• 5
    Feb
  • TREATMENT OF DIFFICULT-TO-CONTROL BLOOD PRESSURE: RESULTS

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.

Table 1. Patient characteristics (n = 50)

Characteristic
Age years, mean ± SD (range)

63

± 11

(27-79)
Women n (%)

33

(66)
Ethnicity n (%)
African American

47

(94)
Hispanic/Latino

3

(6)
Baseline blood pressure mm
Hg, mean ± SD (range)
Systolic blood pressure

177

± 23

(145-240)
Diastolic blood pressure

93

± 15

(60-138)
Duration of hypertension years,

18

± 13

(1-57)
mean ± SD (range)
Number of antihypertensive medications n (%)
3

9

(18)
4

25

(50)
5 or more

16

(32)
Class of antihypertensive medication n (%)
Diuretic

48

(96)
Calcium-channel blocker

39

(78)
Alpha-blocker

34

(68)
Ang iotensin-converti ng-

33

(66)
enzyme inhibitor
Beta-blocker

30

(60)
Vasodilator

20

(40)
Comorbidity n (%)
Diabetes mellitus

25

(50)
Hypercholesterolemia

25

(50)
Left ventricular hypertrophy

17

(34)
Chronic renal insufficiency

15

(30)
Congestive heart failure

11

(22)
Cerebrovascular accident

6

(12)
Documented coronary

3

(6)
artery disease

The most common reasons for poor control were volume overload and poor medication adherence (Table 2). None of the patients had secondary hypertension.
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Figure 1. Initial and final systolic

Figure 1. Initial and final systolic blood pressures for each patient enrolled in the clinic. The circles represent initial systolic blood pressures, and the arrows represent final systolic blood pressures. The horizontal line at 140 mm Hg depicts the target systolic blood pressure for patients without diabetes mellitus. Those with diabetes mellitus had a target systolic blood pressure of 130. Of note, three patients had initial readings at target, though review of medical records revealed uncontrolled blood pressures at previous clinic visits.

Figure 2. Initial and final diastolic blood pressures

Figure 2. Initial and final diastolic blood pressures for each patient enrolled in the clinic. The circles represent initial diastolic blood pressures, and the arrows represent final diastolic blood pressures. The horizontal line at 90 mm Hg depicts the target diastolic blood pressure for patients. Those with diabetes mellitus had a target diastolic blood pressure of 85.

Initial and final systolic and diastolic blood pressures for each patient are shown in Figures 1 and 2. After six months of follow-up, 29 (58%) of the 50 patients had achieved and maintained their target blood pressure and were referred back to their primary physician. The mean duration of time to maintenance of target blood pressure was 3.8 months. Four (8%) patients had improved blood pressure control but had not maintained target levels over two consecutive visits. Six (12%) had not improved, and 11 (22%) were lost to follow-up. The medical interventions are described in Table 3.

Table 2. Primary cause of difficult-to-control hypertension

Cause Number Controlled Number Improved Number Unimproved Number Lost to Follow-up Total
Nonadherance 12(60) 3(15) n (%)2(10) 3(15) 20 (40)
Volume Overload 5 (33) 1 (7) 2(13) 7 (47) 15 (30)
Drug Interactions* 5 (100) 0 0 0 5(10)
Obesity 2(67) 0 0 1 (33) 3(6)
White-Coat 1 (50) 0 1 (50) 0 2(4)
Hypertension
Suboptimal Dosing 2 (100) 0 0 0 2(4)
Undetermined 2 (100) 0 0 0 2(4)
Diet 0 0 1 (100) 0 1 (2)
Total 29 (58) 4(8) 6(12) 11 (22) 50(100)
*Drug interactions all involved non-steroidal anti-inflammatory agent s.

When interviewed at 6-months follow-up, over 75% of patients endorsed the following five interventions as being helpful in achieving better blood pressure control: physicians who specialized in the treatment of hypertension, medication changes, education about hypertension, nutrition, and exercise. Of these, there was no agreement on the single most important factor. viagra soft

Table 3. Medication changes in patients who achieved blood pressure control

Medication Added Increased Decreased Removed
Loop diuretic

5

6

0

1

Calcium-channel

4

9

0

1

blocker
Alpha-blocker

4

7

0

5

Vasodilator

3

3

1

4

Thiazide diuretic

1

1

0

4

Ang iotensi n-converting

1

6

0

0

-enzyme inhibitor
Beta-blocker

1

3

0

4

Total

19

35

1

19

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