# Implementation of hypertension guidelines by general practitioner societies and the use of single pill combinations in Europe- results of the survey of the General Practitioner Nucleus of European Society of Hypertension

János Nemcsik, Enrique Rodilla, Fabiolucio Albini, Michael Doumas, Jean-Marc Boivin, Helga Gyöngyösi, Reinhold Kreutz, Rosa de Pinho

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János Nemcsik, Enrique Rodilla, Fabiolucio Albini, Michael Doumas, Jean-Marc Boivin, et al. Implementation of hypertension guidelines by general practitioner societies and the use of single pill combinations in Europe- results of the survey of the General Practitioner Nucleus of European Society of Hypertension. Blood Pressure, 2025, 34 (1), pp.2487592. 10.1080/08037051.2025.2487592. hal-05016701

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# Implementation of hypertension guidelines by general practitioner societies and the use of single pill combinations in Europe- results of the survey of the General Practitioner Nucleus of European Society of Hypertension

János Nemcsik, Enrique Rodilla, Fabiolucio Albini, Michael Doumas, Jean-Marc Boivin, Helga Gyöngyösi, Reinhold Kreutz & Rosa de Pinho

**To cite this article:** János Nemcsik, Enrique Rodilla, Fabiolucio Albini, Michael Doumas, Jean-Marc Boivin, Helga Gyöngyösi, Reinhold Kreutz & Rosa de Pinho (31 Mar 2025): Implementation of hypertension guidelines by general practitioner societies and the use of single pill combinations in Europe- results of the survey of the General Practitioner Nucleus of European Society of Hypertension, Blood Pressure, DOI: 10.1080/08037051.2025.2487592

**To link to this article:** https://doi.org/10.1080/08037051.2025.2487592

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# Implementation of hypertension guidelines by general practitioner societies and the use of single pill combinations in Europe- results of the survey of the General Practitioner Nucleus of European Society of Hypertension

János Nemcsikª, Enrique Rodillaᵇ.c, Fabiolucio Albiniᵈ, Michael Doumasᵉ, Jean-Marc Boivinf,g, Helga Gyöngyösiª, Reinhold Kreutzh, Rosa de Pinhoi

ªDepartment of Family Medicine, Semmelweis University, Budapest, Hungary; ᵇInternal Medicine Department, Hypertension and Vascular Risk Unit, Hospital Universitario de Sagunto, Sagunto, Spain; ᶜDepartment of Medicine, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain; ᵈMilano Nord-Ambulatory for Hypertension and Cardiovascular Protection, Advanced Clinical Training Academy for selected GPs, Milan, Italy; ᶜ2nd department of Internal Medicine, Aristotle university, Thessaloniki, Greece; ᵈDepartment of Family Medicine, Lorraine University, Nancy, France; ᵉESH Hypertension Excellence Center Coordinator, Nancy, France; ᵃCharité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany; ᵈPrimary Care, São João da Madeira, Portugal.

**Corresponding author:**
János Nemcsik M.D. Ph.D., address: Department of Family Medicine, Semmelweis University, 7-9, Stáhly street, 1085 Budapest, Hungary, telephone: +36 209827367, fax: +36 13558530, e-mail: janos.nemcsik@gmail.com.

## Abstract

### Purpose

The implementation of hypertension guidelines into the everyday practice of general practitioners (GPs) have an outmost importance to provide optimal care for patients. The aim of our study was, on the one hand to gain insight about the relationship between hypertension societies and GP societies, and on the other hand, to get feedback about the use of single pill combinations (SPC) in each country, as an indicator of guideline implementation.

## Materials and Methods

The European Society of Hypertension (ESH) GP Nucleus initiated a survey containing 17 questions about the existence and number of national hypertension and GP societies, the relationship between them and with pharmacists and nurse associations, the authors of national guidelines and the availability of SPCs. The survey was sent to the national hypertension society representatives of ESH. Additionally, data about the number of SPCs sold yearly was also checked using IQVIA database.

## Results

Responses were collected from 25 European countries. In most of the countries there is only one hypertension society (23/25) and one GP society (18/25), most of which having a relationship with each other (22/25). Of the countries with national hypertension guidelines most of them are written by the national hypertension society (45%) followed by the GP society (27%) or by public administration (27%). Two thirds of the national hypertension
societies (16/25) have relationship with nurse societies and half of them (12/25) with
pharmacists. In 65% (15/23) of the guidelines dual SPC therapy is recommended for
treatment initiation however, marked differences are present in the number of yearly sold
SPCs in different countries.

Conclusions

National hypertension societies have remarkable impact on GPs for the management of hypertensive patients. However, improvement is needed in the collaboration with nurse and pharmacist societies and in some countries in the use of SPCs for hypertension therapy.

Keywords: hypertension, guideline implementation, single pill combinations, general practitioner

Plain Language Summary

What is the background? Hypertension guidelines provide up-to-date recommendations for clinicians about the optimal management of hypertensive patients. However, without proper implementation, guidelines can not improve hypertension care. In our study we evaluated the relationship between national hypertension and general practitioner (GP) societies and clarified gaps in the implementation of hypertension guidelines among different European nations. We also aimed to provide a report on the tendency of the use of antihypertensive single pill combinations (SPCs) in the past years in different European countries, which can be a good marker of guideline implementation.

What is new? Based on 25 responder countries our survey discovered that in most of them there is one hypertension society, of which the majority have a relationship with their GP
society. In half of the countries, hypertension guidelines are written by the national
hypertension society, but in many countries by GP societies or by the national administration.
SPCs are available in all countries, however, in the past four years the changes of the
proportion in the use of pills containing one agent and SPCs demonstrated marked differences
throughout Europe.

What is the impact? Our results suggest that hypertension societies and GP societies have
relationship with each other in most of the countries, which facilitates guideline
implementation. Interestingly the use of SPCs in hypertension management shows a variable
picture in Europe with some countries revealing a very low SPC usage, and in which
hypertension guideline implementation could require improvement.
Introduction

European Society of Hypertension (ESH) was established in 1989 and aims to provide a
stable and organized European platform for scientific exchange in hypertension and has also
organized publication of hypertension management guidelines in the past 20 years.

Due to its high prevalence in adulthood, 1.3 Billion people are suffering from hypertension worldwide (1). It has been recognized, that general practitioners (GPs) are the most relevant to perform cardiovascular disease (CVD) prevention, as in most countries >90% of CVD-related consultations are done by GPs (2). The ESH also recognized this fact and established in 2023 the ESH GP Nucleus, which is a kind of special working group aiming to help the implementation of ESH hypertension guidelines among GPs and improving hypertension management at the level of basic care in general (3). Recently, GP Nucleus members were involved in the production of the short, clinical practice guidelines of ESH for the management of arterial hypertension (4), which aims to spread and implement the major issues of the 2023 ESH hypertension guidelines (5) to clinicians, especially GPs.

Since national healthcare systems vary across Europe, the same can be true for the activities
of hypertension and GP societies. The impact of ESH and national hypertension guidelines for
the everyday practice of GPs is also unclear. As the use of single pill combination (SPC) in
general is recommended since 2013 (6), and also for therapy initiation since 2018 (7), an
indicator of adequate guideline-based hypertension care could be the use of SPCs in a country.
The aim of the present study was to discover the relationship between national hypertension
and GP societies and clarify gaps in the implementation of hypertension guidelines among
different European nations which could be the subject for future improvements. We also
aimed to provide a report on the tendency of the use of antihypertensive SPCs in the past
years in different European countries.
Materials and Methods

A 17-item autoquestionnaire was created by the members of the ESH GP Nucleus. Starting
the country of the responder was the first question, followed by questions about the presence
and the number of hypertension and GP societies in the country and about relationship
between them. Next, questions were about which guidelines are followed by the GPs in that
country, who writes them and whether those written by the national hypertension society were
endorsed by GP societies. Questions about the relationship of national hypertension societies
with nurse associations and community pharmacists were next and lastly three questions
about the recommended initial treatment in the national hypertension guidelines for the vast
majority of patients, and the availability and the reimbursement of SPC therapy for
hypertension. Some of the questions were single-choice, some of them multiple choice-type
and in most of them an option was also the “I do not know” answer.

The survey was sent to the GP Nucleus members, as representatives of their countries and in
case of the remaining countries to national representatives of ESH.

With the help of Egis Pharmaceuticals Plc. we gained access to specific IQVIA database
results between 2020-2023. This database provides the exact number of sold boxes of
different medications in a year. Six categories of medications were studied:

- A: monocomponent ACE-inhibitors

- B: SPCs containing ACE-inhibitors plus diuretics

- C: SPCs containing ACE-inhibitors plus calcium channel blockers with or without diuretics

- D: monocomponent ARBs

- E: SPCs containing ARBs plus diuretics
- F: SPCs containing ARBs plus calcium channel blockers with or without diuretics.

During the processing of the answers no statistical method was applied and for the anonymous survey and publicly available data no ethical approval was performed.

## Results

25 responders completed the questionnaire, 24 from European countries and 1 from Kazakhstan. The European countries were Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Czech Republic, Denmark, Finland, France, Germany, Hungary, Italy, Latvia, Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland and Turkey.

In most of the countries there is only one hypertension society (23/25) and one GP society (18/25), most of which have a relationship with each other (22/25). GPs tend to follow hypertension guidelines, mostly written by the ESH and the national hypertension societies. Most of the national hypertension guidelines are written by the national hypertension society (45%) followed by the GP society (27%) or public administration (27%). Two thirds of the national hypertension societies (16/25) have relationship with nurse societies (Figure 1.) and half of them (12/25) with pharmacists (Figure 2.). In 65% (15/23) of the guidelines, SPCs are recommended for treatment initiation and are highly available and reimbursed in most of the countries (21/25), however, marked differences are present in the distribution of the number of delivered drugs in community pharmacies containing monocomponents and SPCs in different countries.

In Great Britain only monocomponent ACE-inhibitors or ARBs were sold in the past decade indicating that SPCs are not used in this country (Figure 3A). In Germany the proportion of
SPCs is also very low and the use of monocomponent ARBs is showing increasing tendency (Figure 3B). In France the proportion of monocomponent ACE-inhibitors and ARBs are high, SPCs containing ACE-inhibitors or ARBs plus diuretics are showing decreasing tendency, while SPCs containing CCBs are showing a slow increasing tendency (Supplementary Figure 1.). In Spain the proportion of SPCs with CCB is also very low, however SPCs with diuretics are more frequently used and are showing increasing tendency (Supplementary Figure 1.). In contrast, in other countries, like Slovakia, Czech Republic, Romania or Poland the sale of monocomponent ACE-inhibitors is decreasing while the proportion of SPCs are growing dinamically (Supplementary Figure 1). An emergent example of this phenomenon is Hungary, where in the last studied year the sale of monocomponent ACE-inhibitors was almost similar with the sale of SPCs containing ACE-inhibitor plus CCB (Figure 3C). Portugal is among the countries with most SPC use, with a growing usage of all SPC components, however the use of SPCs containing ARBs plus diuretics and the use of SPCs containing ACE-inhibitor plus CCB with or without diuretics are among the most sold (Figure 3D).

Discussion

The facilitation of the implementation of hypertension guidelines into clinical practice is an important task of the ESH. Our survey discovered that in most of the responder countries there is one hypertension society, of which the majority have a relationship with their GP society. In half of the countries, hypertension guidelines are written by the national hypertension society, but in many countries by GP societies or by the national administration.

The relationship with pharmacist and nurse societies needs improvement. SPCs are available in all countries, however, in the past four years the changes of the proportion in the use of pills containing one agent and SPCs demonstrated marked differences throughout Europe.
Based on the results of our survey that in most of the European responder countries, there is one hypertension society which has contact with the national GP societies this is a good opportunity for the dissemination of the recent ESH guidelines (4, 5) to GPs. However, with the recently released new European Society of Cardiology (ESC) hypertension guidelines (8) hypertension management may have become confusing for GPs. There is a marked overlap between the ESH and the ESC guidelines, but the differences are also present, which can lead to confusion in the decision making of physicians in different clinical situations. Even though the responsibility of adapting the new circumstances to each country belongs to the national hypertension societies, the recommendation of the ESH GP Nucleus members for national hypertension society decision makers, is to translate the clinical practice guidelines (4) for national languages and to follow these recommendations.

The involvement of pharmacists in CVD care, especially hypertension, has been proven to be effective and can successfully contribute to blood pressure and CV risk reduction (9, 10). Our survey discovered that there is a place for improvement in the relationship between national hypertension societies and community pharmacists as only every second national hypertension society is active in this field. Pharmacists can have a very important role in the follow-up of hypertensive patients with blood pressure measurement, performing ABPM and there are nice examples where they even evaluate hypertension-mediated organ damage like pulse wave velocity (11). Pharmacist-led interventions can also improve medication adherence through education, counseling, or the combination of both (12). An excellent example for the involvement of pharmacists into hypertension care is Canada, where pharmacists have dedicated hypertension guidelines (13).

The use of SPCs in general is recommended since 2013 (6) and as first-line therapy since 2018 (7), so the frequency of their use could potentially be a marker of the clinical implementation these recommendations. Our survey demonstrated that different SPCs are
available in almost all countries and public co-founding or reimbursement is also available in
most of them. We had the opportunity to gain access to the numbers of sold SPCs in the past
four years in different European countries and interestingly we found markedly different
results. The use of SPCs is extremely variable across Europe and some countries provide
better results while others worse. The background of this phenomenon requires further
studies, but the good results e.g. in Hungary might be attributable to printed and online
educational campaigns, congresses in different cities throughout the country, pocket
guidelines for GPs and national blood pressure and ABPM registries (14, 15).

There are some limitations of our study. As our survey was an autoquestionnaire the exclusion of misinterpretation or mistakes were not feasible. Additionally, one expert per country fulfilled the survey, so different opinions about national characteristics were not considered. Moreover, the quality of the relationship between different societies were not evaluated. It was a declarative questionnaire, which did not provide opportunity for the fillers to explain their opinions in details. Finally, the use of single pill combination therapy is not an accepted measure of guideline adherence, so it can happen that other recommendations of guidelines are followed better or worse in each country.

There are many perspectives of our study on national levels. Our results drew attention for the
importance of the critical review of ESH hypertension guidelines implementation in each
country. Collaboration with pharmacists and nurse associations could also markedly improve
hypertension care as many activities of the care could be shared with them. Active
communication should be initiated between countries which are better and worse in SPC use
to identify barriers, which are needed to be resolved and strategies which work well. The
changes should be monitored continuously, so the foundation of special working groups
aiming to gain data and also to communicate with local decision makers and politicians might
also help to improve hypertension management.
In conclusions, our results suggest that hypertension societies and GP societies have relationship with each other in most of the countries, which is good opportunity for guideline implementation. However, the relationship between hypertension societies and nurse or pharmacist societies requires improvement. Interestingly the use of SPCs in hypertension management shows a variable picture in Europe with some countries revealing a very low SPC usage, and in which hypertension guideline implementation require improvement.

Acknowledgements

The authors would like to thank Mandy Elgner for collecting the surveys from the different responders. We would alsolike to thank Egis Pharmaceuticals Plc. and personally to Norbert Habony for providing IQVIA data. We are also thankful for Hungarian Society of Hypertension and Egis Pharmaceuticals Plc. for covering publication fees of this paper.
References

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<figure><img src="image_8.png" /></figure>
Figure legends

<figure><img src="image_9.png" /><figcaption>Figure 1. Relationship between national hypertension societies and nurse associations.</figcaption></figure>
<figure><img src="image_10.png" /><figcaption>Figure 2. Relationship between national hypertension societies and pharmacist associations.</figcaption></figure>
<figure><img src="image_11.png" /><figcaption>3B</figcaption></figure>

<figure><img src="image_12.png" /></figure>
3C

<figure><img src="image_13.png" /></figure>

3D

<figure><img src="image_14.png" /></figure>

Figure 3. Yearly sold boxes of different antihypertensive medications in four European countries; 3A) Great Britain; 3B) Germany; 3C) Hungary; 3D) Portugal. A: monocomponent ACE-inhibitors; B: SPCs containing ACE-inhibitors plus diuretics; C: SPCs containing ACE-inhibitors plus calcium channel blockers with or without diuretics; D: monocomponent ARBs; E: SPCs containing ARBs plus diuretics; F: SPCs containing ARBs plus calcium channel blockers with or without diuretics.