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Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

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Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

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Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

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13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al.  : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

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17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

• hypertension
• blood pressure
• african american

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Pathophysiology and Pharmacotherapy of Cardiovascular Disease pp 635–653 Cite as

Hypertension: Introduction, Types, Causes, and Complications

• Yoshihiro Kokubo MD, PhD, FAHA, FACC, FESC, FESO 4 ,
• Yoshio Iwashima MD, PhD, FAHA 5 &
• Kei Kamide MD, PhD, FAHA 6  

8607 Accesses

3 Citations

Hypertension remains one of the most significant causes of mortality worldwide. It is preventable by medication and lifestyle modification. Office blood pressure (BP), out-of-office BP measurement with ambulatory BP monitoring, and self-BP measurement at home are reliable and important data for assessing hypertension. Primary hypertension can be defined as an elevated BP of unknown cause due to cardiovascular risk factors resulting from changes in environmental and lifestyle factors. Another type, secondary hypertension, is caused by various toxicities, iatrogenic disease, and congenital diseases. Complications of hypertension are the clinical outcomes of persistently high BP that result in cardiovascular disease (CVD), atherosclerosis, kidney disease, diabetes mellitus, metabolic syndrome, preeclampsia, erectile dysfunction, and eye disease. Treatment strategies for hypertension consist of lifestyle modifications (which include a diet rich in fruits, vegetables, and low-fat food or fish with a reduced content of saturated and total fat, salt restriction, appropriate body weight, regular exercise, moderate alcohol consumption, and smoking cessation) and drug therapies, although these vary somewhat according to different published hypertension treatment guidelines.

• Blood pressure
• Epidemiology
• Preventive medicine
• Vegetables/fruits
• Sodium restriction
• Essential hypertension
• Secondary hypertension
• Combination therapy

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Sources of Funding

This study was supported by grants-in-aid from the Ministry of Education, Science, and Culture of Japan (Nos. 25293147 and 26670320), the Ministry of Health, Labor, and Welfare of Japan (H26-Junkankitou [Seisaku]-Ippan-001), the Rice Health Database Maintenance industry, Tojuro Iijima Memorial Food Science, the Intramural Research Fund of the National Cerebral and Cardiovascular Center (22-4-5).

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Kokubo, Y., Iwashima, Y., Kamide, K. (2015). Hypertension: Introduction, Types, Causes, and Complications. In: Jagadeesh, G., Balakumar, P., Maung-U, K. (eds) Pathophysiology and Pharmacotherapy of Cardiovascular Disease. Adis, Cham. https://doi.org/10.1007/978-3-319-15961-4_30

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Patient Case Presentation

Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%.  Glucose  180 mg/dL (fasting).  FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.

Past medical history

Diagnosed with diabetes (type 2) at 32 years old

Overweight, BMI of 31

Had a cholecystomy at 38 years old

Diagnosed with dyslipidemia at 32 years old

Past family history

Mother alive, diagnosed diabetic at 42 years old 

Father alive with Hypertension diagnosed at 55 years old

Brother alive and well at 45 years old

Sister alive and obese at 34 years old 

Pertinent social history

Social drinker on occasion

Smokes a pack of cigarettes per day

Works full time as an IT technician and is in graduate school

An evidence-based practice case study: white coat hypertension

Affiliation.

• 1 Mary Ellis Richardson, BS, RN, resides in Richmond, VA. She is currently pursuing an MS in Nursing at Virginia Commonwealth University School of Nursing. She works at VCU Medical Center as a registered nurse on a general medicine floor.
• PMID: 25730535
• DOI: 10.1097/PSN.0000000000000086

White coat hypertension, also referred to as isolated clinical hypertension, is a condition in which blood pressure rises in the medical setting due to anxiety. White coat hypertension causes no more than 15 mmHg increase in systolic blood pressure or 7 mmHg increase in diastolic blood pressure in normotensive patients, and these increases in blood pressures should return to baseline within 3 visits to the medical provider. In this case, a 77-year-old white man presented to preoperative testing, with a blood pressure of 265/101 mmHg, claiming to have white coat hypertension. This case discusses the interventions implemented for this particular patient and the misdiagnosis and misperceptions of white coat hypertension by both clinicians and patients. This article also addresses recommendations for diagnosis, treatment options, and follow-up for patients with true white coat hypertension.

• Ambulatory Surgical Procedures / psychology
• Blood Pressure Determination*
• Evidence-Based Nursing / methods*
• Hypertension / complications
• Hypertension / etiology*
• White Coat Hypertension / psychology*

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• v.99(52); 2020 Dec 24

Nursing case management for people with hypertension

To explore the effect of management of nursing case on blood pressure control in hypertension patients.

This is a randomized controlled study which will be carried out from May 2021 to May 2022. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808). Our research includes 200 patients. Patients who meet the following conditions will be included in this experiment: the patients aged 18 to 60 years; the patients had the diagnosis of hypertension; and the urban residents. While patients with the following conditions will be excluded: having renal failure, liver failure, heart and respiratory failure; and known pregnancy. Primary result is blood pressure, while secondary results are treatment compliance, waist circumference, body mass index (BMI), type and number of antihypertensive agents used, and the existence of metabolic and cardiovascular comorbidities.

Table 1 shows the clinical outcomes between the two groups.

Conclusion:

Nursing case management is effective to improve the prognosis of hypertension patients.

1. Introduction

Hypertension is one of the cause of death worldwide, which is preventable. [ 1 , 2 ] It is also a significant risk factor for myocardial infarction, heart failure, stroke, as well as other serious renal and cardiovascular diseases. [ 3 – 5 ] The incidence rate of hypertension rises with the age of adults. It is reported that 36% of the adults aged 40 to 64 suffer from hypertension; among adults aged 65 and above, the proportion has increased to 70%. [ 6 , 7 ] It has become a serious problem of public health. Since the hypertension is asymptomatic, its detection and control remains a challenge. The hypertension patients are managed via the primary health care provider. [ 8 ] Nevertheless, although the progress has been made in the management of chronic diseases, the hypertensive patients who receive regular treatment from primary care providers do not meet their targets of blood pressure.

In recent years, more and more researches begin to pay attention to the significant role of the management of nursing case in treating hypertension. [ 9 , 10 ] It requires a complex care, involving major lifestyle changes such as adherence to medication, reduced salt intake, the measurement of blood pressure and exercise. Nevertheless, the hypertension patients have poor self-management behaviors. The self-care and self-efficacy behavior of uncontrolled hypertension patients are lower. Case management is a kind of healthcare strategy that determines patients at high risk, prevents complications and disease progression, and promotes the patients participation in self-care. Other targets involve caring for the perspectives and needs of patients, developing personalized care programs, improving the quality of health care, and decreasing decentralized patient care. The former researches have suggested that management of case may have a positive effect on hypertension. [ 11 – 13 ] In addition, it can increase the knowledge about the disease; adhere to the treatment plans and help the patients improve their own lifestyle. Although it has achieved positive results in the case management of chronic disease, it has not been applied in patients with hypertension. Hence, we conduct the randomized controlled study protocol to explore the effect of management of nursing case on blood pressure control in hypertension patients.

2. Materials and methods

This is a randomized controlled study which will be carried out from May 2021 to May 2022 at the People's Hospital of Chengyang District. The experiment was granted through the Research Ethics Committee of the People's Hospital of Chengyang District (03982808) and recorded in research registry (researchregistry6244).

2.1. Inclusion criteria and exclusion criteria

Patients who meet the following conditions will be included in this experiment: the patients aged 18 to 60 years; the patients had the diagnosis of hypertension; and the urban residents. While patients with the following conditions will be excluded: having renal failure, liver failure, heart and respiratory failure; and known pregnancy. All the patients are randomly assigned to the random number through utilizing a random-number table, and the result of distribution is kept in a random envelope and is invisible. All the patients are randomly divided to the control group and study group, and there are 100 patients in each group.

2.2. Nursing case management

The nursing standards of the control group are as follows: renewal of prescriptions in meetings, free distribution of hypertension medication, and the monitor of blood pressure every 2 months, nursing and medical appointments, and consultation with psychologists and nutritionists based on the needs of patients.

In intervention group, patients are given management of nursing case. From the existing management activities, the arrangements are as follows: telephone contacts, nursing consultations, personal health education activities, and home visits. The nursing consultations are implemented every 6 months. The purpose of the consultation is to gather information that can be utilized to draft personal care plans and to set mutually agreed targets. The consultation lasts about an hour, involving the targeted health education, the measurement of waist circumference and blood pressure, and the calculation of BMI. Telephone contact is conducted every 1 month to reassess the healthcare plans of patients and remind the patients to consult the agendas in a timely manner. WeChat is a kind of instant messaging tool, which allows the voice calls through using the mobile phone, and it is also utilized for communication. Each telephone meeting lasts about 10 min. In the process of home visits, the case manager will observe the home environment, for instance, the living conditions and family's interaction. They offer the health education, check the weight of patient and their blood pressure, and then review the targets and medical plans. All the verbal instructions will be recorded and the patients will be provided the copy for consultation if needed. For the home visits, it lasts about 45 min. And the group activities contain the interactive activities and informational lectures. The focus of these activities is to develop healthy habits. The theme of educational activities is selected according to patients’ main needs. The activities of collective health education are carried out in community space. These group activities last about 1 h. Personalized educational activities are offered in the process of nursing consultation, telephone consultation, and home visit. All information acquired in the process of nursing management will be recorded.

2.3. Outcomes

Primary result is blood pressure, while secondary results are treatment compliance, waist circumference, BMI, type and number of antihypertensive agents used, and the existence of metabolic and cardiovascular comorbidities.

2.4. Statistical analysis

The analysis of all the data are conducted with the software of IBM SPSS Statistics for Windows, version 20 (IBM Corp, Armonk, NY). Afterwards, all the data acquired are represented through the appropriate characteristics, for example, standard deviation, and mean, median as well as percentage. And independent t tests and χ 2 -tests are respectively utilized to analyze the categorical variable and continuous variable. P value < .05 indicates that there is statistical significance.

Table ​ Table1 1 shows the clinical outcomes between the two groups.

The clinical outcomes between the two groups.

4. Discussion

Hypertension is the most significant risk factor for disability and death worldwide, which affects more than one billion people and causes ∼9.4 million deaths each year. [ 14 ] On the basis of a report by the World Health Organization, hypertension is the single most significant risk factor, which accounts for 13% of global mortality. Human hypertension may be the result of lifestyle and genetic factors. [ 15 , 16 ] The current evidence-based treatment for the hypertension is a key intervention measure to reduce the incidence rate and mortality of cardiovascular diseases. Researches have determined a variety of barriers to the control of hypertension in routine care that are composed of factors related to patients, physicians, healthcare system, and healthcare services.

People with lower income and education levels are more likely to be insufficiently physically active, which predisposes them to the risk of complications associated with chronic diseases, particularly the hypertension. [ 17 ] In contrast, people with higher educational and economic levels tend to be more effective at controlling the levels of blood pressure. Therefore, it is essential to consider the effect of these variables and then incorporate these variables into the development of nursing planning and educational activities for hypertension patients. Case management can be utilized for this objective by providing a personalized plan based on each person's needs.

5. Conclusion

Author contributions.

Shiqiang Song designs the protocol. Xianhong Li reviews the protocol. Xueling Ning performs the data collection. Chunjing Song finishes the manuscript. All of the authors approved the submission.

Conceptualization: Xianhong Li.

Data curation: Xianhong Li.

Funding acquisition: Shiqiang Song.

Investigation: Xueling Ning.

Methodology: Xueling Ning.

Writing – original draft: Chunjing Song.

Abbreviations: BMI = body mass index, Trial registration = The protocol was registered in Research Registry (researchregistry6244).

How to cite this article: Song C, Li X, Ning X, Song S. Nursing case management for people with hypertension: A randomized controlled trial protocol. Medicine . 2020;99:52(e23850).

Qingdao Health Bureau project (2013-WSZD120).

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the present study are publicly available.