The RACGP is calling for further ‘clarity, consistency and clinical utility’ on the Heart Foundation’s latest draft hypertension guidelines.
The RACGP has backed the Heart Foundation’s first major update to its ‘Australian Guideline for the diagnosis and management of elevated blood pressure and hypertension in adults’ since 2016, but said some details still needed ironing out.
In its submission to the consultation on foundation’s draft guideline, the college put forward eight recommendations.
For one, the RACGP questioned the recommendation to begin urinary protein assessments with dipstick testing before progressing to urine albumin-creatinine ratio (ACR) testing, which is generally more sensitive for detecting albuminuria and could identify abnormalities undetectable by dipstick testing.
The college also pointed to multiple inconsistencies in recommendations for antihypertensive drug therapy guidelines, which it said could cause confusion, including separating elevated blood pressure into two treatment bands (120-129 and/or 80-89 mmHg and 130-139 and/or 80-89 mmHg) despite the foundation guidelines defining it as a single category elsewhere (120-139 and/or 80-89 mmHg).
Given the 2023 Australian Guideline for Assessing and Managing Cardiovascular Disease Risk did not specify blood pressure thresholds for starting antihypertensive treatment, the college said the forthcoming guidelines should clearly explain when pharmacotherapy should be considered or initiated for each five-year CVD risk category.
This also included explaining how clinicians should interpret situations where systolic and diastolic values indicated different treatment pathways.
RACGP expert committee quality care deputy chair Professor Rowena Ivers told The Medical Republic the recommendations were “pragmatic”, and that the college considered how the guideline would apply across all primary care settings, from remote to metropolitan regions.
“When we put in a submission, we put forth recommendations that reflect our experience as GPs and also our knowledge in our sector,” she said.
Given that registrars and IMGs would also be adhering to the guidelines, Professor Ivers said clarity was essential.
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Screening for primary aldosteronism at the time of diagnosis, adopting lower treatment thresholds, initiating combination pharmacotherapy, shorter up-titration timelines, and more detailed recommendations for lifestyle interventions reflected emerging evidence, the submission read.
But the college said implementation would require “substantial” change management, including changes to established clinical practice and workflows.
While supporting automated office blood pressure measurements using validated upper-arm devices to improve accuracy and consistency, the college also noted that implementation may require additional equipment, workflow changes, or dedicated spaces, and warranted further practical consideration.
Similarly, while guidelines for diagnosis and initiation of treatment were in-depth, there was less emphasis on monitoring and ongoing management of hypertension – which often occurred in primary care.
“More explicit guidance regarding monitoring of renal function, including urine ACR testing, and surveillance for end-organ damage will be helpful,” the submission read.
The RACGP welcomed Aboriginal and Torres Strait Islander-specific guidance that acknowledged health inequities and supported culturally safe, equitable care, including the recognition of their 1.3-times-higher likelihood of high blood pressure than non-Indigenous Australians.
However, “given the time constraints faced by GPs, practice points should be practical, specific and readily applicable during consultations to provide clinicians with meaningful and actionable guidance,” the submission read.
This meant greater specificity than simply ensuring advice was “individualised and consider[ed] cultural context, preferred language and capacity to engage” – a guideline that the college argued would apply to most patients.
Instead, the RACGP recommended including the Finding your way shared decision-making model developed by the NSW Agency for Clinical Innovation.
The submission noted similar concerns in the Heart Foundation’s “priority population[s]” framework, including limited practical guidance for clinicians on transgender and gender-diverse people, and the inclusion of women “despite [them] representing more than half of the Australian population”.
“We know that often women may be diagnosed later with cardiovascular disease,” Professor Ivers said.
By considering priority population groups in isolation, the RACGP highlighted the draft’s lack of intersectional analysis.
“In practice, many patients belong to multiple population groups simultaneously, and the interaction between these factors may have a significant influence on cardiovascular risk, health outcomes, access to care and treatment decisions,” the submission read.
The college anticipated the new guidelines would require updates to its Guidelines for Preventive Activities in General Practice (Red Book) and advised the Heart Foundation to seek RACGP endorsement for the final guidelines.
“GPs have a critical role in prevention, so it’s really critical that we have a voice on these guidelines,” Professor Ivers said.
Dr Dannii Dougherty, head of clinical evidence at the Heart Foundation, said the foundation had received many constructive suggestions from across the sector, and thanked everyone for their contributions.
“Our team and expert steering group are reviewing every submission and revising the guideline in response,” she said.
The draft guidelines, however, would remain unavailable to the public, a spokesperson told The Medical Republic.
“The final guideline, shaped by this feedback, will be released in early 2027,” Dr Dougherty said.
Read the RACGP’s full submission here.
