. tients who underwent screening and were
normotensive?
Harms of the Option: Main potential harm is
raising the levels of anxiety of patients under- Summary of Findings: There is very low quality
going ABPM. evidence from a systematic review of obser-
vational studies.10 The quality of the evidence
Values and Preferences: Although there is no was downgraded due to limitations in the
research evidence, most patients would agree study design. In this systematic review the
that the outcomes considered are relevant. authors reported the risk of long-term out-
comes per increments of 10 mm Hg of blood
Acceptability: There are no acceptability is- pressure, information that was combined with
sues. the baseline risk of the outcomes to estimate
their risk over time (See Evidence Table 4).
Feasibility: ABPM may be more feasible to Due to clinical heterogeneity, the results of
implement in some setting than in others. the studies could not be pooled. The table
shows the point estimates and confidence
Resource Use: ABPM requires acquiring the intervals for the ability of HBPM and CBPM
monitors and training healthcare personnel. increments to predict cardiovascular associat-
The incremental costs are not small compared ed outcomes.
to the net benefit.
Benefits of the Option: The evidence suggests
that there is little to no benefit of using
Screening for Hypertension
16

HBPM; however, there may be other benefits


such as decreasing anxiety levels in the pa- Question 12: Should we use an interval of 1
tients. year versus 2 years to re-screen patients who
were not diagnosed with hypertension after
Harms of the Option: There is no evidence of screening?
harms with this option.
Summary of Findings: There is low quality evi-
Values and Preferences: Although there is no dence from a systematic review of observa-
research evidence, most patients would agree tional studies.10 The authors reported the as-
that the outcomes considered are relevant. sociation between screening intervals and
incidence of HTN. There was no evidence re-
Acceptability: There are no acceptability is- garding the effects of different rescreening
sues. intervals on long-term outcomes.

Feasibility: There are no feasibility issues. Benefits of the Option: The longer the re-
screening interval, the higher the incidence of
Resource Use: The small resources needed to HTN. Therefore, with longer intervals more
acquire the machines are worth the potential patients would not benefit from an early
net benefit. treatment.

Balance between desirable and undesirable Harms of the Option: There is no evidence of
consequences: There is very low quality evi- harms with this option.
dence suggesting little or no benefit of HBPM
for predicting long-term cardiovascular out- Values and Preferences: Although there is no
comes; however, there are other potential research evidence, most patients would agree
benefits of using this option, such as less anxi- that the outcomes considered are relevant.
ety levels. The incremental cost is small rela-
tive to the benefit, and there are no issues Acceptability: There are no acceptability is-
with acceptability and feasibility. sues.

Recommendation 11: Feasibility: There are no feasibility issues.

The panel suggests to use home blood pres- Resource Use: The incremental costs are small
sure measurement (HBPM) as an alterna- relative to the net benefits.
tive to clinic blood pressure measurement
(CBPM) for screening for hypertension in Balance between desirable and undesirable
patients who underwent screening and consequences: There is low quality evidence
were normotensive (conditional recom- regarding the association between screening
mendation, very low quality evidence) intervals and incidence of HTN; however, the
panel gave a high weight in the fact that early
Remarks: detection could potentially prevent the nega-
HBPM could be used as an alternative to tive effects of HTN. The incremental costs are
CBPM, not be preferred over CBPM small relative to the net benefits, and this is
an option acceptable and feasible to imple-
Implementation Considerations and Monitor- ment.
ing: Patients would need specific instructions
regarding how to respond to HBPM, which
need to be discussed between the patient and
physician. They would also need training in
use of the machine at home.
Screening for Hypertension
17

Recommendation 12:

The panel suggests to use an interval of 1


year to re-screen patients who had systolic
blood pressure < 140 mm Hg or diastolic
blood pressure < 90 mm Hg during the first
screening (conditional recommendation,
low quality evidence)

Recommendation 13:

The panel suggests to use an interval of 2


year to re-screen patients who had systolic
blood pressure < 120 mm Hg or diastolic
blood pressure < 80 mm Hg during the first
screening (conditional recommendation,
low quality evidence)
Screening for Hypertension
18

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doi: 10.36/jnnp.2009.176818. Epub 2009 Aug 19.
2. Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease,
2001. Lancet 2008;371:1513-8. doi: 10.016/S0140-6736(08)60655-8.
3. O'Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic
stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010;376:112-23. doi:
10.1016/S0140-6736(10)60834-3. Epub 2010 Jun 17.
4. Woo D, Haverbusch M, Sekar P, et al. Effect of untreated hypertension on hemorrhagic
stroke. Stroke 2004;35:1703-8. Epub 2004 May 20.
5. Al-Nozha MM, Abdullah M, Arafah MR, et al. Hypertension in Saudi Arabia. Saudi Med J
2007;28:77-84.
6. El Bcheraoui C, Memish ZA, Tuffaha M, et al. Hypertension and its associated risk factors in
the kingdom of saudi arabia, 2013: a national survey. Int J Hypertens
2014;2014:564679.:10.1155/2014/564679. Epub 2014 Aug 6.
7. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of
cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from
prospective epidemiological studies. BMJ 2009;338:b1665.:10.1136/bmj.b665.
8. Turnbull F, Neal B, Ninomiya T, et al. Effects of different regimens to lower blood pressure
on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ
2008;336:1121-3. doi: 10.36/bmj.39548.738368.BE. Epub 2008 May 14.
9. Levine M, Neary J. Screening for Hypertension. Hamilton, Ontario, Canada: Canadian Task
Force on Preventive Health Care,; 2012.
10. Piper MA, Evans CV, Burda BU, Margolis KL, O'Connor E, Whitlock EP. Diagnostic and
predictive accuracy of blood pressure screening methods with consideration of rescreening intervals:
a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2015;162:192-204.
doi: 10.7326/M14-1539.
11. Thompson M, Dana T, Bougatsos C, Blazina I, Norris SL. Screening for hypertension in
children and adolescents to prevent cardiovascular disease. Pediatrics 2013;131:490-525. doi:
10.1542/peds.2012-3523. Epub 2013 Feb 25.
12. Wolff T, Miller T. Evidence for the reaffirmation of the U.S. Preventive Services Task Force
recommendation on screening for high blood pressure. Ann Intern Med 2007;147:787-91.
13. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of
evidence and strength of recommendations. Bmj 2008;336:924-6.
14. WHO Handbook for Guideline Development. World Health Organization, 2012. (Accessed
February 7, 2014, at http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf.)
15. Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating the quality of
evidence. Journal of clinical epidemiology 2011;64:401-6.
16. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to
recommendations: the significance and presentation of recommendations. Journal of clinical
epidemiology 2013;66:719-25.
17. World Health Organization. Global health risks: mortality and burden of disease attributable
to selected major risks. Geneva: WHO Press; 2009.
18. Bromfield S, Muntner P. High blood pressure: the leading global burden of disease risk factor
and the need for worldwide prevention programs. Curr Hypertens Rep 2013;15:134-6. doi:
10.1007/s11906-013-0340-9.
19. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and
injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic
Screening for Hypertension
19

analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-60. doi: 10.1016/S0140-
6736(12)61766-8.
20. World Health Organization. WHO STEPwise approach to NCD surveillance, Country specific
standard report. Saudi Arabia2005.
21. Perkovic V, Huxley R, Wu Y, Prabhakaran D, MacMahon S. The burden of blood pressure-
related disease: a neglected priority for global health. Hypertension 2007;50:991-7. Epub 2007 Oct
22.
22. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence
profiles and summary of findings tables. Journal of clinical epidemiology 2011;64:383-94.
23. Kaczorowski J, Chambers LW, Dolovich L, et al. Improving cardiovascular health at
population level: 39 community cluster randomised trial of Cardiovascular Health Awareness
Program (CHAP). BMJ 2011;342:d442.:10.1136/bmj.d442.
24. Benamer HT, Grosset D. Stroke in Arab countries: a systematic literature review. J Neurol Sci
2009;284:18-23. doi: 10.1016/j.jns.2009.04.029. Epub May 9.
25. Ghandehari K, Izadi Z. The Khorasan Stroke Registry: results of a five-year hospital-based
study. Cerebrovasc Dis 2007;23:132-9. Epub 2006 Nov 16.
26. Al-Lawati J, Sulaiman K, Panduranga P. The Epidemiology of Acute Coronary Syndrome in
Oman: Results from the Oman-RACE study. Sultan Qaboos Univ Med J 2013;13:43-50. Epub 2013 Feb
27.
27. Agarwal AK, Venugopalan P, de Bono D. Prevalence and aetiology of heart failure in an Arab
population. Eur J Heart Fail 2001;3:301-5.
28. Global Burden of Disease Project from the Institute for Health Metrics and Evaluation,. at
http://www.healthdata.org/gbd.)
29. Ministry of Health. Health Statistics Annual Book2013.
30. Al-Khashman AS. Screening for hypertension. Assessing the knowledge, attitudes and
practice of primary health care physicians in Riyadh, Saudi Arabia. Saudi Med J 2001;22:1096-100.
31. Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and
adolescents in national surveys, 1963 to 2002. Circulation 2007;116:1488-96. Epub 2007 Sep 10.
32. Obarzanek E, Wu CO, Cutler JA, Kavey RE, Pearson GD, Daniels SR. Prevalence and incidence
of hypertension in adolescent girls. J Pediatr 2010;2010 Sep;157:461-7.
33. Stern B, Heyden S, Miller D, Latham G, Klimas A, Pilkington K. Intervention study in high
school students with elevated blood pressures. Dietary experiment with polyunsaturated fatty acids.
Nutr Metab 1980;24:137-47.
34. Wang YC, Koval AM, Nakamura M, Newman JD, Schwartz JE, Stone PW. Cost-effectiveness of
secondary screening modalities for hypertension. Blood Press Monit 2013;18:1-7. doi:
10.1097/MBP.0b013e32835d0fd3.
35. Hansen TW, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C. Ambulatory blood pressure
and mortality: a population-based study. Hypertension 2005;45:499-504. Epub 2005 Mar 7.
36. Dolan E, Stanton A, Thijs L, et al. Superiority of ambulatory over clinic blood pressure
measurement in predicting mortality: the Dublin outcome study. Hypertension 2005;46:156-61.
Epub 2005 Jun 6.
37. Staessen JA, Thijs L, Fagard R, et al. Predicting cardiovascular risk using conventional vs
ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in
Europe Trial Investigators. JAMA 1999;282:539-46.
38. Gasowski J, Li Y, Kuznetsova T, et al. Is "usual" blood pressure a proxy for 24-h ambulatory
blood pressure in predicting cardiovascular outcomes? Am J Hypertens 2008;21:994-1000. doi:
10.38/ajh.2008.231. Epub Jul 3.
39. Clement DL, De Buyzere ML, De Bacquer DA, et al. Prognostic value of ambulatory blood-
pressure recordings in patients with treated hypertension. N Engl J Med 2003;348:2407-15.
Screening for Hypertension
20

40. Bobrie G, Chatellier G, Genes N, et al. Cardiovascular prognosis of "masked hypertension"


detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA
2004;291:1342-9.
41. Niiranen TJ, Hanninen MR, Johansson J, Reunanen A, Jula AM. Home-measured blood
pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home
study. Hypertension 2010;55:1346-51. doi: 10.161/HYPERTENSIONAHA.109.149336. Epub 2010 Apr
12.
42. Ohkubo T, Kikuya M, Metoki H, et al. Prognosis of "masked" hypertension and "white-coat"
hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the
Ohasama study. J Am Coll Cardiol 2005;46:508-15.
43. Fagard RH, Van Den Broeke C, De Cort P. Prognostic significance of blood pressure measured
in the office, at home and during ambulatory monitoring in older patients in general practice. J Hum
Hypertens 2005;19:801-7.
44. Saudi Hypertension Management Sociaety. Saudi Hypertension Management Guidelines.
Riyadh, SA2011.
Screening for Hypertension
21

Appendices
1. Appendix 1: Evidence-to-Decision Frameworks
2. Appendix 2: Search Strategies and Results
3. Appendix 3: Clinical pathway for screening for hypertension
4. Appendix 4: Blood pressure measurement protocol
Screening for Hypertension
22

Appendix 1: Evidence to Decision Frameworks

Guideline Question 1: Should we screen for hypertension in patients 55 years old who are going to a physician?

Problem: High blood pressure levels in adults over 55 Background: High blood pressure has been identified as the leading single risk factor for global burden of
diseases.18,19 The lack of a healthcare system that it is able to identify and provide periodical follow-up to people
years old who are at a high risk of HTN and cardiovascular diseases has been identified as one of the main barriers to the
Option: Screening for HTN implementation of programs for the control and treatment of HTN.21

Comparison: Not screening for HTN Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such
Setting: Outpatients as myocardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and
dementia.1-4
Perspective: Healthcare system, MoH

Additional consid-
Criteria Judgements Research evidence
erations

The panel agreed that


No
The proportion of the adult population in Saudi Arabia age 65 years or older is 3% of there is no question
Probably no approximately 30 million people (2013).29 However, the prevalence of hypertension regarding the rele-
Is the problem a Uncertain (defined as SBP>140mmHg, including people taking medication) in people 55-64 years vance of the problem
Problem is 51.00% according to the WHO STEPS report.20
priority? Probably yes
Yes Screening for hypertension could lead to an early detection and treatment of this
condition, which could potentially reduce its results.
Varies

The relative importance or values of the main outcomes of interest: The panel was confi-
No included dent that most pa-
studies Relative im- Certainty of the evi-
Outcome tients would think that
What is the over- Very low portance dence (GRADE)
the outcomes consid-
all certainty of
Benefits & this evidence? Low Acute myocardial infarction ered were critical (yet
they acknowledge
harms of the Moderate Congestive heart failure
there were no pa-
options CRITICAL
High Stroke
MODERATE* tients representatives
Death from cardiovascular disease in the panel)
Important un- All-cause mortality The panel judged the
Is there im- certainty or varia- desirable anticipated
*The certainty of the evidence was downgraded due to imprecision and indirectness (the
bility
Screening for Hypertension
23

portant uncer- Possibly im- absolute risk calculations were based on simple modeling using the data from a RCT effects as probably
tainty about how portant uncertain- performed in elderly patients in Canada,23 in which communities were randomized to a large, because some
much people val- ty or variability hypertension prevention program that included screening for HTN. We used baseline of the relative effects
ue the main out- Probably no risks in this age population in Saudi Arabia. Then, the certainty of the evidence was up- were either crossing
comes? important uncer- graded because there is a large body of observational studies suggesting a large benefi- or close to the no
tainty or variability cial effect of screening and early treatment of HTN. effect value. In addi-
No important The population of elderly in Canada was 14.4% in 2011, but only 2.8% in Saudi Arabia. tion, they took into
uncertainty or var- The prevalence of hypertension in the elderly population in the RCT is 35%, but approx- account that the ab-
iability imately 51% in Saudi Arabia. solute effects were
Not known reported on a yearly-
Summary of findings: No screening versus screening for hypertension (numbers were basis, and therefore
No calculated in a one-year basis, which corresponds to the follow-up period of the RCT) the long-term effects
Probably no
No screening Screening for Difference Relative effect
would be even larger
Are the desirable Outcome
anticipated ef-
Uncertain for HTN HTN (95% CI) (RR) (95% CI)
One undesirable antic-
fects large? Probably yes
Acute myocar- 244 per 30 fewer per ipated effects that the
Yes dial infarction 273.82 per 100 000 100 000 0.89
panel discussed was
Varies 100 000 (from 216 to (from 58 to 3 (0.79 to 0.99)
271) fewer) the anxiety that the
screening could pro-
No Congestive 2 fewer per duce, yet they recog-
80 per
Probably no heart failure 82.08 per
100 000
100 000 0.97
nized that this out-
Are the undesira- 100 000 (from 11 fewer (0.87 to 1.08)
ble anticipated
Uncertain (from 71 to 89)
to 7 more) come would be rated

effects small? Probably yes as not-important rela-


Stroke 41 per 0 per 100 000 tive to the others
Yes 41 per
100 000 (from 6 fewer to
1.01
100 000 (0.89 to 1.15)
Varies (from 35 to 47) 6 more)

Death from 311 per 51 fewer per


No cardiovascular 362 per 100 000 100 000 0.86
Are the desirable Probably no disease 100 000 (from 264 to (from 98 fewer (0.73 to 1.01)
366) to 4 more)
effects large rela- Uncertain
tive to undesira- Probably yes 763 per 15 fewer per
ble effects? All-cause mor- 778.3 per 100 000 100 000 0.98
Yes tality 100 000 (from 716 to (from 62 fewer (0.92 to 1.03)
Varies 802) to 24 more)
Screening for Hypertension
24

No research evidence The panel discussed


about:
- Most clinics should
No
already have HTN
Probably no measuring equipment
Are the resources Uncertain available
required small? Probably yes - HTN screening is not
as big increase in
Yes
cost/time, as it is al-
Varies
ready done as part of
Resource use routine nursing as-
sessment in KSA

No research evidence relevant to KSA The panel considered


No that the potential

Is the incremen- Probably no long-term benefits


outweigh the small
tal cost small rel- Uncertain
resources required to
ative to the net Probably yes
screen for HTN
benefits?
Yes
Varies

No research evidence The panel discussed


Increased
that there is variabil-
Probably in-
ity in primary care
creased
availability and acces-
What would be no ef- sibility across the
Equity the impact on fect/uncertain
country; however,
health inequities? Probably re- screening for HTN is
duced
unlikely to have any
Reduced impact on health in-
Varies equities

No A study surveyed 107 physicians in 20 primary health care centers in 1996.30 It found Even though they
Is the option ac- that 28% knew the correct definition of HTN, but that 80 to 90% think that considers recognized that not all
Acceptability ceptable to key
Probably no screening, and think that screening for HTN is worthwhile, practical and not time con- stakeholders were
stakeholders? Uncertain suming. 6% actually screen patients above 35 years of age every 3 or 5 years, and 72%
represented in the
screen patients with risk factors every 6 months.
Probably yes
Screening for Hypertension
25

Yes panel, the panel was


confident about the
Varies
fact that screening for
HTN was an accepta-
ble intervention

No research evidence Some concern was


raised regarding fea-
sibility of screening
No
for HTN in those pa-
Probably no tients with less access
Is the option fea-
Feasibility sible to imple-
Uncertain to healthcare (insur-

ment? Probably yes ance and location


issues mainly); how-
Yes
ever it was still con-
Varies
sidered an interven-
tion feasible to im-
plement.
Screening for Hypertension
26

Recommendation
Should we screen for hypertension in patients 55 years old who are going to a physician?
Desirable consequences Desirable consequences
Undesirable consequences Undesirable consequences The balance between desirable
probably outweigh undesir- clearly outweigh undesirable
clearly outweigh desirable probably outweigh desirable and undesirable consequences
able consequences in most consequences in most set-
Balance consequences in most settings consequences in most settings is closely balanced or uncertain
settings tings


We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
Type of recommen- tion option tion
dation

The panel recommends to screen for hypertension in adults 55 years old who are going to a physician (strong recommendation, moderate quali-
Recommendation
ty evidence)

There is moderate quality evidence suggesting a net benefit on long-term outcomes in patients who undergo screening for hypertension. Patients
Justification values and preferences are likely to have low variability regarding the importance of these health outcomes. The incremental cost relative to the
net benefits is small, and this is an intervention acceptable to key stakeholders and feasible to implement.

Subgroup considera-
In patients with less accessibility to healthcare resources, this recommendation may need special attention.
tions

The panel believes it is necessary to develop guidelines for the implementation of this recommendation. These guidelines would include bench-
Implementation con-
marks for a target proportion of patients who are actually receiving the intervention.
siderations
Another aspect to consider is the need of standardizing the methods and equipment to screen for HTN.

Monitoring and eval- The panel believes that it is necessary to have post-implementation quality improvement projects to ensure take-up of recommendation and
uation proper implementation.

Research possibili-
Well-designed RCTs focusing with a longer follow-up period and other outcomes would help supporting this recommendation.
ties
Screening for Hypertension
27

Guideline Question 2: Should we screen for hypertension in patients 25 and 54 years old, who are going to a physician

Problem: High blood pressure levels in adults 25 Background: High blood pressure has been identified as the leading single risk factor for global burden of diseas-
es.18,19 The lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are
and 54 years old at a high risk of HTN and cardiovascular diseases has been identified as one of the main barriers to the implemen-
Option: Screening for HTN tation of programs for the control and treatment of HTN.21
Comparison: Not screening for HTN Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such
Setting: Outpatients as myocardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and
Perspective: Healthcare system, MoH dementia.1-4

Additional consid-
Criteria Judgements Research evidence
erations

The panel agreed that


The proportion of the adult population in Saudi Arabia age 15-64 years is 65% of 28 million there is no question
people (2011). The prevalence of hypertension (SBP>140mmHg, including people taking
No 20
medication) in people 15-54 years is 22. It has also been found that among people aged 15
regarding the rele-
Probably no years or greater who are hypertensive, 57.8% are undiagnosed and 20.2% are treated but vance of the problem

Is the problem a Uncertain uncontrolled.6


Problem
priority? Probably yes Screening for hypertension could lead to an early detection and treatment of this condition,
Yes which could potentially reduce its results.
Varies

The relative importance or values of the main outcomes of interest: The panel was confi-
No included dent that most pa-
studies Relative im- Certainty of the evi-
Outcome tients would think that
What is the Very low portance dence (GRADE)
the outcomes consid-
overall certainty
Benefits & of this evidence?
Low Acute myocardial infarction ered were critical (yet
they acknowledge
harms of the Moderate Congestive heart failure
there were no patients
options Stroke CRITICAL
High Death from cardiovascular disease
MODERATE* representatives in the
panel)
Important All-cause mortality The panel judged the
Is there im- uncertainty or *The certainty of the evidence was downgraded due to imprecision and indirectness (the desirable anticipated
portant uncer- variability
Screening for Hypertension
28

tainty about Possibly im- absolute risk calculations were based on simple modeling using the data from a RCT per- effects as probably
how much peo- portant uncer- formed in elderly patients in Canada,23 in which communities were randomized to a hyper- large, because some
ple value the tainty or variabil- tension prevention program that included screening for HTN. We used baseline risks in this of the relative effects
main outcomes? ity age population in Saudi Arabia. Then, the certainty of the evidence was upgraded because were either crossing
Probably no there is a large body of observational studies suggesting a large beneficial effect of screening or close to the no ef-
important uncer- and early treatment of HTN. fect value. In addition,
tainty or variabil- they took into account
ity
Summary of findings: No screening versus screening for hypertension (numbers were cal- that the absolute ef-
No important culated in a one-year basis, which corresponds to the follow-up period of the RCT) fects were reported on
uncertainty or
a yearly-basis, and
variability No screening
Screening for Difference Relative effect therefore the long-
Not known Outcome for hyperten-
hypertension (95% CI) (RR) (95% CI)
sion term effects would be
even larger
No Acute myocar- 244 per 30 fewer per
One undesirable antic-
Probably no dial infarction 273.82 per 100 000 100 000 0.89
ipated effects that the
Are the desira- 100 000 (from 216 to (from 58 to 3 (0.79 to 0.99)
ble anticipated
Uncertain 271) fewer) panel discussed was
effects large? Probably yes the anxiety that the
Congestive 139 per 5 fewer per
Yes heart failure 143.77 per 100 000 100 000 0.97
screening could pro-
duce, yet they recog-
Varies 100 000 (from 125 to (from 19 fewer (0.87 to 1.08)
155) to 11 more) nized that this out-
No come would be rated
Stroke 41 per 0 per 100 000 as not-important rela-
41 per 1.01
Probably no
100 000
100 000 (from 6 fewer to
(0.89 to 1.15)
Are the undesir- tive to the others
Uncertain (from 35 to 47) 6 more)
able anticipated
effects small? Probably yes Death from
23 per
4 fewer per
cardiovascular 27.16 per 100 000 0.86
Yes
disease 100 000
100 000
(from 7 to 0 (0.73 to 1.01)
Varies (from 20 to 27)
fewer)

No 109 per 3 fewer per


All-cause mor- 111.73 per 100 000 100 000 0.98
Are the desira- Probably no tality 100 000 (from 103 to (from 9 fewer to (0.92 to 1.03)
ble effects large Uncertain 115) 3 more)
relative to unde- Probably yes
sirable effects?
Yes
Varies
Screening for Hypertension
29

No research evidence The panel discussed


about:
- Most clinics should
already have HTN
measuring equipment
available
- HTN screening is not
No as big increase in
Probably no cost/time, as it is al-
Are the re- ready done as part of
sources required
Uncertain
routine nursing as-
small? Probably yes sessment in KSA
Yes - Although this age
Varies group represents a
Resource larger proportion of
use the population (which
may increase costs),
they will visit primary
care less often com-
pared to older pa-
tients

No research evidence relevant to KSA The panel considered


No that the potential

Is the incremen- Probably no long-term benefits


outweigh the small
tal cost small Uncertain
resources required to
relative to the Probably yes
screen for HTN
net benefits?
Yes
Varies

Increased No research evidence The panel discussed


that there is variability
What would be Probably in-
the impact on in primary care avail-
creased
Equity ability and accessibil-
health inequi- Uncertain/no
ity across the country;
ties? effect
however, screening
Probably re-
Screening for Hypertension
30

duced for HTN is unlikely to


Reduced have any impact on
Varies health inequities

A study surveyed 107 physicians in 20 primary health care centers in 1996.30 It found that Even though they
No 28% knew the correct definition of HTN, but that 80 to 90% think that considers screening, recognized that not all
and think that screening for HTN is worthwhile, practical and not time consuming. 6% actu- stakeholders were
Is the option Probably no ally screen patients above 35 years of age every 3 or 5 years, and 72% screen patients with
represented in the
Acceptability
acceptable to Uncertain risk factors every 6 months.
panel, the panel was
key stakehold- Probably yes confident about the
ers?
Yes fact that screening for
Varies HTN was an accepta-
ble intervention

No research evidence Some concern was


raised regarding fea-
No sibility of screening for
Probably no HTN in those patients
Is the option with less access to
Feasibility feasible to im-
Uncertain
healthcare (insurance
plement? Probably yes and location issues
Yes mainly); however it
Varies was still considered an
intervention feasible
to implement.
Screening for Hypertension
31

Recommendation
Should we screen for hypertension in patients 25 and 54 years old who are going to a physician?
Desirable consequences Desirable consequences
Undesirable consequences Undesirable consequences The balance between desirable
probably outweigh undesir- clearly outweigh undesirable
clearly outweigh desirable probably outweigh desirable and undesirable consequences
able consequences in most consequences in most set-
Balance consequences in most settings consequences in most settings is closely balanced or uncertain
settings tings


We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
Type of recommen- tion option tion
dation

The panel recommends to screen for hypertension in adults 25 and 54 years old who are going to a physician (strong recommendation, mod-
Recommendation
erate quality evidence)

There is moderate quality evidence suggesting a net benefit on long-term outcomes in patients who undergo screening for hypertension. Patients
Justification values and preferences are likely to have low variability regarding the importance of these health outcomes. The incremental cost relative to the
net benefits is small, and this is an intervention acceptable to key stakeholders and feasible to implement.

Subgroup considera-
In patients with less accessibility to healthcare resources, this recommendation may need special attention.
tions

The panel believes it is necessary to develop guidelines for the implementation of this recommendation. These guidelines would include bench-
Implementation con-
marks for a target proportion of patients who are actually receiving the intervention.
siderations
Another aspect to consider is the need of standardizing the methods and equipment to screen for HTN.

Monitoring and eval- The panel believes that it is necessary to have post-implementation quality improvement projects to ensure take-up of recommendation and
uation proper implementation.

Research possibili-
Well-designed RCTs focusing with a longer follow-up period and other outcomes would help supporting this recommendation.
ties
Screening for Hypertension
32

Guideline Question 3: Should we screen for hypertension in patients 15 and 24 years old, who are going to a physician

Problem: High blood pressure levels in adults 15 Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
and 24 years old and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Option: Screening for HTN trol and treatment of HTN.21
Comparison: Not screening for HTN Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
Setting: Outpatients cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4
Perspective: Healthcare system, MoH
Additional considera-
Criteria Judgements Research evidence
tions

The panel agreed that there


is no question regarding
The proportion of people 15-24 years old in the Saudi Arabia population is approxi- the relevance of the prob-
No mately 20% of 28 million people (2011). The prevalence of hypertension lem. They also highlighted
Probably no (SBP>140mmHg, including people taking medication) in this population is 9% accord-
ing to the WHO STEPS report.20 the vulnerability of this

Problem
Is the problem a Uncertain population, despite the
priority? Probably yes Screening for hypertension could lead to an early detection and treatment of this relative low prevalence of
condition, which could potentially reduce its results. HTN. According to the pan-
Yes
el, is in this population
Varies
where lifestyle interven-
tions could have a major
impact.

The relative importance or values of the main outcomes of interest: The panel was confident
No included that most patients would
studies Relative im- Certainty of the evi-
What is the Outcome think that the outcomes
overall certainty Very low portance dence (GRADE)
considered were critical
Benefits & of this evi- Low Acute myocardial infarction (yet they acknowledge
harms of dence? there were no patients rep-
the options Moderate Congestive heart failure
resentatives in the panel)
Stroke CRITICAL
High Death from cardiovascular disease
MODERATE* The panel judged the desir-
able anticipated effects as
Important All-cause mortality probably large, because
Is there im- uncertainty or
Screening for Hypertension
33

portant uncer- variability *The certainty of the evidence was downgraded due to imprecision and indirectness some of the relative effects
tainty about Possibly im- (the absolute risk calculations were based on simple modeling using the data from a were either crossing or
how much peo- portant uncer- RCT performed in elderly patients in Canada,23 in which communities were randomized close to the no effect value.
ple value the tainty or variabil- to a hypertension prevention program that included screening for HTN. We used base- In addition, they took into
main outcomes? ity line risks in this age population in Saudi Arabia. Then, the certainty of the evidence was account that the absolute
Probably no upgraded because there is a large body of observational studies suggesting a large effects were reported on a
important uncer- beneficial effect of screening and early treatment of HTN, which would be even larger yearly-basis, and therefore
tainty or variabil-
when the outcomes are looked at on a long-term basis (something particularly relevant the long-term effects would
ity
for this age group). be even larger, especially
No important
in this population.
uncertainty or
variability Summary of findings: No screening versus screening for hypertension (numbers were One undesirable anticipated
Not known calculated in a one-year basis, which corresponds to the follow-up period of the RCT) effects that the panel dis-
cussed was the anxiety that
No screening Relative effect
Screening for Difference the screening could pro-
No Outcome for hyperten-
hypertension (95% CI)
(RR) (95%
sion CI) duce, yet they recognized
Probably no
Are the desira- that this outcome would be
ble anticipated
Uncertain Acute myocar- 244 per 30 fewer per
rated as not-important rel-
dial infarction 273.82 per 100 000 100 000 0.89
effects large? Probably yes
100 000 (from 216 to (from 58 to 3 (0.79 to 0.99) ative to the others
Yes 271) fewer)
Varies
Congestive 4 per 0 per 100 000
heart failure 4.45 per 0.97
100 000 (from 0 to 1
No 100 000
(from 4 to 5) more)
(0.87 to 1.08)
Probably no
Are the undesir-
able anticipated
Uncertain Stroke
41 per
41 per 0 per 100 000
1.01
100 000 (from 6 fewer
effects small? Probably yes 100 000
(from 35 to 47) to 6 more)
(0.89 to 1.15)
Yes
Death from 1 per 0 fewer per
Varies
cardiovascular
1.48 per
100 000 100 000
0.86
100 000 (0.73 to 1.01)
disease (from 1 to 1) (from 0 to 0)
No
Are the desira- 0 fewer per
Probably no
All-cause mor- 24.18 per
24 per
100 000 0.98
ble effects large 100 000
relative to un-
Uncertain tality 100 000 (from 2 fewer (0.92 to 1.03)
(from 22 to 25)
desirable ef- Probably yes to 1 more)

fects? Yes
Varies
Screening for Hypertension
34

No research evidence The panel discussed about:


No - Most clinics should al-
Probably no ready have HTN measuring
Are the re- equipment available
sources required
Uncertain
- HTN screening is not as
small? Probably yes big increase in cost/time,
Yes as it is already done as part
Varies of routine nursing assess-
Resource ment in KSA
use
No research evidence relevant to KSA The panel considered that
No the potential long-term
Is the incremen- Probably no benefits outweigh the small
resources required to
tal cost small Uncertain
screen for HTN
relative to the Probably yes
net benefits?
Yes
Varies

Increased No research evidence The panel discussed that


there is variability in prima-
Probably in-
ry care availability and ac-
creased
What would be cessibility across the coun-
the impact on Uncertain/no
try; however, screening for
Equity effect
health inequi- HTN is unlikely to have any
ties? Probably re-
impact on health inequities
duced
Reduced
Varies

No A study surveyed 107 physicians in 20 primary health care centers in 1996.30 It found Even though they recog-
that 28% knew the correct definition of HTN, but that 80 to 90% think that considers nized that not all stake-
Is the option Probably no screening, and think that screening for HTN is worthwhile, practical and not time con- holders were represented in
Acceptability
acceptable to Uncertain suming. 6% actually screen patients above 35 years of age every 3 or 5 years, and
the panel, the panel was
72% screen patients with risk factors every 6 months.
key stakehold- Probably yes confident about the fact
ers?
Yes that screening for HTN was
Varies an acceptable intervention
Screening for Hypertension
35

No research evidence Some concern was raised


No regarding feasibility of
Probably no screening for HTN in those
Is the option patients with less access to
Feasibility feasible to im-
Uncertain
healthcare (insurance and
plement? Probably yes location issues mainly);
Yes however it was still consid-
Varies ered an intervention feasi-
ble to implement.
Screening for Hypertension
36

Recommendation
Should we screen for hypertension in patients 15 and 24 years old who are going to a physician?
Desirable consequences Desirable consequences
Undesirable consequences Undesirable consequences The balance between desirable
probably outweigh undesir- clearly outweigh undesirable
clearly outweigh desirable probably outweigh desirable and undesirable consequences
able consequences in most consequences in most set-
Balance consequences in most settings consequences in most settings is closely balanced or uncertain
settings tings


We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
Type of recommen- tion option tion
dation

The panel recommends to screen for hypertension in adults 25 and 54 years old who are going to a physician (strong recommendation, mod-
Recommendation
erate quality evidence)

There is moderate quality evidence suggesting a net benefit on long-term outcomes in patients who undergo screening for hypertension. Patients
Justification values and preferences are likely to have low variability regarding the importance of these health outcomes. The incremental cost relative to the
net benefits is small, and this is an intervention acceptable to key stakeholders and feasible to implement.

Subgroup considera-
In patients with less accessibility to healthcare resources, this recommendation may need special attention.
tions

The panel believes it is necessary to develop guidelines for the implementation of this recommendation. These guidelines would include bench-
Implementation con-
marks for a target proportion of patients who are actually receiving the intervention.
siderations
Another aspect to consider is the need of standardizing the methods and equipment to screen for HTN.

Monitoring and eval- The panel believes that it is necessary to have post-implementation quality improvement projects to ensure take-up of recommendation and
uation proper implementation.

Research possibili-
Well-designed RCTs focusing with a longer follow-up period and other outcomes would help supporting this recommendation.
ties
Screening for Hypertension
37

Guideline Question 4: Should we screen for hypertension in patients < 15 years old, who are going to a physician?

Problem: High blood pressure levels in <15 years old Background: High blood pressure has been identified as the leading single risk factor for global burden of
diseases.18,19 The lack of a healthcare system that it is able to identify and provide periodical follow-up to people who
Option: Screening for HTN are at a high risk of HTN and cardiovascular diseases has been identified as one of the main barriers to the implemen-
Comparison: Not screening for HTN tation of programs for the control and treatment of HTN.21
Setting: Outpatients Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as
Perspective: Healthcare system, MoH myocardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and demen-
tia.1-4

Additional consid-
Criteria Judgements Research evidence
erations

The panel agrees that


Data from the US suggests that blood pressure levels, and the prevalence of hypertension is
No
increasing in children.31 Despite the fact that people under 15 years in Saudi Arabia
this is a relevant
question to address
Probably no accounted for approximately 42% of the population in 2013,29 most of the studies do not
Uncertain provide any data regarding the blood pressure levels or prevalence of hypertension in this
Is the problem a population.
Problem
priority? Probably yes
Yes Screening children for hypertention could lead to early detenction and treatment, and
potentially reduce the adverse effects of hypertension in childhood and adulthood.
Varies

- There are no RCTs evaluating the effectiveness of screening for hypertension in children The panel was confi-
No included (important outcomes take a very long time to occur) dent that most pa-
studies
What is the tients would think that
overall certainty Very low - The prevalence of hypertension in the general population of children is between 1 to 5% 32
the outcomes consid-
of this evi- Low ered were critical (yet
dence? they acknowledge that
Benefits & Moderate Outcome
Relative im- Certainty of the evi-
some of the most pa-
portance dence (GRADE)
harms of
the options
High tients-important out-
comes are long-term
Incidence of hypertension CRITICAL
Important
VERY LOW*
outcomes)
Is there im- uncertainty or The panel judged the
variability desirable anticipated
portant uncer-
CRITICAL
tainty about Possibly im- Prevalence of hypertension
LOW*
effects as probably
how much peo- portant uncer- large, because all es-
tainty or variabil-
Screening for Hypertension
38

ple value the ity timates were higher



main outcomes? Probably no School absenteeism NOT IMPORTANT
VERY LOW*
than 1. Also, they
important uncer- agreed that on the
tainty or variabil- NOT MEASURED long term, the poten-
ity
Anxiety
tial of preventing out-
No important * The evidence comes from observational studies. The quality of the evidence was down-
comes such as cardio-
uncertainty or graded because of limitations in the study design. For the outcome prevalence of hyperten-
sion, the quality of the evidence was upgraded due to large effects. vascular events is
variability
important.
Not known One undesirable antic-
- Five observational studies reported association between elevated BP in childhood and HTN ipated effects that the
No in adulthood (ORs 1.1 to 4.5, RRs 1.5 to 9)11 panel discussed was
Probably no the anxiety that the
Are the desira- - One observational study showed no statistically significant differences in school absentee- screening could pro-
ble anticipated
Uncertain ism when children had been screened for hypertension versus not screened for duce to parents, yet
effects large? Probably yes hypertension33 they recognized that
this outcome would be
Yes rated as not-
Varies important relative to
the others
No
Some panel members
Probably no had doubts regarding
Are the undesir-
able anticipated
Uncertain the applicability of this
evidence to children
effects small? Probably yes <6 years old, due to
Yes the lack of evidence
Varies

No
Are the desira- Probably no
ble effects large
relative to un-
Uncertain

desirable ef- Probably yes


fects? Yes
Varies
Screening for Hypertension
39

No research evidence The panel discussed


about:
No - Most clinics should
Probably no already have HTN
Are the re- measuring equipment
sources required
Uncertain
available
small? Probably yes - HTN screening is not
Yes as big increase in
cost/time, as it is al-
Varies
ready done as part of
Resource routine nursing as-
use sessment in KSA

No research evidence The panel considered


No that the potential
Is the incremen- Probably no long-term benefits
outweigh the small
tal cost small Uncertain
resources required to
relative to the Probably yes
screen for HTN
net benefits?
Yes
Varies

Increased No research evidence The panel discussed


that there is variability
Probably in- in primary care avail-
creased ability and accessibil-
What would be
the impact on Uncertain / no ity across the country;
Equity effect however, screening
health inequi- for HTN is unlikely to
ties? Probably re- have any impact on
duced health inequities
Reduced
Varies

No A study surveyed 107 physicians in 20 primary health care centers in 1996.30 It found that There is uncertainty
Is the option 28% knew the correct definition of HTN, but that 80 to 90% think that considers screening, compared to other
Probably no and think that screening for HTN is worthwhile, practical and not time consuming. 6% actual- populations. The panel
acceptable to
Acceptability
key stakehold-
Uncertain ly screen patients above 35 years of age every 3 or 5 years, and 72% screen patients with discussed about the
risk factors every 6 months. potential issues of
ers? Probably yes
acceptability from the
Yes parents perspective
Screening for Hypertension
40

Varies

No research evidence Some concern was


raised regarding fea-
No
sibility of screening
Probably no for HTN in those pa-
Is the option tients with less access
Feasibility feasible to im-
Uncertain
to healthcare (insur-
plement? Probably yes ance and location is-
Yes sues mainly); howev-
er it was still consid-
Varies ered an intervention
feasible to implement.
Screening for Hypertension
41

Recommendation
Should we screen for hypertension in patients <15 years old who are going to a physician?
Desirable consequences Desirable consequences
Undesirable consequences Undesirable consequences The balance between desirable
probably outweigh undesir- clearly outweigh undesirable
clearly outweigh desirable probably outweigh desirable and undesirable consequences
able consequences in most consequences in most set-
Balance consequences in most settings consequences in most settings is closely balanced or uncertain
settings tings


We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
Type of recommen- tion option tion
dation

The panel suggests to screen for hypertension in patients <15 years old who are going to a physician (conditional recommendation, very low qual-
ity evidence)
Recommendation
Remarks: This recommendation is applicable mainly to children 6 years old

There is very low quality evidence suggesting an association between elevated blood pressure levels in childhood and hypertension in adulthood.
Patients values and preferences are likely to have low variability regarding the importance of preventing hypertension and its associated conse-
Justification
quences in adulthood. There is no evidence available in children < 6 years old. The incremental cost relative to the net benefits is small, and this
is an intervention feasible to implement. However, there may be some issues regarding the acceptability of the intervention.

Subgroup considera-
None
tions

The panel believes it is necessary to develop guidelines for the implementation of this recommendation. These guidelines would include bench-
Implementation con-
marks for a target proportion of patients who are actually receiving the intervention.
siderations
Another aspect to consider is the need of standardizing the methods and equipment to screen for HTN.

Monitoring and eval- The panel believes that it is necessary to have post-implementation quality improvement projects to ensure take-up of recommendation and
uation proper implementation.

Research possibili-
Well-designed RCTs focusing with a longer follow-up period and other outcomes would help supporting this recommendation.
ties
Screening for Hypertension
42

Guideline Question 5: Should we screen for hypertension in patients at high risk of hypertension, who are going to a physician?

Problem: High blood pressure levels in patients at Background: High blood pressure has been identified as the leading single risk factor for global burden of
diseases.18,19 The lack of a healthcare system that it is able to identify and provide periodical follow-up to people who
high risk of HTN are at a high risk of HTN and cardiovascular diseases has been identified as one of the main barriers to the implemen-
Option: Screening for HTN tation of programs for the control and treatment of HTN.21
Comparison: Not screening for HTN Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as
Setting: Outpatients myocardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and demen-
Perspective: Healthcare system, MoH tia.1-4

Criteria Judgements Research evidence Additional considerations

There are many known risk factors for hypertension. The WHO Steps report show The panel agrees that this is
No
that the prevalence of diabetes is approximately 20% in people over 15 years a very important question
Probably no old.20 A survey conducted in Saudi Arabia in 2013 showed that the prevalence of
Is the problem a obesity ranges from 20 to 70% and that the prevalence of other chronic Some of the risk factors
Problem
priority?
Uncertain
identified by the panel in
conditions associated with hypertension ranges from 10 to 60%.6
Probably yes previous discussions were
diabetes, crhonic kidney
Yes Screening for hypertention in these high risk populations could lead to early
disease, and atrial
detection and treatment, and potentially reduce the adverse effects of
Varies hypertension. fibrilation, among others.

The panel was confident that


No included Outcome
Relative im- Certainty of the
most patients would think
studies portance evidence (GRADE)
that the outcomes consid-
What is the over- Very low ered were critical.
all certainty of
this evidence?
Low Prevalence of hypertension (obese CRITICAL

The panel judged the desira-
Benefits & Moderate patients) MODERATE*
ble anticipated effects as
harms of the
options High probably large, because
CRITICAL there seems to be a large
Prevalence of hypertension (diabet-
Important un- association between the
ic patients) MODERATE*
certainty or varia- presence of the risk factors
Is there im- bility and HTN. Also, since these
Prevalence of hypertension (pa- CRITICAL
portant uncer- Possibly im- patients have a higher base-
tients with chronic conditions**) MODERATE*
tainty about how portant uncertain- line risk for long-term out-
much people val- ty or variability
Screening for Hypertension
43

Criteria Judgements Research evidence Additional considerations

ue the main out- Probably no * The evidence comes from observational studies. The high confidence in the comes, the long-term bene-
comes? large effect of the treatment of HTN on long-term outcomes in this population, fits of screening for HTN
important uncer-
and the large association between the risk factors and prevalence of HTN, lead to would be even higher that
tainty or variability
upgrading the quality of the evidence.
No important those observed in adults
uncertainty or var- **Previous diagnosis of stroke, myocardial infarction, atrial fibrillation, cardiac >55 years old.
iability arrest, congestive heart failure, chronic obstructive pulmonary disease, asthma,
Not known renal failure and cancer.

Summary of findings:
No
Are the desirable Probably no
Outcome OR Confidence interval
anticipated ef- Uncertain
fects large? Probably yes
Yes Prevalence of hypertension (obese 2.24 1.39-2.63
Varies patients)

No
Prevalence of hypertension (diabet- 1.95
Are the undesira- Probably no
ic patients)
1.57-2.93
ble anticipated Uncertain
effects small? Probably yes Prevalence of hypertension (pa- 1.28
0.93-1.26
Yes tients with chronic conditions*)
Varies

No
Are the desirable Probably no
effects large rela-
tive to undesira-
Uncertain

ble effects? Probably yes


Yes
Varies
Screening for Hypertension
44

Criteria Judgements Research evidence Additional considerations

No research evidence The panel discussed about:

No - Most clinics should already


Probably no have HTN measuring equip-
Are the resources
required small?
Uncertain ment available
Probably yes
- HTN screening is not as big
Yes increase in cost/time, as it is
Varies already done as part of rou-
tine nursing assessment in
Resource use KSA

No research evidence The panel considered that


the potential long-term ben-
No
efits outweigh the small re-
Is the incremen- Probably no sources required to screen
tal cost small rel-
ative to the net
Uncertain for HTN, especially in this

benefits? Probably yes subgroup of patients in


which the long-term benefits
Yes
would be larger
Varies

Increased No research evidence The panel discussed that


there is variability in primary
Probably in- care availability and accessi-
creased bility across the country;
What would be
Equity the impact on Uncertain / no however, screening for HTN
effect is unlikely to have any im-
health inequities? pact on health inequities
Probably re-
duced
Reduced
Varies

Is the option ac- A study surveyed 107 physicians in 20 primary health care centers in 1996.30 It Even though they recognized
No found that 28% knew the correct definition of HTN, but that 80 to 90% think that that not all stakeholders
Acceptability ceptable to key
stakeholders?
Probably no considers screening, and think that screening for HTN is worthwhile, practical and were represented in the
not time consuming. 6% actually screen patients above 35 years of age every 3 panel, the panel was confi-
Uncertain
or 5 years, and 72% screen patients with risk factors every 6 months. dent about the fact that
Screening for Hypertension
45

Criteria Judgements Research evidence Additional considerations

Probably yes screening for HTN was an


acceptable intervention.
Yes
Varies The panel also believes that
the option would be even
more acceptable than in oth-
er subgroups of patients, sue
to the higher risk of HTN in
this population

No research evidence Some concern was raised


No
regarding feasibility of
Is the option fea- Probably no screening for HTN in those
Feasibility sible to imple- Uncertain patients with less access to
healthcare (insurance and
ment? Probably yes location issues mainly);
Yes however it was still consid-
ered an intervention feasible
Varies to implement.
Screening for Hypertension
46

Recommendation
Should we screen for hypertension in patients at high risk of hypertension, who are going to a physician?
Desirable consequences Desirable consequences
Undesirable consequences Undesirable consequences The balance between desirable
probably outweigh undesir- clearly outweigh undesirable
clearly outweigh desirable probably outweigh desirable and undesirable consequences
able consequences in most consequences in most set-
Balance consequences in most settings consequences in most settings is closely balanced or uncertain
settings tings


We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
Type of recommen- tion option tion
dation

The panel recommends to screen for hypertension in patients at high risk of hypertension, who are going to a physician (strong recommendation,
Recommendation
moderate quality evidence)

There is moderate quality evidence suggesting an association between risk factors and the presence of hypertension. Even more, the net benefit
on long-term outcomes in patients who undergo screening for hypertension would be large. Patients values and preferences are likely to have low
Justification
variability regarding the importance of these health outcomes. The incremental cost relative to the net benefits is small, and this is an intervention
acceptable to key stakeholders and feasible to implement.

Subgroup considera-
None
tions

The panel believes it is necessary to develop guidelines for the implementation of this recommendation. These guidelines would include bench-
Implementation con-
marks for a target proportion of patients who are actually receiving the intervention.
siderations
Another aspect to consider is the need of standardizing the methods and equipment to screen for HTN.

Monitoring and eval- The panel believes that it is necessary to have post-implementation quality improvement projects to ensure take-up of recommendation and
uation proper implementation.

Research possibili-
None
ties
Screening for Hypertension
47

Guideline Question 6: Should we use a cut-off point of systolic blood pressure of 140 mm Hg versus a higher cut-off point to confirm a
diagnosis of hypertension?

Problem: Confirmation of HTN diagnosis in Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The lack of
a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN and cardio-
patients who are screened for HTN vascular diseases has been identified as one of the main barriers to the implementation of programs for the control and treatment
Option: Cut-off point of SBP of 140 mm Hg of HTN.21
Comparison: Cut-off point of SBP of 150 Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myocardial
mm Hg or higher infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4
Setting: Outpatients
Perspective: Healthcare system, MoH
Additional considera-
Criteria Judgements Research evidence
tions

It has been estimated that among people aged 15 years or greater who are The panel agrees that this
No hypertensive, 57.8% are undiagnosed and 20.2% are treated but uncontrolled.6 is a very relevant ques-
An optimal cut-off point for diagnosing HTN would allow to obtain the highest tion, especially due to the
Probably no possible net benefit from treatment presence of other guide-

Problem
Is there a problem pri- Uncertain lines and how they differ
with respect to their rec-
ority?
Probably yes ommendations and which
evidence drives them.
Yes
Varies
The relative importance or values of the main outcomes of interest: The panel was confident
No included that most patients would
studies Certainty of the evidence
Outcome Relative importance
(GRADE) think that the outcomes
What is the overall cer-
Very low considered were critical.
Benefits &
harms of
tainty of this evidence? Low All-cause mortality CRITICAL
The panel also discussed
LOW* regarding the limitations
the options Moderate of the data (very low qual-
High Stroke CRITICAL
ity evidence, based on
VERY LOW** modeling using estimates
Is there important un- Important un- of risks in the Saudi popu-
Screening for Hypertension
48

certainty about how certainty or varia- lation), which was consid-


much people value the bility Coronary heart dis-
CRITICAL
ered only as a reference
main outcomes? ease LOW*
Possibly im- * Data from observational studies
point to make their judg-
portant uncertain- ments.
** Downgrading due to indirectness
ty or variability Another important point of
Probably no Summary of findings (Evidence Table 1):
discussion was the differ-
ence between this ap-
important uncer- proach and the one taken
tainty of variabil- Benefits:
by existing guidelines,
ity - In patients with SBP=140 mm Hg, the predicted all-cause mortality,
where observational com-
stroke and coronary heart failure are 744, 36 and 125, respectively
No important - Raising the cut-off point to SBP= 150 mm Hg would result in failing to
parisons among RCTs are
usually done. The model-
uncertainty of predict (and potentially prevent) 121 deaths, 20 strokes, and 46 epi-
ling approach does not
variability sodes of coronary artery disease
provide with better quality
No known un- evidence to make the de-
desirable cision, however it is a for-
mal approach as opposed
to the former.
If the cut-off point were
No raised, fewer patients
Probably no would be treated for HTN;
however, this is thought to
Are the desirable antic- Uncertain be associated with more
harms than benefits.
ipated effects large?
Probably yes
Yes
Varies
No
Probably no
Are the undesirable
anticipated effects
Uncertain
small? Probably yes
Yes
Varies
Are the desirable ef-
fects large relative to
No
undesirable effects? Probably no
Screening for Hypertension
49

Uncertain
Probably yes
Yes
Varies
No research evidence. Having a higher cut-off
No point results in treating for
Probably no HTN to fewer patients, and
potentially saving money.
Are the resources re- Uncertain However, the resources to
quired small? treat patients when diag-
Probably yes nosed at a SBP level of
140 mm Hg were judged
Yes to be small

Resource
Varies
use
No research evidence. Since there were more
No benefits when using a cut-
Probably no off point of 140 mm Hg,
and the costs associated
Is the incremental cost
small relative to the
Uncertain with this were judged to
be small, the incremental
net benefits? Probably yes costs relative to the bene-
fits was judged to be
Yes small.
Varies
No research evidence The panel considered that
Increased this question was not ap-
Probably in- plicable, since all patients
would undergo the diagno-
creased
sis process irrespective of
What would be the im- Uncertain / no the cut-off point suggested
Equity pact on health inequi- impact
ties?
Probably re-
duced
Reduced
Varies
Screening for Hypertension
50

No research evidence. The panel discussed that


No the current standard in
Probably no Saudi Arabia is to use 140
mm Hg, and therefore
Is the option accepta-
Acceptability ble to key stakehold-
Uncertain using this cut-off point
would be more acceptable
ers? Probably yes to stakeholders.

Yes
Varies
No research evidence. The panel discussed about
No this being very feasible,
Probably no because it is already im-
plemented.

Feasibility
Is the option feasible Uncertain
to implement?
Probably yes
Yes
Varies
Screening for Hypertension
51

Recommendation
Should a cut-off of systolic blood pressure of 140 mm Hg versus a higher cut-off point be used to diagnose hy-
pertension in people who are going to a physician?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommen- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
dation tion option tion


The panel suggests to use a cut-off point of systolic blood pressure of 140 mm Hg over a higher cut-off point to diagnose hypertension in patients
Recommendation
who are screened at a physicians office (conditional recommendation, very low quality evidence)

There is very low quality evidence regarding the benefits of using different cut-off points for diagnosing HTN: however, when balancing the poten-
tial prevention in HTN associated cardiovascular events with the potential harms of treating extra patients, the panel considered that the benefits
Justification
of using a cut-off point of 140 mm Hg outweighed the harms. According to the panels judgment, this option was also more acceptable and feasi-
ble to implement.

Subgroup considera-
None
tions

Implementation con-
None
siderations

Monitoring and eval-


None
uation

Research possibili-
There is a need of RCTs comparing the benefits and harms of using different cut-off points of SBP for diagnosing HTN
ties
Screening for Hypertension
52

Guideline Question 7: Should we use a cut-off point of diastolic blood pressure of 90 mm Hg versus another cut-off point to confirm a di-
agnosis of hypertension?

Problem: Confirmation of HTN diagnosis in patients Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
who are screened for HTN and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Option: Cut-off point of DBP of 90 mm Hg trol and treatment of HTN.21
Comparison: Cut-off point of DBP of 85 or 95 mm Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
Hg cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4
Setting: Outpatients
Perspective: Healthcare system, MoH
Additional considera-
Criteria Judgements Research evidence
tions

It has been estimated that among people aged 15 years or greater who are hyper- The panel agrees that
No 6
tensive, 57.8% are undiagnosed and 20.2% are treated but uncontrolled. An op- this is a very relevant
question, especially due
Probably no timal cut-off point for diagnosing HTN would allow to obtain the highest possible to the presence of other

Problem
Is there a problem pri- Uncertain net benefit from treatment guidelines and how they
differ with respect to
ority?
Probably yes their recommendations
and which evidence
Yes drives them.

Varies
The relative importance or values of the main outcomes of interest: The panel was confident
No included that most patients
studies Certainty of the evidence
Outcome Relative importance
(GRADE) would think that the
What is the overall cer-
Very low outcomes considered
Benefits &
harms of
tainty of this evidence? Low All-cause mortality CRITICAL
were critical.
LOW* The panel also discussed
the options Moderate regarding the limitations
High Stroke CRITICAL
of the data (very low
VERY LOW** quality evidence, based
Is there important un- Important un- on modeling using esti-
Screening for Hypertension
53

certainty about how certainty or varia- mates of risks in the


much people value the bility Coronary heart dis-
CRITICAL
Saudi population), which
main outcomes? ease LOW*
Possibly im- * Data from observational studies
was considered only as
portant uncertain- a reference point to
** Downgrading due to indirectness
ty or variability make their judgments.
Probably no Summary of findings (Evidence Table 2): Another important point
of discussion was the
important uncer-
Benefits: difference between this
tainty of variabil-
- In patients with DBP=90 mm Hg, the predicted all-cause mortality, approach and the one
ity
stroke and coronary heart failure are 755, 38 and 129, respectively taken by existing guide-
No important - Lowering the cut-off point to DBP= 85 mm Hg would result in predicting lines, where observa-
uncertainty of (and potentially preventing) 105 extra deaths, 14 strokes and 35 epi- tional comparisons
variability sodes of coronary heart disease among RCTs are usually
done. The modelling
No known un- - Raising the cut-off point to DBP= 95 mm Hg would result in failing to
predict (and potentially prevent) 123 deaths, 21 strokes, and 47 epi- approach does not pro-
desirable sodes of coronary artery disease vide with better quality
evidence to make the
No decision, however it is a
formal approach as op-
Probably no posed to the former.
If the cut-off point were
Are the desirable antic- Uncertain lowered, more patients
would be treated for
ipated effects large?
Probably yes HTN, which is thought to
Yes be associated with more
harms than benefits.
Varies
No
Probably no
Are the undesirable
anticipated effects
Uncertain
small? Probably yes
Yes
Varies
Are the desirable ef-
fects large relative to
No
undesirable effects? Probably no
Screening for Hypertension
54

Uncertain
Probably yes
Yes
Varies
No research evidence. Having a higher cut-off
point results in treating
No for HTN to fewer pa-
Probably no tients, and potentially
saving money. On the
Are the resources re- Uncertain other hand, having low-
er cut-off point results
quired small?
Probably yes in treating more pa-
tients. The resources to
Yes treat patients when di-
agnosed at a DBP level
Resource
Varies of 90 mm Hg were
use judged to be small

No research evidence. Since there were more


No benefits when using a
Probably no cut-off point of 140 mm
Hg, and the costs asso-
Is the incremental cost
small relative to the
Uncertain ciated with this were
judged to be small, the
net benefits? Probably yes incremental costs rela-
tive to the benefits was
Yes judged to be small.
Varies
No research evidence The panel considered
Increased that this question was
Probably in- not applicable, since all
patients would undergo
creased
the diagnosis process
What would be the im-
Equity pact on health inequi- Uncertain / no irrespective of the cut-
impact off point suggested
ties?
Probably re-
duced
Reduced
Screening for Hypertension
55

Varies
No research evidence. The panel discussed that
No the current standard in
Probably no Saudi Arabia is to use
90 mm Hg, and there-
Is the option accepta-
Acceptability ble to key stakehold-
Uncertain fore using this cut-off
point would be more
ers? Probably yes acceptable to stakehold-
ers.
Yes
Varies
No research evidence. The panel discussed
No about this being very
Probably no feasible, because it is
already implemented.

Feasibility
Is the option feasible Uncertain
to implement?
Probably yes
Yes
Varies
Screening for Hypertension
56

Recommendation
Should a cut-off of diastolic blood pressure of 90 mm Hg versus another cut-off point be used to diagnose hy-
pertension in people who are going to a physician?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommen- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
dation tion option tion


The panel suggests to use a cut-off point of diastolic blood pressure of 90 mm Hg over a higher or lower cut-off point to diagnose hypertension in
Recommendation
patients who are screened at a physicians office (conditional recommendation, very low quality evidence)

There is very low quality evidence regarding the benefits of using different cut-off points for diagnosing HTN; however, when balancing the poten-
tial prevention in HTN associated cardiovascular events with the potential harms of treating extra or less patients, the panel considered that the
Justification
benefits of using a cut-off point of 90 mm Hg outweighed the harms. According to the panels judgment, this option was also more acceptable and
feasible to implement.

Subgroup considera-
None
tions

Implementation con-
None
siderations

Monitoring and eval-


None
uation

Research possibili-
There is a need of RCTs comparing the benefits and harms of using different cut-off points of SBP for diagnosing HTN
ties
Screening for Hypertension
57

Guideline Question 8: Should we use a cut-off point of systolic blood pressure of 120 mm Hg versus another cut-off point (130 mm Hg) to
rule-out a diagnosis of hypertension?

Problem: Ruling-out of HTN diagnosis in patients who Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
are screened for HTN and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Option: Cut-off point of SBP of 120 mm Hg trol and treatment of HTN.21
Comparison: Cut-off point of SBP of 130 mm Hg Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
Setting: Outpatients cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4
Perspective: Healthcare system, MoH

Additional considera-
Criteria Judgements Research evidence
tions

It has been estimated that among people aged 15 years or greater who are hy- The panel agrees that this
No pertensive, 57.8% are undiagnosed and 20.2% are treated but uncontrolled. An
6 is a very relevant ques-
tion, especially due to the
Probably no optimal cut-off point for diagnosing HTN would allow to obtain the highest pos- presence of other guide-

Problem
Is there a problem pri- Uncertain sible net benefit from treatment lines and how they differ
with respect to their rec-
ority?
Probably yes ommendations and which
evidence drives them.
Yes
Varies
The relative importance or values of the main outcomes of interest: The panel was confident
No included that most patients would
studies Certainty of the evidence
Outcome Relative importance
(GRADE) think that the outcomes
What is the overall cer-
Very low considered were critical.
tainty of this evidence? Low All-cause mortality CRITICAL
The panel also discussed
Benefits & LOW* regarding the limitations
harms of Moderate of the data (very low qual-
the options
High Stroke CRITICAL
ity evidence, based on
VERY LOW** modeling using estimates
Is there important un- of risks in the Saudi popu-
certainty about how Important un- Coronary heart dis-
CRITICAL
lation), which was consid-
much people value the certainty or varia- ease LOW*
bility ered only as a reference
main outcomes?
Screening for Hypertension
58

* Data from observational studies point to make their judg-


Possibly im- ** Downgrading due to indirectness ments.
portant uncertain-
ty or variability Another important point of
Summary of findings (Evidence Table 1): discussion was the differ-
Probably no Benefits:
ence between this ap-
important uncer- proach and the one taken
- In patients with SBP=120 mm Hg, the predicted all-cause mortality, by existing guidelines,
tainty of variabil-
stroke and coronary heart failure are 550, 15 and 67, respectively where observational com-
ity
- Raising the cut-off point to SBP= 130 mm Hg would result in predicting parisons among RCTs are
No important (and potentially preventing) 90 extra deaths, 8 strokes and 24 epi- usually done. The model-
uncertainty of sodes of coronary heart disease ling approach does not
variability provide with better quality
No known un- evidence to make the de-
cision, however it is a for-
desirable mal approach as opposed
to the former.
No Another benefit of using
120 mm Hg as the cut-off
Probably no point is the health-
promotion activities that
Are the desirable antic- Uncertain would be done in those
ipated effects large?
Probably yes patients with blood pres-
sure levels between 120-
Yes 130 mm Hg, and the po-
tential to follow-up more
Varies closely to those patients
with higher risk. Neverthe-
No less, there may be other
undesirable effects, such
Probably no as stigmatizing patients in
this range of blood pres-
Are the undesirable
anticipated effects
Uncertain sure, who are otherwise
living a healthy life
small? Probably yes
Yes
Varies

Are the desirable ef-


No
fects large relative to Probably no
undesirable effects?
Uncertain
Screening for Hypertension
59

Probably yes
Yes
Varies
No research evidence. Having a cut-off point of
No 130 mm Hg results in do-
ing lifestyle interventions
Probably no and less close follow up to
many patients (approxi-
Are the resources re- Uncertain mately 23% of the popula-
quired small?
Probably yes tion), and potentially
spending more money.
Yes Therefore, there are more
resources needed if the

Resource
Varies cut-off point is set at 120
mm Hg
use
No research evidence. The panel could not make
No a decision about the ex-
Probably no tent of the incremental
costs relative to the bene-
Is the incremental cost
small relative to the
Uncertain fits. Both, the potential
benefits and the costs
net benefits? Probably yes were thought to be im-
portant.
Yes
Varies
No research evidence The panel considered that
Increased this question was not ap-
Probably in- plicable, since all patients
would undergo the diagno-
creased
sis process irrespective of
What would be the im- Uncertain / no the cut-off point suggested
Equity pact on health inequi- impact
ties?
Probably re-
duced
Reduced
Varies
Screening for Hypertension
60

No research evidence. The panel discussed about


No the potential to confusing
Probably no practitioners of the cut-off
point is too low; therefore,
Is the option accepta-
Acceptability ble to key stakehold-
Uncertain this would make it an op-
tion not acceptable to all
ers? Probably yes stakeholders.
Yes
Varies
No research evidence. The panel discussed about
No a cut-off point of 130 be-
Probably no ing more feasible to im-
plement, since many prac-

Feasibility
Is the option feasible Uncertain titioners believe patients
to implement? are already using this cut-
Probably yes off point.
Yes
Varies
Screening for Hypertension
61

Recommendation
Should a cut-off of systolic blood pressure of 120 mm Hg versus another cut-off point (130 mm Hg) be used to
rule-out hypertension in people who are going to a physician?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommen- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
dation tion option tion


The panel suggests to use a cut-off point of systolic blood pressure of 120 mm Hg over a cut-off point of 130 mm Hg to rule-out HTN in patients
who are screened at a physicians office (conditional recommendation, very low quality evidence)
Recommendation
Remarks: This cut-off point may be particularly useful in patients with other risk factors for HTN

There is very low quality evidence regarding the benefits of using different cut-off points for diagnosing or ruling-out HTN; however, when balanc-
ing the potential prevention in HTN associated cardiovascular events by doing lifestyle interventions and health promotion, with the potential
Justification
harms of treating less patients, the panel considered that the benefits of using a cut-off point of 120 mm Hg probably outweighed the harms.
Some undesirable consequences of this option may be applicability and feasibility issues.

Subgroup considera-
None
tions

Implementation con-
None
siderations

Monitoring and eval-


None
uation

Research possibili-
There is a need of RCTs comparing the benefits and harms of using different cut-off points of SBP for diagnosing HTN
ties
Screening for Hypertension
62

Guideline Question 9: Should we use a cut-off point of diastolic blood pressure of 80 mm Hg versus a higher to rule-out a diagnosis of
hypertension?

Problem: Ruling-out of HTN diagnosis in patients who Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
are screened for HTN and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Option: Cut-off point of DBP of 80 mm Hg trol and treatment of HTN.21
Comparison: Cut-off point of DBP of 85 mm Hg or Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
higher cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4
Setting: Outpatients
Perspective: Healthcare system, MoH

Criteria Judgements Research evidence Additional considerations

It has been estimated that among people aged 15 years or greater who are The panel agrees that this is
No hypertensive, 57.8% are undiagnosed and 20.2% are treated but uncon- a very relevant question,
especially due to the pres-
Probably no 6
trolled. An optimal cut-off point for diagnosing HTN would allow to obtain ence of other guidelines and

Problem
Is there a problem pri- Uncertain the highest possible net benefit from treatment how they differ with respect
to their recommendations
ority?
Probably yes and which evidence drives
them.
Yes
Varies
The relative importance or values of the main outcomes of interest: The panel was confident that
No included most patients would think
studies Certainty of the evidence
Outcome Relative importance
(GRADE) that the outcomes consid-
What is the overall cer-
Very low ered were critical.
tainty of this evidence? Low All-cause mortality CRITICAL
The panel also discussed
Benefits & LOW* regarding the limitations of
harms of
the options
Moderate the data (very low quality

High Stroke CRITICAL
VERY LOW**
evidence, based on modeling
using estimates of risks in
Is there important un- the Saudi population), which
certainty about how Important un- Coronary heart dis-
ease
CRITICAL

was considered only as a
LOW*
much people value the certainty or varia-
Screening for Hypertension
63

main outcomes? bility * Data from observational studies reference point to make their
** Downgrading due to indirectness
Possibly im- judgments.
portant uncertain- Another important point of
Summary of findings (Evidence Table 2): discussion was the difference
ty or variability
between this approach and
Probably no Benefits:
- In patients with DBP=80 mm Hg, the predicted all-cause mortality,
the one taken by existing
important uncer- guidelines, where observa-
stroke and coronary heart failure are 559, 16 and 69, respectively tional comparisons among
tainty of variabil-
- Raising the cut-off point to DBP= 85 mm Hg would result in predict- RCTs are usually done. The
ity
ing (and potentially preventing) 91 extra deaths, 8 strokes and 25 modelling approach does not
No important episodes of coronary heart disease provide with better quality
uncertainty of evidence to make the deci-
variability sion, however it is a formal
No known un- approach as opposed to the
former.
desirable Another benefit of using 80
mm Hg as the cut-off point
No is the health-promotion ac-
tivities that would be done in
Probably no those patients with blood
pressure levels between 80-
Are the desirable antic- Uncertain 85+ mm Hg, and the poten-
ipated effects large?
Probably yes tial to follow-up more closely
to those patients with higher
Yes risk. Nevertheless, there
may be other undesirable
Varies effects, such as stigmatizing
patients in this range of
No blood pressure, who are oth-
erwise living a healthy life
Probably no
Are the undesirable
anticipated effects
Uncertain
small? Probably yes
Yes
Varies

Are the desirable ef-


No
fects large relative to Probably no
undesirable effects?
Uncertain
Screening for Hypertension
64

Probably yes
Yes
Varies
No research evidence. Having a cut-off point of 80
No mm Hg results in doing life-
Probably no style interventions and less
close follow up to many pa-
Are the resources re- Uncertain tients and potentially spend-
quired small? ing more money. Therefore,
Probably yes there are more resources
needed if the cut-off point is
Yes set at 80 mm Hg than higher

Resource
Varies
use
No research evidence. Despite the extra costs of
No setting the cut-off point as
Probably no lower, the panel agreed that
the incremental cost is worth
Is the incremental cost
small relative to the
Uncertain the benefits

net benefits? Probably yes


Yes
Varies
No research evidence The panel considered that
Increased this question was not appli-
Probably in- cable, since all patients
would undergo the diagnosis
creased
process irrespective of the
What would be the im- Uncertain / no cut-off point suggested
Equity pact on health inequi- impact
ties?
Probably re-
duced
Reduced
Varies
No research evidence. The panel did not think there
Acceptability Is the option accepta- No
Screening for Hypertension
65

ble to key stakehold- were issues regarding the


ers?
Probably no acceptability of using a cut-
Uncertain off point of 80 mm Hg as
compared with a higher one
Probably yes
Yes
Varies
No research evidence. The panel did not think there
No were issues regarding the
Probably no feasibility of implementing a
cut-off point of 80 mm Hg as

Feasibility
Is the option feasible Uncertain compared with a higher one
to implement?
Probably yes
Yes
Varies
Screening for Hypertension
66

Recommendation
Should a cut-off of diastolic blood pressure of 80 mm Hg versus a higher cut-off point be used to rule-out hyper-
tension in people who are going to a physician?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommen- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
dation tion option tion


The panel suggests to use a cut-off point of diastolic blood pressure of 80 mm Hg over a higher cut-off point to rule-out hypertension in patients
Recommendation who are screened at a physicians office (conditional recommendation, very low quality evidence)

There is very low quality evidence regarding the benefits of using different cut-off points for diagnosing or ruling-out HTN; however, when balanc-
ing the potential prevention in HTN associated cardiovascular events by doing lifestyle interventions and health promotion, with the extra re-
Justification
sources required, the panel considered that the benefits of using a cut-off point of 80 mm Hg probably outweighed the harms. There are no issues
of acceptability and feasibility.

Subgroup considera-
None
tions

Implementation con-
None
siderations

Monitoring and eval-


None
uation

Research possibili-
There is a need of RCTs comparing the benefits and harms of using different cut-off points of SBP for diagnosing HTN
ties
Screening for Hypertension
67

Evidence Table 1: GRADE Evidence Table for patient-important outcomes using different cut-off points for diag-
nosing or ruling-out hypertension: Systolic Blood Pressure in patients 55-64 years old

Number of events predicted per 100000 patients, over a 1-year period

Outcomes Blood pressure value

160 mm Hg 150 mm Hg 140 mm Hg 130 mm Hg 120 mm Hg 110 mm Hg

1006 865 744 640 550 473


All-Cause Mortality* (910-1138) (783-979) (717-764) (565-707) (486-608) (418-523)

88 56 36 23 15 10
Stroke** (82-95) (62-71) (35-37) (22-25) (14-16) (9-11)

234 171 125 91 67 49


Coronary Heart Disease*** (222-244) (172-178) (122-127) (88-96) (64-71) (47-51)

* Assumed baseline risk of 778.3 per 100,000 patients28 in patients who have an average of systolic blood pressure of 143 mm Hg,20 and a relative risk
of the outcome of 0.86 (95% CI 0.76-0.95) per 10 mm Hg reduction in blood pressure7

** Assumed baseline risk of 41 per 100,000 patients25 in patients who have an average of systolic blood pressure of 143 mm/Hg,20 and a relative risk of
the outcome of 0.64 (95% CI 0.59-0.69) per 10 mm Hg reduction in blood pressure7

*** Assumed baseline risk of 136.9 per 100,000 patients28 in patients who have an average of systolic blood pressure of 143 mm/Hg,20 and a relative
risk of the outcome of 0.73 (95% CI 0.70-0.77) per 10 mm Hg reduction in blood pressure7
Screening for Hypertension
68

Evidence Table 2: GRADE Evidence Table for patient-important outcomes using different cut-off points for diag-
nosing or ruling-out hypertension: Diastolic Blood Pressure in patients 55-64 years old

Number of events predicted per 100000 patients, over a 1-year period

Outcomes Blood pressure value

100 mm Hg 95 mm Hg 90 mm Hg 85 mm Hg 80 mm Hg 75 mm Hg 70 mm Hg

1020 878 755 650 559 480 413


All-Cause Mortality* (924-1155) (795-994) (737-769) (574-717) (486-608) (425-530) (365-457)

92 59 38 24 16 10 7
Stroke** (85-100) (55-64) (37-39) (23-26) (15-17) (9-11) (6-7)

242 176 129 94 69 50 37


Coronary Heart Disease*** (229-252) (167-184) (128-130) (90-99) (66-73) (48-53) (35-39)

* Assumed baseline risk of 778.3 per 100,000 patients28 in patients who have an average of diastolic blood pressure of 92 mm/Hg,20 and a relative risk
of the outcome of 0.86 (95% CI 0.76-0.95) per 5 mm Hg reduction in blood pressure7

** Assumed baseline risk of 41 per 100,000 patients25 in patients who have an average of diastolic blood pressure of 92 mm/Hg,20 and a relative risk of
the outcome of 0.64 (95% CI 0.59-0.69) per 5 mm Hg reduction in blood pressure7

*** Assumed baseline risk of 136.6 per 100,000 patients28 in patients who have an average of diastolic blood pressure of 92 mm/Hg,20 and a relative
risk of the outcome of 0.73 (95% CI 0.70-0.77) per 5 mm Hg reduction in blood pressure7
Screening for Hypertension
69

Guideline Question 10: Should ambulatory blood pressure measurement (ABPM) be used as an alternative to clinic blood pressure
measurement (CBPM) for screening for hypertension in patients who underwent screening and were normotensive?

Problem: Follow-up in patients who were diagnosed Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
as normotensive (< 140 mm Hg or < 90 mm Hg) and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Option: Ambulatory blood pressure measurement trol and treatment of HTN.21
Comparison: Clinic blood pressure measurement Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
Setting: Outpatients cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4
Perspective: Healthcare system, MoH
Additional con-
Criteria Judgements Research evidence
siderations

It has been estimated that among people aged 15 years or greater who are hyperten- The panel agrees
No 6
sive, 57.8% are undiagnosed and 20.2% are treated but uncontrolled. An optimal cut- that this is a rele-
vant question
Probably no off point for diagnosing HTN would allow to obtain the highest possible net benefit
from treatment
Problem
Is there a problem pri- Uncertain
ority?
Probably yes
Yes
Varies
The relative importance or values of the main outcomes of interest: The panel was
No included confident that
studies Relative im- Certainty of the evidence
Outcome
portance (GRADE) most patients
What is the overall cer-
Very low would think that
tainty of this evidence? Low All-cause mortality CRITICAL
the outcomes con-
Benefits & VERY LOW** sidered were criti-
harms of
the options
Moderate cal.

High Cardiovascular mortality CRITICAL
VERY LOW**
The panel dis-
cussed that alt-
Is there important un- hough there may
certainty about how Important un- MI or stroke (fatal and non-
fatal)
CRITICAL
be some benefits
VERY LOW** when using ABPM,
much people value the certainty or varia-
Screening for Hypertension
70

main outcomes? bility the main undesir-


able effects is the
Possibly im- Non-fatal stroke CRITICAL
VERY LOW** potential anxiety
portant uncertain- cause by the use
ty or variability of the monitor.
* Data from observational studies
Probably no ** Downgrading due to indirectness Therefore, the
extent to which
important uncer-
Summary of findings (See Evidence Table 3): the desirable ef-
tainty of variabil-
- There was little to no difference in ABPM and CBPM for predicting cardiovascular fects outweigh the
ity
events undesirable effects
No important depends on the
uncertainty of circumstance and
variability the levels of pa-
tient anxiety.
No known un-
desirable

No
Probably no
Are the desirable antic- Uncertain
ipated effects large?
Probably yes
Yes
Varies
No
Probably no
Are the undesirable
anticipated effects
Uncertain
small? Probably yes
Yes
Varies

Are the desirable ef-


No
fects large relative to Probably no
undesirable effects?
Uncertain
Screening for Hypertension
71

Probably yes
Yes
Varies
No research evidence. The panel dis-
cussed about the
No potential costs
Probably no associated with
the acquisition of
Are the resources re- Uncertain the blood pressure
monitors and the
quired small?
Probably yes training for the
operator. There-
Yes fore, ABPM is con-
sidered as a more
Varies expensive alterna-
Resource
tive
use
A systematic review of assessed costs and cost-effectiveness of adding HBPM and Since it is not clear
No ABPM, and showed ABPM to be cost-saving for diagnostic confirmation following an ele- that there is a net
Probably no vated CBPM in 6/9 studies, 3/4 studies found adding HBPM to an elevated CBP was
cost-effective, 7/14 were conducted in Europe, 4 in US, 2 in Japan, and 1 in Australia.
benefit, the incre-
mental cost of
Is the incremental cost
small relative to the
Uncertain Cost savings were due to fewer false positives (white coat) receiving treatment34 ABPM is not small.
The incremental
net benefits? Probably yes costs would be
small in those set-
Yes ting where the
option is already
Varies being offered.

No research evidence The panel dis-


Increased cussed about only
Probably in- a proportion of the
population having
creased
access to this op-
What would be the im-
Equity pact on health inequi- Uncertain / no tion of screening,
impact therefore, health
ties?
inequities would
Probably re- probably increase
duced
Reduced
Screening for Hypertension
72

Varies
No research evidence. The panel dis-
No cussed about some
Probably no potential concerns
mainly by
Is the option accepta-
Acceptability ble to key stakehold-
Uncertain healthcare person-
nel and patients,
ers? Probably yes which may cause
some acceptability
Yes issues; however,
they were thought
Varies to be minor

No research evidence. The panel was not


No sure regarding the
Probably no feasibility of im-
plementing this

Feasibility
Is the option feasible Uncertain option, due to the
to implement? need of acquiring
Probably yes the monitors and
do training.
Yes
Varies
Screening for Hypertension
73

Recommendation
Should ambulatory blood pressure measurement (ABPM) be used as an alternative to clinic blood pressure
measurement (CBPM) for screening for hypertension in patients who underwent screening and were normoten-
sive?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommenda- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
tion tion option tion


The panel suggests to use ambulatory blood pressure measurement (ABPM) as an alternative to clinic blood pressure measurement (CBPM) for
screening for hypertension in patients who underwent screening and were normotensive (conditional recommendation, very low quality evidence)
Recommendation
Remarks:
ABPM could be used as an alternative to CBPM, not be preferred over CBPM

There is very low quality evidence suggesting little or no benefit of ABPM for predicting long-term cardiovascular outcomes. The resources re-
Justification quired are large, and probably worth it only on those setting where the option is available already. There are no major concerns regarding the
acceptability and feasibility of implementing this option.

Subgroup considera-
This recommendation is mainly applicable in those patients in whom the net benefits are thought to be larger
tions

Implementation con-
None
siderations

Monitoring and eval-


None
uation

Research possibilities None


Screening for Hypertension
74

Evidence Table 3: GRADE Evidence Table for patient-important outcomes when using different methods for di-
agnosing hypertension. Ambulatory Blood Pressure measurement vs. Clinic Blood pressure measurement

Risk of the outcome per 10 mm Hg or 5 mm Hg (Hazard


ratio)
Outcomes Study MQ
SBP DBP
ABPM CBPM ABPM CBPM
1.18 1.05 1.18 1.06
Hansen35* Fair
(1.06-1.31) (0.96-1.14) (1.09-1.18) (0.99-1.14)
1.11 1.02 1.06 1.01
All-cause mortality Dolan36
(1.07-1.16) (0.99-1.05) (1.02-1.09) (0.99-1.04)
Fair
1.16 1.24
Staessen37 - - Good
(0.99-1.35) (1.03-1.49)
1.51 1.25 1.43 1.21
Hansen35* Fair
(1.28-1.77) (1.1-1.42) (1.26-1.61) (1.08-1.35)
1.19 1.06 1.07 1.03
Dolan36 Fair
(1.14-1.26) (1.02-1.1) (1.03-1.12) (1-1.07)
Cardiovascular mortality 1.2 1.32
Staessen37 - - Good
(0.98-1.49) (1.03-1.68)
1.38 1.1
Gasowski38 - - Fair
(1.14-1.68) (0.94-1.29)
MI or stroke (fatal and non- 1.3 1.1
Clement39 - - Good
fatal) (1.12-1.51) (0.98-1.25)
1.27 1.07 1.13 1.06
Non-fatal stroke Dolan36
(1.15-1.43) (1-1.15) (1.05-1.22) (0.99-1.12)
Fair
* Relative risks
Abbreviations: SBP: systolic blood pressure, DBP: Diastolic blood pressure, ABPM: ambulatory blood pressure measurement, CBPM: clinic
blood pressure measurement, MQ: methodological quality (assessed by the USPTF), MI: myocardial infarction

The colors are used to illustrate which method for diagnosing HTN is more effective for predicting future outcomes. Green shows that the
highlighted method is more effective, according to the estimate and the 95% CI. Yellow shows that both methods seem to perform simi-
larly.
Screening for Hypertension
75

Guideline Question 11: Should home blood pressure measurement (HBPM) be used as an alternative to clinic blood pressure measure-
ment (CBPM) for screening for hypertension in patients who underwent screening and were normotensive?

Problem: Follow-up in patients who were diagnosed Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
as normotensive (< 140 mm Hg or < 90 mm Hg) and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Option: Home blood pressure measurement trol and treatment of HTN.21
Comparison: Clinic blood pressure measurement Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
Setting: Outpatients cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia.1-4
Perspective: Healthcare system, MoH
Additional considera-
Criteria Judgements Research evidence
tions

It has been estimated that among people aged 15 years or greater who are hy- The panel agrees that this
No pertensive, 57.8% are undiagnosed and 20.2% are treated but uncontrolled. An is a relevant question
6

Probably no optimal cut-off point for diagnosing HTN would allow to obtain the highest pos-
sible net benefit from treatment
Problem
Is there a problem pri- Uncertain
ority?
Probably yes
Yes
Varies
The relative importance or values of the main outcomes of interest: The panel was confident
No included that most patients would
studies Relative im- Certainty of the evi-
Outcome
portance dence (GRADE) think that the outcomes
What is the overall cer-
Very low considered were critical.
tainty of this evidence? Low All-cause mortality CRITICAL
The panel discussed that
Benefits & VERY LOW** HBPM would cause less
harms of
the options
Moderate anxiety to the patients and
would allow to obtain mul-
High Cardiovascular mortality CRITICAL
VERY LOW** tiple measures per day on
an environment that they
Is there important un- consider safe. The also
certainty about how Important un- Cardiovascular events (CV
death, MI, stroke)
CRITICAL

agreed this will have a
VERY LOW**
much people value the certainty or varia-
Screening for Hypertension
76

main outcomes? bility positive impact on health


* Data from observational studies promotion (other family
Possibly im- ** Downgrading due to indirectness members may benefit)
portant uncertain- and may decrease the
ty or variability Summary of findings (See Evidence Table 4): incidence of white coat
Probably no - There was little to no difference in HBPM and CBPM for predicting cardiovascu-
lar events
HTN
important uncer-
tainty of variabil-
ity
No important
uncertainty of
variability
No known un-
desirable

No
Probably no
Are the desirable antic- Uncertain
ipated effects large?
Probably yes
Yes
Varies
No
Probably no
Are the undesirable Uncertain
anticipated effects
small? Probably yes
Yes
Varies

Are the desirable ef-


fects large relative to
No
undesirable effects? Probably no
Screening for Hypertension
77

Uncertain
Probably yes
Yes
Varies
No research evidence. The panel discussed about
No the potential costs associ-
Probably no ated with the acquisition
of the machines, yet they
Are the resources re- Uncertain considered these costs to
be probably small
quired small?
Probably yes
Yes
Resource
Varies
use
A systematic review of assessed costs and cost-effectiveness of adding HBPM Since there is a potential
No and ABPM, and showed ABPM to be cost-saving for diagnostic confirmation fol- net benefit and a probably
Probably no lowing an elevated CBPM in 6/9 studies, 3/4 studies found adding HBPM to an
elevated CBP was cost-effective, 7/14 were conducted in Europe, 4 in US, 2 in
small resource need, the
incremental cost relative
Is the incremental cost
small relative to the
Uncertain Japan, and 1 in Australia. Cost savings were due to fewer false positives (white to the net benefits is
coat) receiving treatment34 small.
net benefits? Probably yes
Yes
Varies
No research evidence Patients with less re-
Increased sources would have less
Probably in- access to the machines;
on the other hand, HBPM
creased
could provide access to
What would be the im- Uncertain / no screening to those patients
Equity pact on health inequi- impact who cannot access the
ties? healthcare system
Probably re-
duced
Reduced
Varies
Screening for Hypertension
78

No research evidence. The option would be ac-


No ceptable to most stake-
Probably no holders

Is the option accepta-


Acceptability ble to key stakehold-
Uncertain
ers? Probably yes
Yes
Varies
No research evidence. The panel did not think
No there were any implemen-
Probably no tation issues

Feasibility
Is the option feasible Uncertain
to implement?
Probably yes
Yes
Varies
Screening for Hypertension
79

Recommendation
Should home blood pressure measurement (HBPM) be used as an alternative to clinic blood pressure measure-
ment (CBPM) for screening for hypertension in patients who underwent screening and were normotensive?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommenda- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
tion tion option tion


The panel suggests to use home blood pressure measurement (HBPM) as an alternative to clinic blood pressure measurement (CBPM) for screen-
ing for hypertension in patients who underwent screening and were normotensive (conditional recommendation, very low quality evidence)
Recommendation
Remarks:
HBPM could be used as an alternative to CBPM, not be preferred over CBPM

There is very low quality evidence suggesting little or no benefit of HBPM for predicting long-term cardiovascular outcomes; however, there are
Justification other potential benefits of using this option, such as less anxiety levels. The incremental cost is small relative to the benefit, and there are no
issues with acceptability and feasibility.

Subgroup considera-
None
tions

Implementation con- Patients would need specific instructions regarding how to respond to HBPM, which need to be discussed between the patient and physician. They
siderations would also need training in use of the machine at home.

Monitoring and evalu-


None
ation

Research possibilities None


Screening for Hypertension
80

Evidence Table 4: GRADE Evidence Table for patient-important outcomes when using different methods for di-
agnosing hypertension. Home Blood Pressure measurement vs. Clinic Blood pressure measurement

Risk of the outcome per 10 mm Hg or 5 mm Hg


(Hazard ratio)
Outcomes Study MQ
SBP DBP
HBPM CBPM HBPM CBPM
1 0.9 1.05 0.95
Bobrie40 Good
(1-1.01) (0.9-1) (0.95-1.1) (0.86-1.05)
1.11 1.05 1.08 0.95
All-cause mortality Niiranen41
(1.01-1.23) (0.96-1.15) (0.98-1.12) (0.87-1.04)
Good
1.15 1.01 1.06 1.01
Ohkubo42 Good
(1.03-1.2) (0.92-1.09) (0.96-1.15) (0.95-1.08)
1.1 1 1.1 0.95
Bobrie40 Good
(0.9-1.12) (0.82-1.1) (0.95-1.22) (0.86-1.1)
Cardiovascular mortality 1.23 1.05 1.07 1.04
Okhubo42 Good
(1.01-1.26) (0.9-1.2) (0.95-1.2) (0.92-1.18)
Cardiovascular events (CV death, 1.13 1.06
Fagard43 - - Good
MI, Stroke) (1.03-1.24) (0.94-1.18)
* Relative risks
Abbreviations: SBP: systolic blood pressure, DBP: Diastolic blood pressure, ABPM: ambulatory blood pressure measurement, CBPM: clinic
blood pressure measurement, MQ: methodological quality (assessed by the USPTF), MI: myocardial infarction

The colors are used to illustrate which method for diagnosing HTN is more effective for predicting future outcomes. Green shows that the
highlighted method is more effective, according to the estimate and the 95% CI. Yellow shows that both methods seem to perform simi-
larly.
Screening for Hypertension
81

Guideline Question 12: Should we use an interval of 1 year versus 2 years to re-screen patients who were not diagnosed with hyperten-
sion after screening?

Problem: Time interval for re-screening for HTN Background: High blood pressure has been identified as the leading single risk factor for global burden of diseases.18,19 The
lack of a healthcare system that it is able to identify and provide periodical follow-up to people who are at a high risk of HTN
Option: 1 year and cardiovascular diseases has been identified as one of the main barriers to the implementation of programs for the con-
Comparison: 2 years trol and treatment of HTN.21
Setting: Outpatients Hypertension has been recognized as an important risk factor of cardiovascular diseases, with consequences such as myo-
Perspective: Healthcare system, MoH cardial infarction, stroke, and death. It has also been linked to chronic kidney disease, heart failure, and dementia. 1-4

Additional con-
Criteria Judgements Research evidence
siderations

The WHO STEPS report identified populations with confirmed or new diagnosis of The panel agrees
No hypertension at 31.37% (55-64 years), 9.08% (25-54 years), and 1.79% (15-24 that this is a rele-
years).20 It has also been found that among people aged 15 years or greater who are vant question
Probably no hypertensive, 57.8% are undiagnosed and 20.2% are treated but uncontrolled.6

Problem
Is there a problem pri- Uncertain Shorter intervals for re-screening would allow doing an early diagnosis of HTN, poten-
ority?
Probably yes tially preventing its negative consequences.

Yes
Varies
The relative importance or values of the main outcomes of interest: The panel was con-
No included fident that most
studies
Relative im- Certainty of the evi- patients would think
Very low Outcome
portance dence (GRADE) that the outcomes
What is the overall cer-
tainty of this evidence? Low considered were
Incidence of hypertension critical.
Benefits &
harms of
Moderate CRITICAL
LOW* Despite the evi-
the options High dence regarding the
effects of different
Acute myocardial infarction rescreening interval
Congestive heart failure on long-term out-
Is there important un- Not measured
certainty about how Important un- Stroke comes, the panel
certainty or varia- was confident that
much people value the Death from cardiovascular disease
bility detecting HTN early
main outcomes?
Screening for Hypertension
82

could potentially
Possibly im- All-cause mortality reduce its conse-
portant uncertain- quences
*Indirect data: Included studies were conducted in Asia (19 studies), the United
ty or variability
States (8 studies), Europe (10 studies), the United Kingdom, and Australia. Variation
Probably no in hypertension incidence across studies is related in part to the criteria used to diag-
important uncer- nose, and in some studies confirm, incident hypertension. Some variation probably
tainty of variabil-
also arises from differences in study populations.
ity
No important
uncertainty of Systematic review of the literature (Piper et al, 2015),10 showing the incidence of HTN
variability according to rescreening interval. The incidence of HTN increases with the length of
No known un- the interval.

desirable

No
Probably no
Are the desirable antic-
Uncertain
ipated effects large? Probably yes
Yes
Varies

No
Probably no
Are the undesirable Uncertain
anticipated effects
small?
Probably yes
Yes
Varies

Are the desirable ef-


fects large relative to
No
undesirable effects? Probably no
Screening for Hypertension
83

Uncertain
Probably yes
Yes
Varies
No research evidence. The costs of re-
No screening for HTN
Probably no were judged to be
small, despite of

Are the resources re-


Uncertain doing it more often

quired small? Probably yes


Yes
Varies
Resource
use
No research evidence The incremental
No cost was judged to
Probably no be small relative to
the potential net
Is the incremental cost Uncertain benefit.
small relative to the
net benefits?
Probably yes
Yes
Varies
No research evidence
Increased
Probably in-
What would be the im- creased
Equity pact on health inequi-
ties? Uncertain / no
impact
Probably re-
duced
Screening for Hypertension
84

Reduced
Varies
No research evidence. The option would be
No acceptable to most
Probably no stakeholders

Is the option accepta- Uncertain


Acceptability ble to key stakehold-
ers?
Probably yes
Yes
Varies
No research evidence. The panel did not
No think there were
Probably no any implementation
issues. The dis-

Is the option feasible


Uncertain cussed about pa-
tients attending to
Feasibility
to implement? Probably yes the physician in the
time interval for
Yes other reasons,
which makes more
Varies feasible to rescreen
for HTN
Screening for Hypertension
85

Recommendation
Should we use an interval of 1 year versus 2 years to re-screen patients who were not diagnosed with hyper-
tension after screening?
Undesirable consequences Undesirable consequences The balance between desira- Desirable consequences Desirable consequences
Balance of con- clearly outweigh desirable probably outweigh desirable ble and undesirable conse- probably outweigh undesira- clearly outweigh undesirable
sequences consequences in most set- consequences in most set- quences is closely balanced or ble consequences in most consequences in most set-
tings tings uncertain settings tings


Type of recommenda- We recommend against offering this op- We suggest not offering this We suggest offering this op-
We recommend offering this option
tion tion option tion


The panel suggests to use an interval of 1 year to re-screen patients who had systolic blood pressure < 140 mm Hg or diastolic blood pressure <
90 mm Hg during the first screening (conditional recommendation, low quality evidence)
Recommendations
The panel suggests to use an interval of 2 year to re-screen patients who had systolic blood pressure < 120 mm Hg or diastolic blood pressure <
80 mm Hg during the first screening (conditional recommendation, low quality evidence)

There is low quality evidence regarding the association between screening intervals and incidence of HTN; however, the panel gave a high weight
Justification in the fact that early detection could potentially prevent the negative effects of HTN. The incremental costs are small relative to the net benefits,
and this is an option acceptable and feasible to implement.

Subgroup considera-
None
tions

Implementation con-
None
siderations

Monitoring and evalu-


None
ation

Research possibilities None


Screening for Hypertension
86

Appendix 2: Search Strategies and Results

Benefits & Harms Searches:

Data base: OVID Medline


Search strategy: Date of search: October 30, 2014
1. exp Hypertension/
2. hypertens*.ti.
3. hypertension.tw.
4. high blood pressure.mp.
5. or/1-4
6. mass screening/
7. screen*.mp.
8. diagnos*.ti.
9. or/6-8
10. 5 and 9
12. 10 or 11
13. animals/ not (animals/ and humans/)
14. 12 not 13
15. limit 14 to (english or french)
16. limit 15 to yr="1985 -Current"
Records Retrieved (using RCT filter) 273

Data base: OVID EMBASE


Search strategy: Date of search: October 30, 2014
1. mass screening/
2. screen*.mp.
3. diagnos*.ti.
4. or/1-3
5. ((blood pressure or hypertension) adj3 (screen* or diagnos*)).tw.
6. exp *hypertension/
7. hypertens*.ti.
8. high blood pressure.mp.
9. 6 or 7 or 8
10. 4 and 9
11. 5 or 10
12. limit 11 to yr="1985 -Current"
13. limit 12 to (english or french)
14. limit 13 to human
15. limit 14 to (book or editorial or letter or note)
16. 14 not 15 -> 5334
17. random:.tw.
18. placebo:.mp.
19. double-blind:.tw.
20. 17 or 18 or 19
21. 16 and 20
22. remove duplicates from 21
Records Retrieved 571
Screening for Hypertension
87

Summary of Searches: Benefits & Harms

Total No. Retrieved: 844


Medline: 273
Embase: 571

Duplicates: 101
No. Total 743
without duplicates:
Screening (Title and Abstract Review)
No. Excluded: 736
Included for Full Text 7
review:
Selection (Full Text Review)
No. Excluded: 7
Reasons for exclusions:
1. No RCTs

Patients Values and Preferences Searches:

Data base: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid
MEDLINE(R)
Search strategy: Date of search: Nov 8, 2014
1. Saudi Arab$.mp,in. or Saudi Arabia/
2. Riyadh.mp,in.
3. Jeddah.mp,in.
4. Kh*bar.mp,in.
5. Dammam.mp,in.
6. 1 or 2 or 3 or 4 or 5
7. Kuwait$.mp,in. or Kuwait/
8. United Arab Emirates.mp,in. or United Arab Emirates/
9. Qatar$.mp,in. or Qatar/
10. Oman$.mp,in. or Oman/
11. Yemen$.mp,in. or Yemen/
12. Bahr*in$.mp,in. or Bahrain/
13. 7 or 8 or 9 or 10 or 11 or 12
14. Middle East$.mp,in. or Middle East/
15. Jordan$.mp,in. or Jordan/
16. Libya$.mp,in. or Libya/
17. Egypt$.mp,in. or Egypt/
18. Syria$.mp,in. or Syria/
19. Iraq$/ or Iraq.mp,in.
20. Morocc$.mp,in. or Morocco/
21. Tunisia$.mp,in. or Tunisia/
22. Leban$.mp,in. or Lebanon/
23. West Bank.mp,in.
24. Iran$.mp,in. or Iran/
25. Turkey/ or (Turkey or Turkish).mp,in.
26. Algeria$.mp,in. or Algeria/
27. Arab$.mp,in. or Arabs/
28. 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26
29. 27 or 28
30. 6 or 13 or 29
Screening for Hypertension
88

31. patient$ participation.mp. or exp patient participation/


32. patient$ satisfaction.mp. or exp patient satisfaction/
33. attitude to health.mp. or exp Attitude to health/
34. (patient$ preference$ or patient$ perception$ or patient$ decision$ or patient$ perspective$ or user$ view$ or
patient$ view$ or patient$ value$).mp.
35. (patient$ utilit$ or health utilit$).mp.
36. health related quality of life.mp. or exp "quality of life"/
37. (health stat$ utilit$ or health stat$ indicator$ or (health stat$ adj 2 valu$)).mp. or exp Health Status Indicators/
38. 31 or 32 or 33 or 34 or 35 or 36 or 37
39. "journal of epidemiology and global health".jn.
40. "journal of infection and public health".jn.
41. "saudi journal of kidney diseases & transplantation".jn.
42. saudi medical journal.jn.
43. saudi pharmaceutical journal.jn.
44. "annals of saudi medicine".jn.
45. "saudi journal of gastroenterology".jn.
46. 39 or 40 or 41 or 42 or 43 or 44 or 45
47. exp hypertension/
48. hypertens*.ti.
49. hypertension.tw.
50. high blood pressure.mp.
51. or/47-50
52. 30 or 46
53. 38 and 51 and 52

Records Retrieved 570

Summary of Searches: Values and Preferences

Total No. Retrieved: 570


Screening (Title and Abstract Review)
No. Excluded: 557
Included for Full Text 13
review:
Selection (Full Text Review)
No. Excluded: 6
Reasons for exclusions:
1. Not addressing screening

Cost-Effectiveness Search:

Data base: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid
MEDLINE(R)
Search strategy: Date of search: Nov 8, 2014
1. Saudi Arab$.mp,in. or Saudi Arabia/
2. Riyadh.mp,in.
3. Jeddah.mp,in.
4. Kh*bar.mp,in.
5. Dammam.mp,in.
6. 1 or 2 or 3 or 4 or 5
7. Kuwait$.mp,in. or Kuwait/
8. United Arab Emirates.mp,in. or United Arab Emirates/
9. Qatar$.mp,in. or Qatar/
Screening for Hypertension
89

10. Oman$.mp,in. or Oman/


11. Yemen$.mp,in. or Yemen/
12. Bahr*in$.mp,in. or Bahrain/
13. 7 or 8 or 9 or 10 or 11 or 12
14. Middle East$.mp,in. or Middle East/
15. Jordan$.mp,in. or Jordan/
16. Libya$.mp,in. or Libya/
17. Egypt$.mp,in. or Egypt/
18. Syria$.mp,in. or Syria/
19. Iraq$/ or Iraq.mp,in.
20. Morocc$.mp,in. or Morocco/
21. Tunisia$.mp,in. or Tunisia/
22. Leban$.mp,in. or Lebanon/
23. West Bank.mp,in.
24. Iran$.mp,in. or Iran/
25. Turkey/ or (Turkey or Turkish).mp,in.
26. Algeria$.mp,in. or Algeria/
27. Arab$.mp,in. or Arabs/
28. 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26
29. 27 or 28
30. 6 or 13 or 29
31. "journal of epidemiology and global health".jn.
32. "journal of infection and public health".jn.
33. "saudi journal of kidney diseases & transplantation".jn.
34. saudi medical journal.jn.
35. saudi pharmaceutical journal.jn.
36. "annals of saudi medicine".jn.
37. "saudi journal of gastroenterology".jn.
38. 31 or 32 or 33 or 34 or 35 or 36 or 37
39. exp hypertension/
40. hypertens*.ti.
41. hypertension.tw.
42. high blood pressure.mp.
43. or/39-42
44. economics/ or exp economics, hospital/ or exp economics, medical/ or economics, nursing/ or economics,
pharmaceutical/
45. exp "Costs and Cost Analysis"/
46. Value-Based Purchasing/
47. exp "Fees and Charges"/
48. budget$.mp. or Budgets/
49. (low adj cost).mp.
50. (high adj cost).mp.
51. (health?care adj cost$).mp.
52. (cost adj estimate$).mp.
53. (cost adj variable$).mp.
54. (unit adj cost$).mp.
55. (fiscal or funding or financial or finance).tw.
56. (economic$ or pharmacoeconomic$ or price$ or pricing).tw.
57. 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56
58. 30 or 38
59. 43 and 57 and 58
Records Retrieved 150
Summary of Searches: Cost-effectiveness

Total No. Retrieved: 150


Screening (Title and Abstract Review)
Screening for Hypertension
90

No. Excluded: 147


Included for Full Text 3
review:
Selection (Full Text Review)
No. Excluded: 3
Reasons for exclusions:
1. Not relevant to screening or SA setting
Screening for Hypertension
91

Appendix 3: Clinical pathway for screening for HTN


Screening for Hypertension
92

Appendix 4: Blood pressure measurement protocol

With regards to the protocol for measuring blood pressure, we refer to the guidelines published by
the Saudi Hypertension Management Society.44

According to these guidelines, it is essential to follow these standards

Patient-Related Standards
1. Patient should have 3 to 5 minutes of physical rest before measuring BP.
2. Patient should relax in a quiet environment before measurement.
3. BP should be measured in sitting position with back supported.
4. BP measurement should be taken in both arms at initial visit.
5. Upper arm should not be covered by clothing.
6. Elbow should be supported at heart level.
7. BP should be measured in standing position, if indicated (e.g. diabetics and elderly patients).
8. Patient should avoid nicotine and caffeine one hour prior to BP measurement.

Equipment-Related Standards
1. Appropriate cuff size: The cuff bladder should encircle 80% of the arm, and the cuff width should
be 40% of the arm circumference. Standard cuff bladder size is 12 cm in width and 24 cm in length. If
the upper arm circumference is 33 to 41 cm, a cuff bladder width of 15 cm and length of 30 cm
are required. If the upper arm circumference is >42 cm, a cuff bladder width of 18 cm and length of
36 cm is required.
2. Correct cuff position: A distance of 2.5 cm (2 fingers) between the lower end of the cuff and the
antecubital fossa should be maintained.
a. Cuff bladder should be centered over the brachial artery.
b. Cuff should be wrapped around the upper arm, firmly in contact with the arm, but not too tight
(smooth) and not too loose (snug), allowing 2 fingers to be put under the cuff comfortably.
3. Correct stethoscope position: The bell orifice of the stethoscope should be placed just above and
medial to the antecubital fossa but below the edge of the cuff. The stethoscope bell orifice should
not touch the cuff bladder or tubing.
4. Correct manometer position: The position of the mercury manometer should be upright at exam-
iners eye level.
5. Cuffs with complete and steady compression on the brachial artery (adhesive cuffs, Velcro with
grip on the adjoining surfaces) should be used. Rolling up the sleeve cuff on the arm results in a
tourniquet effect.

Examiner-Related Standards
1. Inflate the cuff bladder rapidly to 30 mm Hg above the level of the estimated SBP (too slow infla-
tion can be uncomfortable for the patient).
2. Apply mild pressure on the stethoscope bell (firmly but gently, without excessive pressure).
3. Deflate the cuff bladder pressure at the rate of 2 mm Hg/sec.
4. Deflate the cuff bladder rapidly and completely at DBP to prevent venous congestion.
5. BP should be measured at least twice at each visit and the mean value documented.
6. The SBP is defined as the cuff pressure at which the Korotkoff sound can be heard with the steth-
oscope (Phase I), and the DBP as the cuff pressure at which the Korotkoff sound disappears over the
brachial artery (Phase V)
Screening for Hypertension
93

7. Record SBP and DBP immediately, rounded off to 2 mm Hg.


8. Repeat BP measurement if necessary after a break of 1 min.
9. Avoid reinflation and correction of stethoscope position during measuring procedure.