The practice guideline 'Hypertension' (third revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

In the revised practice guideline on hypertension from the Dutch College of General Practitioners, some changes have been made in the areas of diagnosis and therapy in comparison to the previous edition. Finding people with hypertension is a major goal for the prevention of cardiovascular disease. A systolic blood pressure > 140 mmHg (> 160 mmHg in patients > 60 years) necessitates non-pharmaceutical advice and antihypertensive therapy with diuretics, beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors or calcium antagonists, either as monotherapy or in combination. In view of the ever-increasing importance of ACE inhibitors in antihypertensive therapy, we expect that the next revision of the practice guideline will soon be necessary.     

The practice guideline 'Hypertension' (third revision) from the Dutch College of General Practitioners; a response from the perspective of internal medicine

The revised practice guideline on hypertension from the Dutch College of General Practitioners is a useful document for the management of hypertension. The decision to limit antihypertensive treatment to patients with at least a 20% risk of developing cardiovascular disease within 10 years may, however, be criticised. Prolonged untreated mild hypertension may lead to macro- and microvascular myocardial sclerosis and disturbed systolic and diastolic function of the left ventricle. A 10% risk is preferred. On the other hand, case-finding and treatment of patients with hypertension will increasingly be a major time-consuming activity in general practice. This calls for a change in organisation: well-trained vascular assistants should be employed to fulfill most of this task.     

Summary of the practice guideline 'CVA' from the Dutch College of General Practitioners

The practice guideline 'CVA' from the Dutch College of General Practitioners provides guidelines for the management of stroke patients. The guideline is in agreement with the changing insights about the benefits of stroke-units and thrombolysis. The most important recommendations are the following. In the acute phase, most patients with a cerebrovascular accident should be referred for admission to a stroke-unit. Exceptions are patients with only slight neurological disability and patients with severe comorbidity. Patients with a CVA that started less than three hours ago should be referred for emergency thrombolytic therapy in regions where this possibility exists. In situations in which the general practitioner considers a home visit to involve an unacceptable loss of time, he may decide to refer on the basis of the results of the 'face-arm-speech-time' (FAST) test, which can be administered by telephone. For patients that remain at home, the general practitioner sees to the early start of a rehabilitation programme, and takes the initiative if necessary. The general practitioner can support stroke patients with permanent neurological deficits by considering them to be chronically ill patients requiring regular check-ups.     

Summary of the practice guideline 'Headache' from the Dutch College of General Practitioners

The previous guideline 'Migraine' has been replaced by the guideline 'Headache', which includes tension headache, migraine, substance-induced headache and cluster headache. For evaluation of the diagnosis and treatment of these types of headache, regular follow-up of these patients is necessary, preferably on the basis of a headache diary. In an individual patient, migraine and tension headache can occur interchangeably, even in the course of one attack. Ergotamine is no longer recommended for the treatment of migraine attacks in new patients. The pharmacotherapy of migraine must be adjusted to the medication already used by the patient and the severity of the attacks. The recommended treatment for substance-induced headache is to withdraw the responsible medicines completely; explanation, motivation, and support are very important.     

Summary of the practice guideline 'Acne' (second revision) from the Dutch College of General Practitioners

The 1999 practice guideline 'Acne vulgaris' from the Dutch College of General Practitioners has been revised. Benzoyl peroxide and local retinoids are first choice in local treatment of acne. When treatment with oral antibiotics is indicated, doxycycline is first choice. Use of minocycline is not recommended in general practice. It is recommended that both local and oral antibiotics are always combined with local benzoyl peroxide or a local retinoid. Oral contraceptives are only recommended in women with acne who also desire contraception. Use of oral contraceptives containing cyproterone acetate is no longer recommended in women with acne, because they are not more effective than other oral contraceptives. Treatment with oral isotretinoin may be given by the general practitioner, as long as the treatment guidelines are carefully followed.     

Summary of the practice guideline 'Dementia' (second revision) from the Dutch College of General Practitioners

The general practitioner (GP) should be aware of clues pointing to dementia. The GP can establish the diagnosis himself or refer the patient for extended testing. The diagnosis of dementia focuses on memory impairment, other cognitive impairments and decreased functioning in daily life. For patients with dementia and their relatives, information and advice are more important than medication. The GP must take care aspects into consideration as well as the way patients' relatives cope with the dementia patient. The treatment and care of the patient with dementia and the relatives requires good coordination and collaboration with other health workers.     

Summary of the Dutch College of General Practitioners (NHG) practice guideline on 'Diverticulitis'

The NHG practice guideline on 'Diverticulitis' provides general practitioners with directions on the diagnosis and treatment of uncomplicated and complicated diverticulitis. Diverticulitis is primarily a clinical diagnosis which can be supported by assessment of CRP. Uncomplicated diverticulitis is strongly suspected if the patient reports the development of persistent sharp, stabbing pain in the lower left abdomen within a couple of days; if there is pressure or rebound tenderness only in the lower left abdomen; and if there are no alarm signals. Alarm signals of complicated diverticulitis are: guarded muscle response, signs of intestinal obstruction, locally palpable resistance, rectal loss of blood, hypotension, and high fever. The policy for uncomplicated diverticulitis is waiting without specific measures, provided that the general practitioner monitors the course actively. There is no indication for antibiotics in patients with uncomplicated diverticulitis. Patients with signs of complicated diverticulitis or with persisting symptoms should be referred.     

Summary of the practice guideline 'atrial fibrillation' from the Dutch College of General Practitioners

The practice guideline 'Atrial fibrillation' from the Dutch College of General Practitioners provides the general practitioner with guidelines for the diagnosis and management of patients with atrial fibrillation. Atrial fibrillation can be detected by observation of the cardiac rhythm during every measurement of the blood pressure. The diagnosis 'atrial fibrillation' must be made on the basis of an ECG. Atrial fibrillation must not be looked upon as an isolated phenomenon: possible comorbidity (cerebral infarction ('transient ischaemic attack'; TIA), hypertension, diabetes mellitus, heart failure, coronary heart disease, hyperthyroidism) should be taken into consideration in the evaluation. Particular attention should be given to determining whether heart failure is also present. An important goal of treatment is the prevention of thromboembolic complications. Cardioversion is not generally recommended. The symptoms may be an indication that an attempt should be made to restore sinus rhythm. This constitutes one of the indications for referral for specialised treatment.     

Summary of the practice guideline 'Refraction errors' from the Dutch College of General Practitioners

The practice guideline 'Refraction errors' from the Dutch College of General Practitioners describes the examinations that need to be carried out in patients complaining about a gradual loss of vision. A measurement of vision by means of a Snellen chart is insufficient to determine if the condition is caused by a refraction error or if other pathology of the eye such as cataract, glaucoma or retinopathy is involved. It is therefore recommended that the vision should also be measured with a simple device containing spherical lenses of +0.5 and -0.5 dioptre, so-called diagnostic refraction. Improvement of vision with the negative lens indicates myopia. Improvement or at least a stable vision with the positive lens makes hyperopia very likely. Diagnostic refraction, which can be used in patients of six years and older, enables the general practitioner to distinguish between patients needing glasses or contact lenses, and patients requiring referral to an ophthalmologist.     

Summary of the practice guideline 'Smoking cessation' from the Dutch College of General Practitioners

In general practice important health gain is obtainable by encouraging patients to stop smoking with support from the general practitioner. The practice guideline 'Smoking cessation' differentiates between smokers who are motivated to stop smoking, smokers who are considering smoking cessation, and smokers who are unmotivated to stop smoking. It is important to offer smokers, who are motivated to stop, intensive support at the right moment. Medicinal support in the way of nicotine replacement therapy, nortriptyline or bupropion is, ifpossible, recommended in motivated smokers who smoke at least 10 cigarettes daily.     

Summary of the Dutch College of General Practitioners practice guideline 'The menopause'

In the Dutch College of General Practitioners' practice guideline 'The menopause', the menopause is viewed as a physiological phase of life with its associated discomforts, which sometimes require treatment. The GP should inform women with menopausal symptoms about the extent to which oestrogens can diminish vasomotor symptoms and about the benefits and risks of hormonal therapy on various organ systems. Oestrogens can be used when vasomotor symptoms cause serious limitations in daily life. First choice is a sequential combination of oestrogen and progestagen hormones, in which progestagens are given at least ten days per month. When urogenital complaints need to be treated, vaginally applied oestrogens can be prescribed. Depressive symptoms, fatigue, myalgia or arthralgia should not be treated with hormonal therapy. Nor are oestrogens recommended for the prevention of osteoporosis and cardiovascular diseases.