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Teaching and Disseminating Guidelines
In terms of teaching, and disseminating the guidelines that do exist, in a practical
and pragmatic way, this is best done in three complementary ways:
(a) A referral system to a specialist centre which mandates the provision of ‘check-
list’ information on the patient referral pathway screen or sheet. Links to expla-
nations for the need to provide the information should be readily accessible,
ideally prompted as the form is completed by the referring team. This will
prompt referrers to recognise the features which are the most insightful in terms
of making a correct diagnosis.
(b) In the patient evaluation and treatment recommendation report which the sec-
ondary or evaluating centre sends back to the referring physician or unit, a styl-
ised check-list response should list the relevant questions selected from the
whole investigation set, with an explanation as to why some tests were done
(e.g. patient blood levels of measurable antihypertensive drugs, renal angiogra-
phy, adrenal vein sampling) and why other tests were not done (e.g. adrenal
gland imaging, cardiac MRI). Not all investigations will necessarily be needed
to be repeated if they have been done before—if a coarctation of the aorta has
previously been excluded by imaging, it is unlikely that repeat imaging to detect
that condition will be diagnostically fruitful.
(c) A physical or video/VOIP linked complex case multidisciplinary meeting, to
provide service needs but also to allow for teaching and training of juniors.
Ideally, the patient history would be presented by the referring team, additional
features then added by the attending physician team and then biochemical,
radiological, haemodynamic, psychological, pharmacological, pathological and
other relevant perspectives would be added in. This case presentation and the
associated discussion and recommendations could easily be recorded as a file,
and perhaps as a CD, and, with some anonymization, could act as an excellent
teaching case to permit trainees and less experienced consultants learn the
nuances and finer points of this challenging condition. Formalising a service of
this type will help encourage and refine future referrals; help to coordinate
future research, teaching and training initiatives; and allow for potential research
study participation now and in the future.
Future Perspectives
Prospective epidemiological studies are required to delineate the true prevalence,
incidence and prognostic implications of resistant hypertension, and a consensus
between national and international professional bodies is required on a universal defi-
nition of resistant hypertension to allow robust comparisons between future studies.
D. Goldsmith and S. Badarau