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Clinical Crossroads | Clinician's Corner

A 41-Year-Old African American Man With Poorly Controlled Hypertension Review of Patient and Physician Factors Related to Hypertension Treatment Adherence

Lisa A. Cooper, MD, MPH, Discussant
JAMA. 2009;301(12):1260-1272. doi:10.1001/jama.2009.358.
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Mr R is an African American man with a long history of poorly controlled hypertension and difficulties with adherence to recommended treatments. Despite serious complications such as hypertensive emergency requiring hospitalization and awareness of the seriousness of his illness, Mr R says at times he has ignored his high blood pressure and his physicians' recommendations. African Americans are disproportionately affected by hypertension and its complications. Although most pharmacological and dietary therapies for hypertension are similarly efficacious for African Americans and whites, disparities in hypertension treatment persist. Like many patients, Mr R faces several barriers to effective blood pressure control: societal, health system, individual, and interactions with health professionals. Moreover, evidence indicates that patients' cognitive, affective, and attitudinal factors and the patient-physician relationship play critical roles in improving outcomes and reducing racial disparities in hypertension control.

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Barriers and bridges: Controlling hypertension in African Americans
Posted on March 22, 2009
Khendi T White, B.S., First year medical student
Howard University College of Medicine
Conflict of Interest: None Declared
Hypertension and associated outcomes such as stroke and cardiovascular disease disproportionately affect African Americans in the United States(1). Cases like Mr. R suggest that we need a deeper understanding of why such a disparity exists between blacks and nonblacks even after controlling for socioeconomic factors(2). Cultural beliefs and the effects of a discontinuous and tortuous health care system may present potent obstacles toward providing treatment for hypertension in African Americans. My recommendation for Mr. R is to prescribe Exforge 5mg/160 mg of Amlodipine and Valsartan. The benefits of this particular drug are many. First, combining medications will reduce the number of pills taken thereby increasing adherence, which plays a major role in controlling hypertension(3). In studies among African Americans as well as the general population, people who took a combination drug for hypertension and hypercholesteremia were significantly more likely to adhere six months later than those who were given the same drugs separately(4, 5). The second reason is that by switching from an ACE inhibitor (Lisinopril) to an angiotension receptor blocker (Valsartan), Mr. R may experience a considerable reduction in side effects(6). For patients like Mr. R who are sensitive to thiazide diuretics, current research suggests that a CCB such as Amlodipine would be preferable to an ACE inhibitor because of the greater risk for stroke, combined CHD, combined CVD, end stage renal disease, and angioedema seen with ACE inhibitors in blacks(7).
I would encourage Mr. R's physician to utilize the full resources available to him as well as encourage his patient to mobilize family support. This includes using auxiliary staff to follow up with Mr. R in between appointments and to respond to questions or concerns that may arise. Visits should be scheduled monthly until his blood pressure is under control and then gradually increase the time between visits. Lastly, I would refer Mr. R to a dietician or nutritionist who will assist with healthy food options that fit his busy lifestyle. While Mr. R’s case is not unique in medicine, it is one that continues to challenge and perplex the best of practitioners.
References (1) Flack J, Ferdinand K, Nasser S. Epidemiology of hypertension and cardiovascular disease in African Americans. J Clin Hypertens. 2003;5(1 suppl 1):5-11.
(2) Kramer H, Han C, Post W, et al. Racial/Ethnic differences in hypertension and hypertension treatement and control in the multi-ethnic study of atherosclerosis (MESA). Amer J Hypertens. 2004;17:963-970.
(3) Chapman R, Benner J, Petrilla A, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147-1152.
(4) Flack J, Victor R, Watson K, et al. Improved attainment of blood pressure and cholesterol goals using single pill amlodipine/atorvastatin in African Americans: The CAPABLE trial. Mayo Clin Proc 2008;83:35-45.
(5) Nichol M, Patel B, Thiebaud P, et al. A single pill combining antihypertensive and statin therapies improves patient adherence compared to multidrug combinations: results from the Caduet Adherence Research Program and Education (CARPE)-PBM Adherence study [abstract]. J Clin Hyperten. 2006;8:456.
(6) Farsang, C., Fisher, J. Analogue-based drug discovery (Optimizing antihypertensive therapy by angiotensin receptor Blockers. Fischer, J., Ganellin, R., eds. Wiley-VCH 2006:157-167.
(7) Wright J, Dunn J, Cutler J, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA 2005;293:1595-1608.
No relevant financial interests.
Treatment of Hypertension In African American Patients Requires Patience and Understanding
Posted on March 18, 2009
Randell K Wexler, MD, MPH
The Ohio State University
Conflict of Interest: None Declared
Mr. R was approximately 30 years old when he was first diagnosed with hypertension. Although renovascular hypertension is less common in African Americans than Caucasians (1), based on reported history, Mr. R has had hypertension since he was approximately 30 years old. Therefore, given current ACC/AHA guidelines he should be screened for renovascular hypertension (2). Although Mr R is not currently taking lisinopril as a single agent (nifedipine has also been prescribed) the ethnic variation in blood pressure response to an angiotensin converting enzyme inhibitor is nullified when a thiazide diuretic has been added (3,4). As such, changing Mr. R's lisinopril to lisinopril-HCTZ would be an appropriate pharmacotherapeutic intervention.
Behavior modification is an important intervention in the treatment of all patients with hypertension. Mr. R should receive appropriate education and guidance on exercise, weight loss, moderation of alcohol consumption, the Dietary Approaches to Stop Hypertension (D.A.S.H.) eating plan, and dietary sodium reduction which is of particular importance as African Americans tend to be more salt sensitive than their Caucasian counterparts (4,5).
The D.A.S.H. eating plan, a diet rich in fruits and vegetables, high in low fat dairy products, low in total saturated fats, and high in potassium, magnesium, and calcium, has been shown to reduce blood pressure, and when combined with a low sodium diet, provides additional benefits in blood pressure reduction(6). The D.A.S.H. sodium trial demonstrated an even greater degree of blood pressure lowering benefit in African American patients (6,7).
A difficult, but important aspect of Mr. R's treatment is to address both his ambivalence towards treatment as well as his potential lack of trust in the health care system as evidenced by his comments: "Do I believe this doctor, or that doctor? Are they giving me medication? Is it just to throw them at me, hoping for a cure?" "You ask yourself, why are you taking the medication?" and "we are all supposed to be the same inside and out". Such concern regarding hypertension treatment is not uncommon in African American patients (8). It is important to address this concern in an empathetic and understanding manner. Patient experience is a crucial component of quality health care and directly influences outcomes (9). Improved communication with patients allows physicians to better understand what patients need and want. Improved communication, especially in the context of cultural norms, helps physicians to understand what matters to their patients, and can be reflected in physiologic parameters such as lipids and blood pressure (10).
The successful treatment of Mr. R's blood pressure can be accomplished, but requires a combination of pharmacotherpay, behavioral modification, and a better understanding of his personal needs and concerns.
1. Svetkey LP; Kadir S; Dunnick NR et al. Similar prevalence of renovascular hypertension in selected blacks and whites. Hypertension. 1991;5:678-83.
2. Hirsch, AT, Haskal, ZJ, Hertzer, NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113:e463-e654.
3. Douglas JG, Bakris GL, Epstein M, et al. Management of high blood pressure in African Americans: consensus statement of the hypertension in African Americans working group of the international society on hypertension in Blacks. Arch Intern Med. 2003;163:525-541.
4. Chobanian A, Bakris G, Black H, et al. Seventh Report of The Joint National Committee on Prevention, Detection, Evaluation, and Management of High Blood Pressure (JNC-7). Hypertension. 2003;42:1206-1252.
5. Schmidlin O. Forman A, Sebastian A, et al. Sodium selective salt sensitivity: Its occurrence in blacks. Hypertension. 2007;50:1085-1092.
6. Vollmer W, Sacks F, Ard J, Appel L, Bray G, Simons-Morton D, et al. Effects of diet and sodium intake on blood pressure: Subgroup analysis of the DASH- Sodium Trial. Annals of Internal Medicine. 2001;135:1019-1028.
7. Sacks F, Svetkey L, Vollmer W, Appel L, Bray G, Harsha D et al. Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. The New England Journal of Medicine. 2001;344:3-10.
8. Wexler RK, Elton T, Pleister A, Feldman DS. Barriers To Blood Pressure Control As Reported By African-American Patients. Journal of the National Medical Association. 2009. In Press.
9. Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling. 2009;74:295-301.
10. Wasson JH. Technical notes. When all things are not equal. J Ambulatory Care Management. 2006 ;29 :235-237.
Disclosure: Funding from Pfizer's Fellowship in Health Disparities.
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