Category: Blood pressure

patient care team

We demonstrated that a multidisciplinary clinic for difficult-to-control blood pressure can be successful in a public health setting serving a disadvantaged minority population. Our success rate over 6 months of 58% compares favorably to the success rate (64%) in a private setting that serves primarily well-educated, Caucasian patients. The fact that eleven subjects of fifty were lost to follow-up highlights why blood pressure can be so difficult to control in a population in which intense personal and socioeconomic pressures supersede health care priorities. If these eleven subjects had been excluded, the success rate would have been 74%.

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The characteristics of the first fifty patients enrolled in the clinic are described in Table 1. The typical patient was a 60-year-old diabetic African-American woman with a history of hypertension for 18 years taking 4 different antihypertensive medications, including a diuretic, calcium-channel blocker, alpha-blocker, and ACE-inhibitor. Of the fifty patients, 33 (66%) were female and 25 (50%) were diabetic.

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A multidisciplinary hypertension clinic was established in the summer of 2000 to treat patients with difficult-to-control hypertension within the Cook County ambulatory health care network. The team of providers included three general internists, a nurse health educator, pharmacist, and dietician. Eligible patients with difficult-to-control hypertension were defined as having blood pressure persistently greater than 140 mm Hg systolic or 90 mm Hg diastolic despite concurrent treatment with three or more anti-hypertensive medications for at least three months. A classification of resistant hypertension usually necessitates use of a diuretic; two of our patients did not use a diuretic due to intolerable side effects, but met other criteria for the definition and were included in the study.

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refractory hypertension

INTRODUCTION

The treatment of difficult-to-control hypertension in disadvantaged populations—poor, urban, or ethnically diverse—is a challenge that few individual practitioners or institutions have successfully addressed. This is a public health issue of significant importance, as uncontrolled hypertension leads to increased health care expenditures as well as higher rates of morbidity and mortality. The high prevalence of poor blood pressure control in such populations is multifactorial. Even when barriers such as access to blood pressure screening, primary care, and medications have been overcome, significant numbers of patients have persistently elevated blood pressures despite the use of multiple medications and the best efforts of their primary care physicians. For this group of patients with difficult-to-control blood pressure, we organized a multidisciplinary clinic to examine the reasons for the problem and to devise strategies to successfully address them.

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