OBJECTIVES:To determine associations between arm and ankle systolic blood pressures (SBPs), develop and validate a multivariable model predicting arm SBP from ankle SBP, and investigate associations between ankle SBP, cardiovascular disease and mortality. DESIGN:Ankle-arm SBP differences were examined in two-stage individual participant data (IPD) meta-analyses using multivariable hierarchical linear regression models. Models were used to derive and validate a prediction model for arm SBP based on ankle SBP. Model performance was assessed using area under the receiver operating characteristic (AUROC) curve analyses. Prognostic associations of ankle SBP with outcomes were examined using Cox proportional hazards models. DATA SOURCES:Searches identified cohorts for the Inter-arm Blood Pressure Difference IPD (INTERPRESS-IPD) Collaboration from Medline, Old Medline, Medline in process, Embase and CINAHL databases from inception until January 2017; unpublished data were also sought. Required primary outcomes were all-cause mortality, cardiovascular mortality, and/or fatal and non-fatal cardiovascular events. ELIGIBILITY CRITERIA:Prospective studies from community, primary care or general clinic settings, without language restriction, that recorded SBP in both arms were eligible. Adults aged ≥18 years with SBP measured in all four limbs, in a supine position, were included in the current analyses. People with peripheral artery disease were excluded. DATA EXTRACTION AND SYNTHESIS:Anonymised datasets were individually cleaned and then combined into a single dataset for the INTERPRESS-IPD Collaboration. RESULTS:The current dataset included 33 710 participants from 14 studies; mean age 58 years, 45% female, mean baseline arm blood pressure 138/80 (SD: 20/12) mm Hg. Mean ankle SBP was 12.0 mm Hg (95% CI 8.8 to 15.2) higher than arm SBP. The multivariable model predicting arm SBP from ankle SBP demonstrated excellent performance (AUROC curves, sensitivities and specificities were >0.82, 0.80 and 0.82, respectively, at all BP thresholds from 130 to 160 mm Hg). Model performance was superior to existing arithmetic formulae.Ankle SBP was neither associated with all-cause nor cardiovascular mortality (HR 1.000 (0.997 to 1.002; p=0.682) and 1.001 (0.996 to 1.005; p=0.840), respectively). However, lower-reading ankle SBP was associated with fatal or non-fatal cardiovascular events (HR 1.005 (1.002 to 1.007; p<0.001). CONCLUSIONS:On average, ankle SBP is 12 mm Hg higher than arm SBP. Estimating individual arm SBP from ankle SBP measurements with a multivariable model is more accurate than existing fixed arithmetic formulae. This model, operationalised in an online calculator (https://ablebp. RESEARCH:exeter.ac.uk/), could facilitate hypertension management and cardiovascular care for people unable to have arm SBP measured. PROSPERO REGISTRATION NUMBER:CRD42015031227.

Background Methotrexate (MTX) is the first-line drug in the treatment of rheumatoid arthritis (RA) and many other rheumatic and musculoskeletal diseases (RMDs). It is widely recognized that patients prescribed with this, or other similar drugs, should be properly educated, namely by rheumatology nurses,[1] to better understand why and how to take it, the possible side effects and how to prevent and manage them. However, high disparities may exist across European countries regarding patient education (PE) and support about MTX. Objectives To assess patients’ and clinicians’ perspectives and experiences on education and support received about MTX treatment in Europe. Methods A survey was developed by a team of international researchers and clinicians, including rheumatology nurses (from adult and paediatric care), a pharmacist, a rheumatologist, and patient representatives. Common and sample-specific questions were conceived for adult patients or carers (≥18 years) of children/young with RMDs, nurses, and physicians working in rheumatology in Europe. The survey was available in English and, for patients, in 12 additional languages, disseminated between May and December 2022. Ethics committee approval was obtained (116_CEIPC/2022_IPC). Results Complete responses were obtained from 1536 patients (52% with RA), 154 careers, 335 nurses, and 299 physicians (96% rheumatologists), from 24 European Countries, mainly from Northern (nurses) and Southern Europe (patients and physicians) (Table 1). Only 28% of patients had a specific nurse consultation when they started oral MTX, slightly increasing when the subcutaneous form was prescribed (42%), with variations across Europe, being higher in the Western (43%) and Northern (39%) and lower in Eastern (29%) and Southern (11%). These patients’ perspectives are somewhat in line with physicians’ perspectives, although according to nurses the access to them is higher, independent of the form of prescription (Table 1). Clinicians perceive higher opportunities to discuss patients’ MTX concerns than the patients themselves (Table 1). Patients had more opportunities to voice their concerns (≥7 on a scale from 0 to 10) about MTX before starting it, in Western (57%) and Northern (42%) than in Southern (36%) and Eastern (31%) Europe. According to 47% of nurses, PE occurs on the same day of prescription, with the consultation lasting between 10-30 minutes in 50% of cases or even less than 10’ (15%). 37% of nurses do not perform MTX-related follow-up appointments. Only half of the nurses (49%) received specific training to advise patients about MTX (data not shown). The priority ranking of topics to be addressed was also assessed, with agreement on the top one (side effects and their management) (Figure 1). Around 77% of patients had/have concerns about potential unpleasant side effects, which were discussed with health professionals (mainly with rheumatologists) in 68% of the cases, despite not being clarified 46% of the times. Conclusion PE and support about MTX are unequal across Europe and can be improved by providing opportunities to clarify concerns, namely by providing patients with more access to nursing consultations. There is an overall agreement between patients and clinicians regarding key information areas of education, although a tailored approach is required. Reference [1]Bech B, et al. Annals Rheum Diseases 2020;79:61-68. Acknowledgements This study was funded by an unrestricted grant from medac, without any involvement in the scientific work. Disclosure of Interests Cristiano Matos: None declared, Andrea Marques: None declared, Khadija El Aoufy: None declared, Kristina Buerki: None declared, Ágnes Ágoston-Szabó: None declared, Darja Batšinskaja: None declared, Jana Melicharová: None declared, Marie-Louise Karlsson Speakers bureau: Novartis, Grant/research support from: Novartis, Karlien Claes: None declared, Ana Isabel Rodriguez Vargas: None declared, Ellen Moholt: None declared, Ane Ludvigsen: None declared, Una Martin: None declared, Ulrike Erstling: None declared, Angela Camon: None declared, Ana Pais: None declared, Mikaella Konstantinou: None declared, Myrto Nikoloudaki: None declared, Souzi Makri: None declared, Elena Nikiphorou Speakers bureau: Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Fresenius, Paid instructor for: Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Fresenius, Grant/research support from: Lilly, Pfizer, Claudia Paiva: None declared, Polly Livermore Consultant of: Nordic Pharma, Grant/research support from: GOSH NIHR BRC and NIHR Personal Fellowship, Ricardo J. O. Ferreira Speakers bureau: Sanofi, MSD, Paid instructor for: UCB, Consultant of: medac, abbvie, roche, Sanofi, Amgen, Grant/research support from: Abbvie.

IntroductionBlood pressure (BP) is normally measured on the upper arm, and guidelines for the diagnosis and treatment of high BP are based on such measurements. Leg BP measurement can be an alternative when brachial BP measurement is impractical, due to injury or disability. Limited data exist to guide interpretation of leg BP values for hypertension management; study-level systematic review findings suggest that systolic BP (SBP) is 17 mm Hg higher in the leg than the arm. However, uncertainty remains about the applicability of this figure in clinical practice due to substantial heterogeneity.AimsTo examine the relationship between arm and leg SBP, develop and validate a multivariable model predicting arm SBP from leg SBP and investigate the prognostic association between leg SBP and cardiovascular disease and mortality.Methods and analysisIndividual participant data (IPD) meta-analyses using arm and leg SBP measurements for 33 710 individuals from 14 studies within the Inter-arm blood pressure difference IPD (INTERPRESS-IPD) Collaboration. We will explore cross-sectional relationships between arm and leg SBP using hierarchical linear regression with participants nested by study, in multivariable models. Prognostic models will be derived for all-cause and cardiovascular mortality and cardiovascular events.Ethics and disseminationData originate from studies with prior ethical approval and consent, and data sharing agreements are in place—no further approvals are required to undertake the secondary analyses proposed in this protocol. Findings will be published in peer-reviewed journal articles and presented at conferences. A comprehensive dissemination strategy is in place, integrated with patient and public involvement.PROSPERO registration numberCRD42015031227.

Introduction Blood pressure (BP) is normally measured on the upper arm, and guidelines for the diagnosis and treatment of high BP are based on such measurements. Leg BP measurement can be an alternative when brachial BP measurement is impractical, due to injury or disability. Limited data exist to guide interpretation of leg BP values for hypertension management; study- level systematic review findings suggest that systolic BP (SBP) is 17 mm Hg higher in the leg than the arm. However, uncertainty remains about the applicability of this figure in clinical practice due to substantial heterogeneity. Aims To examine the relationship between arm and leg SBP, develop and validate a multivariable model predicting arm SBP from leg SBP and investigate the prognostic association between leg SBP and cardiovascular disease and mortality. Methods and analysis Individual participant data (IPD) meta- analyses using arm and leg SBP measurements for 33 710 individuals from 14 studies within the Inter- arm blood pressure difference IPD (INTERPRESS-IPD) Collaboration. We will explore cross- sectional relationships between arm and leg SBP using hierarchical linear regression with participants nested by study, in multivariable models. Prognostic models will be derived for all- cause and cardiovascular mortality and cardiovascular events. Ethics and dissemination Data originate from studies with prior ethical approval and consent, and data sharing agreements are in place—no further approvals are required to undertake the secondary analyses proposed in this protocol. Findings will be published in peer-reviewed journal articles and presented at conferences. A comprehensive dissemination strategy is in place, integrated with patient and public involvement. as a rule of thumb. 5 11 This study aims to provide the first evidence- based method for estimating individual brachial SBP and cardiovascular risk from leg SBP measurements. Our findings will support clinicians and patients in detecting and managing hypertension more effectively where leg measurements are required.

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Analysis of urine samples using liquid chromatography-tandem mass spectrometry (LC-MS/MS) has previously revealed high rates of non-adherence to antihypertensive medication. It is unclear whether these rates represent those in the general population. This study aimed to investigate whether it is feasible to collect urine samples in a primary care setting and analyse them using LC-MS/MS to detect non-adherence to antihypertensive medication. This study used a prospective, observational cohort design. Consecutive patients were recruited opportunistically from five general practices in UK primary care. They were aged ≥65 years with hypertension and had at least one antihypertensive prescription. Participants were asked to provide a urine sample for analysis of medication adherence. Samples were sent to a laboratory via post and analysed using LC-MS/MS. Predictors of adherence to medication were explored with multivariable logistic regression. Of 349 consecutive patients approached for the study, 214 (61.3%) gave informed consent and 191 (54.7%) provided a valid urine sample for analysis. Participants were aged 76.2 ± 6.6 years and taking a median of 2 antihypertensive medications (IQR 1–3). A total of 27/191 participants (14.2%) reported not taking all of their medications on the day of urine sample collection. However, LC-MS/MS analysis of samples revealed only 4/27 (9/191 in total; 4.7%) were non-adherent to some of their medications. Patients prescribed more antihypertensive medications were less likely to be adherent (OR 0.24, 95%CI 0.09–0.65). Biochemical testing for antihypertensive medication adherence is feasible in routine primary care, although non-adherence to medication is generally low, and therefore widespread testing is not indicated.

Ankle blood pressure (BP) measurement is necessary for the diagnosis of hypertension where measurements are not possible due to medical conditions or limb deformities. Based on a recent review of the evidence, we recommend an ankle BP threshold of ≥155/90 mmHg to define high blood pressure in patients who do not have vascular disease. We recommend that ankle BP readings are taken with the subject lying down, using a validated automated device with the cuff placed around the ankle/lower calf.

Objective: Nonadherence to medication is present in at least 50% of patients with apparent treatment-resistant hypertension. We examined the factors associated with nonadherence as detected by a liquid chromatography-tandem mass spectrometry (LC-MS/MS)-based urine antihypertensive drug assay. Methods: All urine antihypertensive test results, carried out for uncontrolled hypertension (BP persistently >140/90 mmHg) between January 2015 and December 2016 at a single toxicology laboratory were analysed. Drugs detected were compared with the antihypertensive drugs prescribed. Patients were classified as adherent (all drugs detected), partially nonadherent (at least one prescribed drug detected) or completely nonadherent (no drugs detected). Demographic and clinical parameters were compared between the adherent and nonadherent groups. Binary logistic regression analysis was performed to determine association between nonadherence and demographic and clinical factors. Results: Data on 300 patients from nine hypertension centres across the United Kingdom were analysed. The median age was 59 years, 47% women, 71% Caucasian, median clinic BP was 176/95 mmHg and the median number of antihypertensive drugs prescribed was four. One hundred and sixty-six (55%) were nonadherent to prescribed medication with 20% of these being completely nonadherent. Nonadherence to antihypertensive medication was independently associated with younger age, female sex, number of antihypertensive drugs prescribed, total number of all medications prescribed (total pill burden) and prescription of a calcium channel blocker. Conclusion: This LC-MS/MS urine analysis-based study suggests the majority of patients with apparent treatment-resistant hypertension are nonadherent to prescribed treatment. Factors that are associated with nonadherence, particularly pill burden, should be taken into account while treating these patients.

BACKGROUND:Self-monitoring of blood pressure better predicts prognosis than clinic measurement, is popular with patients, and endorsed in hypertension guidelines. However, there is uncertainty over the optimal self-monitoring schedule. We therefore aimed to determine the optimum schedule to predict future cardiovascular events and determine "true" underlying blood pressure. METHODS:Six electronic databases were searched from November 2009 (updating a National Institute for Health and Care Excellence [NICE] systematic review) to April 2017. Studies that compared aspects of self-monitoring schedules to either prognosis or reliability/reproducibility in hypertensive adults were included. Data on study and population characteristics, self-monitoring regime, and outcomes were extracted by 2 reviewers independently. RESULTS:From 5,164 unique articles identified, 25 met the inclusion criteria. Twelve studies were included from the original NICE review, making a total of 37 studies. Increasing the number of days of measurement improved prognostic power: 72%-91% of the theoretical maximum predictive value (asymptotic maximum hazard ratio) was reached by 3 days and 86%-96% by 7 days. Increasing beyond 3 days of measurement did not result in better correlation with ambulatory monitoring. There was no convincing evidence that the timing or number of readings per day had an effect, or that ignoring the first day's measurement was necessary. CONCLUSIONS:Home blood pressure should be measured for 3 days, increased to 7 only when mean blood pressure is close to a diagnostic or treatment threshold. Other aspects of a monitoring schedule can be flexible to facilitate patient uptake of and adherence with self-monitoring.

OBJECTIVESTo define the relationship between arm and leg blood pressure (BP) to inform the interpretation of leg BP readings in routine clinical practice where arm readings are not available.METHODSSystematic review of all existing studies comparing arm and leg BP measurements. A search strategy was designed in MEDLINE and adapted to be run across six further databases. Articles were deemed eligible for inclusion if they measured and reported arm and leg BP taken in the supine position and/or the difference between the two. Mean values for arm-leg BP difference and measures of precision [95% confidence intervals (CIs) or SD] were extracted and entered into a random-effects meta-analysis.RESULTSA total of 887 articles were screened and 44 were included in the descriptive analyses, including 9771 patients. In the general population, ankle SBP was 17.0 mmHg (95% CI 15.4-21.3 mmHg) higher than arm BP in the supine position. For DBP, there was no difference between arm and ankle BP (-0.3 mmHg, 95% CI -1.5-1.0 mmHg). In patients with vascular disease, SBP was -33.3 mmHg (95% CI -59.1 to -7.6 mmHg) lower in the ankle compared with the arm.CONCLUSIONThis is the first review to provide empirical data defining the difference between BP in the arm and leg in the general population. Findings suggest a diagnostic threshold of 155/90 mmHg could be used for diagnosing hypertension when only ankle measurements are available in routine practice.

IMPORTANCE Evidence to support initiation of pharmacologic treatment in low-risk patients with mild hypertension is inconclusive, with previous trials underpowered to demonstrate benefit. Clinical guidelines across the world are contradictory. OBJECTIVE To examine whether antihypertensive treatment is associated with a low risk of mortality and cardiovascular disease (CVD) in low-risk patients with mild hypertension. DESIGN, SETTING, AND PARTICIPANTS In this longitudinal cohort study, data were extracted from the Clinical Practice Research Datalink, from January 1, 1998, through September 30, 2015, for patients aged 18 to 74 years who had mild hypertension (untreated blood pressure of 140/90-159/99 mm Hg) and no previous treatment. Anyone with a history of CVD or CVD risk factors was excluded. Patients exited the cohort if follow-up records became unavailable or they experienced an outcome of interest. EXPOSURES Prescription of antihypertensive medication. Propensity scores for likelihood of treatment were constructed using a logistic regression model. Individuals treated within 12 months of diagnosis were matched to untreated patients by propensity score using the nearest-neighbor method. MAIN OUTCOMES AND MEASURES The rates of mortality, CVD, and adverse events among patients prescribed antihypertensive treatment at baseline, compared with those who were not prescribed such treatment, using Cox proportional hazards regression. RESULTS A total of 19 143 treated patients (mean [SD] age, 54.7 [11.8] years; 10 705 [55.9%] women; 10 629 [55.5%] white) were matched to 19 143 similar untreated patients (mean [SD] age, 54.9 [12.2] years; 10 631 [55.5%] female; 10 654 [55.7%] white). During a median follow-up period of 5.8 years (interquartile range, 2.6-9.0 years), no evidence of an association was found between antihypertensive treatment and mortality (hazard ratio [HR], 1.02; 95% CI, 0.88-1.17) or between antihypertensive treatment and CVD (HR, 1.09; 95% CI, 0.95-1.25). Treatment was associated with an increased risk of adverse events, including hypotension (HR, 1.69; 95% CI, 1.30-2.20; number needed to harm at 10 years [NNH10], 41), syncope (HR, 1.28; 95% CI, 1.10-1.50; NNH10, 35), electrolyte abnormalities (HR, 1.72; 95% CI, 1.12-2.65; NNH10, 111), and acute kidney injury (HR, 1.37; 95% CI, 1.00-1.88; NNH10, 91). CONCLUSIONS AND RELEVANCE This prespecified analysis found no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension. There was evidence of an increased risk of adverse events, which suggests that physicians should exercise caution when following guidelines that generalize findings from trials conducted in high-risk individuals to those at lower risk.

Objective: Evidence to support initiation of pharmacological treatment in patients with uncomplicated (low risk) mild (stage 1) hypertension is inconclusive and clinical guidelines are contradictory. The aim of this study was to use electronic health records and statistical methods which minimise bias in non-randomised studies to examine whether treatment is safe and effective at reducing the risk of mortality and cardiovascular disease in uncomplicated mild hypertensives. Design and method: This study had a longitudinal cohort design using electronic health records from Primary Care. Data were extracted from patients in the Clinical Practice Research Datalink from England, aged 18–74 years, with stage 1 hypertension (blood pressure between 140/90–159/99 mmHg), no cardiovascular disease (CVD) risk factors and no treatment, from 1998–2015. Patients exited if follow-up records became unavailable due to death or moving away from a participating practice. Propensity scores predicting likelihood of treatment were constructed using a logistic regression model. Individuals on treatment were matched to those not on treatment 12 months after a diagnosis of hypertension, by propensity score using the nearest neighbour method. The rate of mortality, cardiovascular disease and adverse events in patients on treatment were compared to those not on treatment using Cox regression. Results: A total of 19,143 untreated patients (mean age 54.7 ± 12.2 years, 56.0% female) were matched to 19,143 similar patients on treatment. During a period of up to 15 years follow-up, no association was found between antihypertensive treatment and mortality (HR 1.07, 95%CI 0.97–1.18), cardiovascular disease (HR 1.02, 95%CI 0.92–1.14) or any individual cardiovascular disease endpoints. Treatment was associated with an increased risk of adverse events including hypotension (HR 1.63, 95%CI 1.34–1.97), syncope (HR 1.26, 95%CI 1.12–1.42), electrolyte abnormalities (HR 1.50, 95%CI 1.09–2.07) and acute kidney injury (HR 1.41, 95%CI 1.13–1.76). Conclusions: This appropriately powered study found no evidence to support the initiation of antihypertensive treatment in patients with uncomplicated mild hypertension. However, there was evidence of an increased risk of adverse events and clinicians should refrain from using treatment in this population, since it may do more harm than good.

Hypertension is one of the most important risk factors for cardiovascular disease, which is a significant cause of morbidity and mortality worldwide. Resistant (or difficult) hypertension is thought to affect 1 in 6 patients with treated hypertension and carries an increased risk of death and cardiovascular disease. It is generally defined as uncontrolled clinic blood pressure (>140/90 mmHg) after treatment with three or more antihypertensives to include optimal doses of an ACE inhibitor (or an angiotensin receptor blocker), a calcium channel blocker and a diuretic. There are some factors that must be taken into account before a diagnosis of resistant hypertension can be made. ‘Pseudo-resistant’ hypertension can be caused by poor clinic blood pressure measurement technique, patient non-adherence to prescribed medication, patient intolerance to certain anti-hypertensive medications and white coat hypertension (where blood pressure appears high in the clinic but is controlled out-of-the-office on home or ambulatory measurements). Pharmacological treatment of resistant hypertension is focused on the addition of fourth-line therapy and recent evidence supports the use of spironolactone. Lifestyle should be reviewed and patients encouraged to exercise regularly and lose weight, reduce their alcohol and sodium consumption and stop smoking. In patients who remain uncontrolled on optimal treatment, there are a number of alternative treatment options and surgical procedures which can be considered. However, the evidence supporting each of these is limited and in some cases, conflicting and therefore more prospective randomised controlled trials are required before any can be adopted into routine clinical practice.

Background Studies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. Methods This study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisation was by a secure web-based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pressure at 12 months from randomisation. Primary analysis was of available cases. The trial is registered with ISRCTN, number ISRCTN 83571366. Findings 1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups compared with usual care (self-monitoring, 137.0 [SD 16.7] mm Hg and telemonitoring, 136.0 [16.1] mm Hg vs usual care, 140.4 [16.5]; adjusted mean differences vs usual care: self-monitoring alone, -3.5 mm Hg [95% CI -5.8 to -1.2]; telemonitoring, -4.7 mm Hg [-7.0 to -2.4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference -1.2 mm Hg [95% CI -3.5 to 1.2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups. Interpretation Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care.

Objectives Evidence to support initiation of pharmacological treatment in patients with uncomplicated (low risk) mild hypertension is inconclusive. As such, clinical guidelines are contradictory and healthcare policy has changed regularly. The aim of this study was to determine the incidence of lifestyle advice and drug therapy in this population and whether secular trends were associated with policy changes. Design Longitudinal cohort study. Setting Primary care practices contributing to the Clinical Practice Research Datalink in England. Participants Data were extracted from the linked electronic health records of patients aged 18-74 years, with stage 1 hypertension (blood pressure between 140/90 and 159/99mm Hg), no cardiovascular disease (CVD) risk factors and no treatment, from 1998 to 2015. Patients exited if follow-up records became unavailable, they progressed to stage 2 hypertension, developed a CVD risk factor or received lifestyle advice/treatment. Primary outcome measures The association between policy changes and incidence of lifestyle advice or treatment, examined using an interrupted time-series analysis. Results A total of 108843 patients were defined as having uncomplicated mild hypertension (mean age 51.912.9 years, 60.0% female). Patientsspent a median 2.6 years (IQR 0.9-5.5) in the study, after which 12.2% (95% CI 12.0% to 12.4%) were given lifestyle advice, 29.9% (95% CI 29.7% to 30.2%) were prescribed medication and 19.4% (95% CI 19.2% to 19.6%) were given both. The introduction of the quality outcomes framework (QOF) and subsequent changes to QOF indicators were followed by significant increases in the incidence of lifestyle advice. Treatment prescriptions decreased slightly over time, but were not associated with policy changes. Conclusions Despite secular trends that accord with UK guidance, many patients are still prescribed treatment for mild hypertension. Adequately powered studies are needed to determine if this is appropriate.