Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population

Relationship of depressive symptoms to hypertension in a household survey in Harlem

OBJECTIVE

Two possible explanations for an hypothesized association between depression and hypertension were examined: (1) shared stress-related risk factors are associated with both depression and hypertension and (2) life-style factors associated with depression lead to hypertension.

METHODS

A predominantly black sample of 695 adults were interviewed in the Harlem Household Survey. Two measures of hypertension were used and compared-1) self-report and 2) elevated blood pressure (above 140/90 mm Hg)-on the basis of the mean of two blood pressure measures. Depressive symptoms were measured by use of a 24-item scale based on the Diagnostic Interview Schedule. Logistic regression models were used to test associations between hypertension and depressive symptoms, stressors, and life-style factors.

RESULTS

Depressive symptoms were associated with self-reported hypertension but not with elevated blood pressure. The association between self-reported hypertension and depressive symptoms was explained partly by shared stress-related risk factors but not by life-style factors. Several stressors and life-style variables were risk factors for elevated blood pressure independently of depressive symptoms. The findings are consistent with studies that have measured hypertension variously by either self-report or blood pressure. Possible explanations were explored (labeling and help-seeking) but were not supported by the data.

CONCLUSIONS

An association was found between self-reported hypertension and depressive symptoms, which was explained partly by shared stress-related risk factors. Elevated blood pressure was associated with stressors and life-style factors but not with depressive symptomatology. Research on illness representations and cultural dimensions of health suggest avenues for further investigation.

Inequalities in the treatment and control of hypertension: age, social isolation and lifestyle are more important than economic circumstances

OBJECTIVE

To describe socio-economic variations in the treatment and control of hypertension in England.

DESIGN

Population based survey.

SUBJECTS

Hypertensives numbering 5019, identified in the Health Survey for England for 1993-1994.

OUTCOME

Drug treatment and control of hypertension.

RESULTS

A total of 1119/2208 (50.7%) hypertensive men, and 1620/2811 (57.6%) hypertensive women, were receiving anti-hypertensive medication. For men, the likelihood of receiving treatment increased with age, widowerhood or divorce, a family history of heart disease, low social support and increasing weight, but was decreased for men who lived alone, owned their own house, smoked or drank heavily. For women, obesity, a family history of heart disease and low social support increased their chance of treatment. A total of 534/1119 (47.7%) men, and 816/1620 (50.4%) of women on treatment, had their hypertension controlled to below 160/90 mmHg. Lack of control was more commonly due to isolated systolic hypertension rather than diastolic hypertension. Increasing age and smoking were associated with poorer control. Men who lived alone and had low social support were less likely to have their hypertension controlled, while those with a family history of heart disease were more likely to be controlled.

DISCUSSION

We found little evidence for socio-economic or geographic differences in the management of hypertension. Variations in treatment rates can be explained by variations in use of primary care and opportunistic screening. Control was poorest among older people who are at the highest risk of cardiovascular events. Socially isolated men and smokers were less likely to be treated or controlled, and need to be targeted by future programmes to detect and treat hypertension.

Is rheumatoid arthritis care more costly when provided by rheumatologists compared with generalists?

OBJECTIVE

Controversy surrounds the cost-effectiveness of rheumatologist care compared with generalist care for patients with rheumatoid arthritis (RA). Rheumatologists can provide 2 distinct types of care for RA patients: primary care and specialist care. We sought to examine the relationship between cost and type of care in a population-based cohort of patients with RA.

METHODS

Data regarding specialty of care and use of health services (i.e., total direct medical costs, surgeries, radiographs, laboratory tests, hospital days) were collected from a community sample of 249 patients with RA (defined using the 1987 American College of Rheumatology diagnostic criteria) among Rochester, Minnesota residents > or =35 years of age. In a randomly selected subset of 99 of these RA patients, detailed information on all physician encounters was collected and categorized according to whether or not the care received constituted "primary care" according to the Institute of Medicine definition. Using these data, we evaluated the influence of type of care as well as specialty of provider on utilization. For these analyses, total direct costs included all inpatient and outpatient health care costs incurred by all local providers (excluding outpatient prescription drugs).

RESULTS

The 249 patients with RA (mean age 64 years, 75% women) were followed up for a median of 5.4 years, while the subset of 99 RA patients (mean age 64 years, 77% women) were followed up for a median of 4.7 years. The overall median direct medical costs per person per year were $2,749 and $2,929 for the total cohort and for the subset of 99 patients, respectively. Generalized linear regression analyses (considering all visits of the 249 RA patients) revealed that after adjusting for demographics and disease characteristics, rheumatologist care (compared with nonrheumatologist care) was not associated with higher total direct medical costs (P = 0.85) or more hospital days (P = 0.35), but was associated with slightly more radiographs (P = 0.037) and significantly more laboratory tests (P < 0.0001). When considering only primary care, such care by rheumatologists was, again, not associated with higher total direct medical costs (P = 0.11) or more hospital days (P = 0.69) or more laboratory tests (P = 0.54), but was associated with slightly more radiographs (P = 0.035).

CONCLUSION

Rheumatologist care is not more costly than generalist care for patients with RA. Important differences (especially in the use of laboratory tests) become apparent when the type of care provided as well as the specialty of the provider are considered in the analyses.

Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care

Reducing and eliminating health status disparities by providing access to appropriate health care is a goal of the nation's health care delivery system. This article reviews the literature that demonstrates a relationship between access to appropriate health care and reductions in health status disparities. Using comprehensive site-level data, patient surveys, and medical record reviews, the authors present an evaluation of the ability of health centers to provide such access. Access to a regular and usual source of care alone can mitigate health status disparities. The safety net health center network has reduced racial/ethnic, income, and insurance status disparities in access to primary care and important preventive screening procedures. In addition, the network has reduced low birth weight disparities for African American infants. Evidence suggests that health centers are successful in reducing and eliminating health access disparities by establishing themselves as their patients' usual and regular source of care. This relationship portends well for reducing and eliminating health status disparities.

Antihypertensive medication use in Hispanic adults: a comparison with black adults and white adults

BACKGROUND

Variations in awareness, treatment, and control of hypertension among different racial/ethnic groups have been widely reported. It is unclear whether these differences are explained fully by differences in socioeconomic status, insurance coverage, health status, and health behaviors, or whether these differences indicate that racial/ethnic subgroups have unique barriers to hypertension control.

OBJECTIVES

Determine whether there are significant differences between racial/ethnic groups in medication use for hypertension after adjusting for potentially confounding variables.

RESEARCH DESIGN

Cross-sectional analysis of the 1992 Health and Retirement Study.

SUBJECTS

2450 non-Hispanic white, 939 non-Hispanic black, and 345 Hispanic participants, ages 51 to 61, reporting a history of hypertension.

MEASURES

Self-reported current antihypertensive medication use. We used logistic regression to adjust for demographics, socioeconomic status, health status, insurance, and health risk behaviors.

RESULTS

63.6% of white adults, 72.6% of black adults, and 52.5% of Hispanic adults reported current medication use to control hypertension (P <0.001 across all three groups). In stratified analysis, the lower rate of use for Hispanic adults was consistent regardless of gender, insurance coverage, or health status. After controlling for all variables, the adjusted prevalence for Hispanic adults was 50.8% and 73.3% for black adults.

CONCLUSIONS

The differences in antihypertensive medication use between white adults, black adults, and Hispanic adults, particularly the markedly lower rates among Hispanic adults, are not explained by differences in demographics, socioeconomic status, health insurance coverage, health status, or health risk behaviors. Alternative explanations for these results and areas for future research and intervention are explored.

Hypertensive emergencies

In summary, patients presenting with a true hypertensive emergency should be diagnosed quickly and promptly started on effective parenteral therapy (typically nitroprusside 0.5 microgram/kg/min or fenoldopam 0.1 microgram/kg/min) in an intensive care unit. Blood pressure should be reduced about 25% gradually over 2 to 3 hours. Oral antihypertensive therapy (often with an immediate-release calcium antagonist) can be instituted after 6 to 12 hours of parenteral therapy, and consideration should be given to secondary causes of hypertension after transfer out of the intensive care unit. Because of advances in antihypertensive therapy and management, "malignant hypertension" should be truly malignant no longer.

O perfil de um grupo de pessoas hipertensas de acordo com conhecimento e gravidade da doença

Foram entrevistados 205 hipertensos em tratamento ambulatorial para avaliar o papel do perfil bio-social no conhecimento e grau de gravidade da doença. As características da população foram: 72% mulheres, 63% brancos, 78% com mais de 40 anos, 60% casados, 68% com baixa escolaridade, 41% com renda de 1 a 3 salários, 75% com peso elevado, 76% não fumantes, 89% sem atividade física regular, e das mulheres 48% já tinham usado hormônios anticoncepcionais. A análise evidenciou que a ausência de conhecimento se associou com sexo masculino, idade entre 20 e 40 anos, viúvo, não branco e peso normal. Pressão arterial mais elevada (diastólica> 110 mm Hg) se associou com mais de 60 anos, não casado, acima do peso, baixa escolaridade, baixa renda, com mais de 5 anos de hipertensão e já ter feito tratamento anterior.

Primary care, income inequality, and self-rated health in the United States: a mixed-level analysis

Using the 1996 Community Tracking Study household survey, the authors examined whether income inequality and primary care, measured at the state level, predict individual morbidity as measured by self-rated health status, while adjusting for potentially confounding individual variables. Their results indicate that distributions of income and primary care within states are significantly associated with individuals' self-rated health; that there is a gradient effect of income inequality on self-rated health; and that individuals living in states with a higher ratio of primary care physician to population are more likely to report good health than those living in states with a lower such ratio. From a policy perspective, improvement in individuals' health is likely to require a multi-pronged approach that addresses individual socioeconomic determinants of health, social and economic policies that affect income distribution, and a strengthening of the primary care aspects of health services.

Elevated mortality rates from circulatory disease in African American men and women of Los Angeles County, California--a possible genetic susceptibility?

OBJECTIVE

Reports of higher mortality in African Americans have often focused on socioeconomic differences. Such differences do not explain the excess mortality in African Americans compared with Hispanics in Los Angeles County. We suggest the existence of genetic factors to explain at least some of the differences in mortality risk.

METHODS

We compared the mortality rates from circulatory diseases in African American and Hispanic adults of Los Angeles County for 1988 to 1992 with the frequency of the angiotensin-converting enzyme (ACE) genotype.

RESULTS

African American adults 45 to 74 years old had a 2-fold higher overall mortality rate than Hispanics. The largest differences were seen for hypertensive disease and cardiomyopathy in men; the most striking differences were seen in the youngest age group. Rates were lower in women than in men, but African American women also showed substantial excess compared with Hispanics. ACE genotype also showed a significant difference between the Hispanic and African American population; the latter had a significantly higher prevalence of the DD genotype, which is associated with a higher level of circulating enzyme, and lower prevalence of the II genotype, which is associated with a lower enzyme level.

CONCLUSION

African American adults aged 45 to 74 years in Los Angeles County have a substantial excess mortality from hypertensive diseases compared with a similar Hispanic population. The frequency of the ACE DD genotype was higher in African Americans than in Hispanics. These studies may indirectly support the possibility of a genetic contribution to the excess hypertensive disease mortality in African Americans.

Fenoldopam, a dopamine agonist, for hypertensive emergency: a multicenter randomized trial. Fenoldopam Study Group

Despite successful therapies for chronic hypertension, hospital admissions for hypertensive emergency more than tripled between 1983 and 1992.

OBJECTIVE

To examine the safety and efficacy of fenoldopam, the first antihypertensive with selective and specific action on vascular dopamine (DA1) receptors, in a clinical trial involving emergency department patients with true hypertensive emergencies.

METHODS

Patients with a sustained diastolic blood pressure (DBP) of > or =120 mm Hg and evidence of target organ compromise were randomized in a double-blinded manner to one of four fixed doses of intravenous fenoldopam (0.01, 0.03, 0.1, or 0.3 microg/kg/min) for 24 hours. The primary endpoint was the magnitude of DBP reduction in each of the three higher-dose groups after four hours of fenoldopam treatment compared with the lowest-dose group.

RESULTS

One hundred seven participants from 21 centers were enrolled, and 94 patients received fenoldopam. Evidence of acute target-organ damage included new renal dysfunction or hematuria (50%), acute congestive heart failure or myocardial ischemia (48%), and papilledema or grade III-IV hypertensive retinopathy (34%). The DBP decreased in a dose-dependent fashion, with significant differences between the 0.1- and 0.3-microg/kg/min groups compared with the lowest-dose group. Treatment was well tolerated, and there were no deaths or serious adverse events during follow-up, up to 48 hours. All patients were successfully transitioned to oral or transdermal antihypertensives with maintenance of blood pressure control.

CONCLUSIONS

Fenoldopam safely and effectively lowers blood pressure in a dose-dependent manner in patients with hypertensive emergencies. Observations supporting potential risk factors for hypertensive emergency are discussed.

Diagnosis and management of hypertensive emergencies

It has been estimated that approximately 600,000 to 800,000 Americans will develop a hypertensive crisis (Calhoun and Oparil, 1990). Although such numbers represent only about 1% of the estimated 60 million Americans with hypertension, hypertensive crisis often constitutes a major medical emergency, necessitating a focused, assertive, and reasoned therapeutic intervention. When such patients are seen in the emergency department or in a physician's office with a critical elevation in blood pressure (BP), appropriate and efficacious management is essential to avoid catastrophic injury to vital target organs, including the central nervous system, the heart, and the kidneys. Delays in initiating effective therapy or, equally important, overzealous therapy leading to a too-rapid reduction in BP can produce severe complications involving these target organs. This article reviews the spectrum of clinical syndromes that comprise hypertensive emergencies, highlighting 2 to illustrate the complexities of clinical presentation and management. The newly advocated treatment guidelines based on the category of acute severe hypertension (including asymptomatic hypertensive urgencies) are also considered, as are therapeutic strategies utilizing currently available antihypertensive agents.

Ethnic variation in attitudes toward hypertension in adults ages 75 and older

BACKGROUND

Although critical to the management of hypertension, the attitudes of geriatric patients and possible ethnic group differences in attitudes concerning the disease are poorly understood.

METHODS

Data from a 1995-1996 population-based survey of 507 Hispanic American, African American, and non-Hispanic white adults ages 75 and older were used to assess ethnic differences in perceptions regarding the cause, prevention, and treatment of hypertension, as well as associations between perceptions and use of preventive health services.

RESULTS

African Americans were more likely to attribute hypertension to health behaviors and stress. In contrast, Hispanic Americans were more likely consider the disease a normal part of aging, whereas non-Hispanic whites were more likely to attribute hypertension to heredity or mechanistic causes. Non-Hispanic whites were less likely to perceive hypertension as preventable, whereas Hispanic Americans were less likely to feel that hypertension was treatable. The odds of having a primary care physician, blood pressure checked, or glaucoma checked were lower among older African Americans and Hispanic Americans than older non-Hispanic whites. The odds of having had a recent physical and of emergency room use were higher among African Americans and lower among Hispanic Americans, in relation to non-Hispanic whites.

CONCLUSION

Ethnic differences regarding hypertension were clearly evident in this sample of older adults. In addition, attitudes regarding the cause and treatment of hypertension were found to be associated with both the use and the underuse of preventive health services in all three ethnic groups.

Hypertension in multicultural and minority populations: linking communication to compliance

Cardiovascular disease disproportionately affects minority populations, in part because of multiple sociocultural factors that directly affect compliance with antihypertensive medication regimens. Compliance is a complex health behavior determined by a variety of socioeconomic, individual, familial, and cultural factors. In general, provider-patient communication has been shown to be linked to patient satisfaction, compliance, and health outcomes. In multicultural and minority populations, the issue of communication may play an even larger role because of linguistic and contextual barriers that preclude effective provider-patient communication. These factors may further limit compliance. The ESFT Model for Communication and Compliance is an individual, patient-based communication tool that allows for screening for barriers to compliance and illustrates strategies for interventions that might improve outcomes for all hypertensive patients.

Home blood pressure teletransmission for better diagnosis and treatment

The rate of control of high blood pressure is disappointing, and noncompliance is one factor that contributes to this. The reasons for poor compliance are complex and include factors related to the patient, the healthcare provider, and the medical system. In general, the lack of regular communication between the patient and the physician, as occurs in the traditional model of clinic-based care, predicts a low rate of blood pressure control. In addition, clinic-based blood pressure rates are notoriously unreliable. A solution to this dilemma is teletransmission of self- measured blood pressure readings, which offers the dual advantages of more reliable measurements, and the establishment of regular telephone communication between the patient and the healthcare provider. Preliminary evidence with this type of system suggests that blood pressure control can be improved substantially.

Undertreatment of hypertension in community-dwelling older adults: a drug-utilization study in Dicomano, Italy

OBJECTIVE

To define: (1) the prevalence of and (2) factors associated with undertreatment of hypertension in older persons; and (3) the prevalence of specific drug regimens and reasons for their selection.

PARTICIPANTS

Cross-sectional survey of persons aged > or =65 years living in Dicomano, Italy.

MAIN OUTCOME MEASURES

Prevalence of untreated and uncontrolled hypertension, both defined on the basis of two blood pressure (BP) cut-off points (> or =140/90 and > or =160/90 mm Hg) and of the presence of pharmacological treatment Predictors of undertreatment were analysed for the higher BP cut-off only.

RESULTS

Five hundred of 692 (72.3%) and 380/692 (54.9%) participants met the 140/90 and the 160/90 mm Hg BP criterion, respectively. Of the latter, 162 (42.6%) were untreated, 119 (31.3%) had uncontrolled and 99 (26.1%) controlled hypertension. Women [odds ratio (OR), 0.4; 95% confidence interval (CI), 0.2-0.7], participants with coronary artery disease (CAD) (OR, 0.2; 95% CI, 0.1-0.6), stroke (OR, 0.3; 95% CI, 0.1-0.7), and preserved cognitive status (Mini Mental State Examination score >21: 0.3; 95% CI, 0.2-0.7) were more frequently treated. Uncontrolled hypertension was less likely in women (OR, 0.5; 95% CI, 0.3-1.0) and CAD patients (OR, 0.3; 95% CI, 0.1-0.7). Angiotensin converting enzyme (ACE)-inhibitors (55%), calcium (Ca)-antagonists (31%) and diuretics (20%) were the drugs most commonly prescribed. ACE-inhibitors were preferred, and diuretics rarely used, in diabetic subjects. Ca-antagonists were used mostly in CAD participants.

CONCLUSIONS

Hypertension is undertreated in the majority of noninstitutionalized older adults, especially in men with impaired cognition and no vascular disease. Drug regimens are mostly based on ACE-inhibitors and Ca-antagonists, as a result of associated clinical conditions, requiring individualized treatment.

The prevalence and effects of hunger in an emergency department patient population

OBJECTIVES

Little is known about the prevalence and health effects of hunger among ED patients. The objectives of this study were to determine the prevalence of hunger among patients in a large urban ED and to examine whether it has adverse health effects.

METHODS

A survey about hunger, choices between buying food and buying medicine, and adverse health outcomes related to food adequacy over the preceding 12 months was administered to a convenience sample of adult non-critically ill ED patients from afternoon and evening shifts. The study was conducted in the ED of Hennepin County Medical Center in Minneapolis, Minnesota.

RESULTS

Of the 302 eligible patients who were asked to participate, 297 (98%) agreed. Eighteen percent reported not having enough to eat at least once in the preceding 12 months: 14% reported that they had "gotten sick" as a result of not being able to afford their medicine, resulting in an ED visit or hospital admission 50% of the time. Predictors of making choices about buying food vs medicine include having a chronic health condition, lack of private health insurance, having a reduction in food stamps, having an annual income less than $10,000, and lack of alcohol use. By patient report, a reduction in food stamps was a predictor of ED visits and hospitalizations as a result of making choices about buying food over medicine.

CONCLUSION

The ED patients in this urban setting have high rates of hunger and many must make choices between buying food and medicine, which patients report results in otherwise preventable ED visits and hospitalization. Loss or reduction of food stamps is associated with increased hunger and increased perceived adverse health outcomes as a result of not being able to afford medicine.

The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit

OBJECTIVE

To assess the influence of patient access to a private attending physician on the withdrawal of life-sustaining therapies in a medical intensive care unit (ICU).

DESIGN

Prospective cohort study.

SETTING

A university-affiliated teaching hospital.

PATIENTS

A total of 501 consecutive patients admitted to the medical ICU during a 5-month period.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Among patients dying in the medical ICU, those without a private attending physician (n = 26) were statistically more likely to undergo the active withdrawal of life-sustaining therapies than patients with a private attending physician (n = 87) (80.8% vs. 29.9%; relative risk = 2.70; 95% confidence interval = 1.86-3.92; p < .001). Despite having similar predicted mortality rates by Acute Physiology and Chronic Health Evaluation II score (60.5% +/- 27.0% vs. 66.1% +/- 21.3%; p = .280), patients dying in the medical ICU without a private attending physician had statistically shorter hospital and ICU lengths of stay, a shorter duration of mechanical ventilation, and fewer total hospital costs and charges compared with patients with access to a private attending physician. Multiple logistic regression analysis, controlling for severity of illness, demographic characteristics, and patient diagnoses, demonstrated that lack of access to a private attending physician (adjusted odds ratio = 23.10; 95% confidence interval = 9.10-58.57; p < .001) and the presence of a do-not-resuscitate order while in the ICU (adjusted odds ratio = 7.33; 95% confidence interval = 3.69-14.54; p = .004) were the only variables independently associated with the withdrawal of life-sustaining therapies before death.

CONCLUSIONS

Patients dying in a medical ICU setting without access to a private attending physician are more likely to undergo the active withdrawal of life-sustaining therapies before death than patients with a private attending physician. Health care providers should be aware of possible variations in the practice of withdrawal of life-sustaining therapies in their ICUs based on this patient characteristic.

Contemporary management of refractory hypertension

Refractory or resistant hypertension is conventionally defined as systolic or diastolic blood pressure that remains uncontrolled despite sustained therapy with at least three different classes of antihypertensive agents. Refractory hypertension is estimated to affect less than 5% of the general population with hypertension; however, its prevalence increases with increasing severity of blood pressure. Patients presenting with refractory hypertension usually have progressed from mild, to moderate, to severe hypertension because of lack of or inadequate treatment. Other common contributing factors include obesity, medical nonadherence, suboptimal medical regimens, excessive dietary salt ingestion, secondary forms of hypertension, sleep apnea, and ingestion of substances that interfere with treatment. Combination therapy that includes appropriate doses of a diuretic is recommended for treatment of refractory hypertension. Use of fixed-dose combinations enhances compliance through cost savings, more convenient dosing, and reduced pill burdens.

Inadequate management of blood pressure in a hypertensive population

BACKGROUND

Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care.

METHODS

We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure.

RESULTS

Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment.

CONCLUSIONS

In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.

[Compliance in antihypertensive therapy: analyses in scientific articles]

The aim of this study was to evaluate scientific articles published between 1991-1995, in order to identify the compliance in antihypertensive therapy, One hundred seven scientific articles were evaluated. The results showed that 68% were related to patient, 63% to pharmacological treatment, 62% general, 39% non pharmacological treatment, 34% organizational factors, and 8% related to disease. Compliance with antihypertensive therapy was the major challenge of hypertension management and to know how this aspect was focalized in scientific articles possible reduce non compliance in hypertension.

Health insurance status and cardiovascular disease risk factors among 50-64-year-old U.S. women: findings from the Third National Health and Nutrition Examination Survey

To examine the cardiovascular disease risk factors profile and use of preventive health services for cardiovascular disease among uninsured women aged 50-64 years, we studied data from the National Health and Nutrition Examination Survey III (NHANES III), conducted from 1988 to 1994. Insured women (n = 1308) and uninsured women (n = 303) had similar levels of blood pressure and lipids, but uninsured women were more likely to be current smokers, sedentary, and overweight and to consume less fiber, vitamin C, folate, calcium, and potassium than insured women. Compared with insured women, uninsured women were less likely to have had their blood pressure checked during the previous 6 months, to have had their cholesterol level checked, and to be aware of hypercholesterolemia. Insured women (24.9%) were three times more likely to use estrogen replacement therapy than uninsured women (7.9%). NHANES III data suggest that women without health insurance have a worse cardiovascular disease risk factor profile and use healthcare services less frequently than women with health insurance.

Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE

To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use.

DESIGN

Cohort observational study.

SETTING

A public hospital in Atlanta, Georgia.

PATIENTS

Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years.

MEASUREMENTS AND MAIN RESULTS

Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse.

CONCLUSIONS

All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.

Mortality in Hartford, Connecticut: a comparison with the South Bronx, New York

Very high mortality rates have been reported in large inner-city areas such as the South Bronx and Harlem in New York City, but also may occur in smaller US urban areas. Using published death rates for the South Bronx as the standard, the standardized mortality ratio was slightly lower than 1.00 for Hartford, Connecticut (population 139,739 in 1990), but more than 1.00 for three impoverished Hartford census tracts that contained public housing projects. Compared with the South Bronx, death rates in Hartford were lower for human immunodeficiency virus (HIV), injury-homicide, and alcohol-drugs, but higher for hypertension-stroke (in all three tracts) and cancer (in two of the three tracts). Variations in patterns of causes of death among impoverished US urban areas have implications for planning epidemiologic studies and targeting interventions.

Social and economic factors as obstacles to blood pressure control

Further improvement in blood pressure control at the population level will result from dealing with hard-to-solve problems, such as access to care, long-term management of a chronic disease, and societal influences on lifestyle. Additional knowledge and experimental data are needed, reinforced by clear public health choices in this direction.

Monitoring the consequences of uninsurance: a review of methodologies

The proportion of the United States population without health insurance continues to grow. How will this affect the health of the nation? Prior research suggests that the uninsured are at risk for poor health outcomes. They use fewer medical services and have higher mortality rates than do insured persons. The episodic nature of uninsurance and its prevalence among disadvantaged groups makes it difficult to ascertain the health effects of uninsurance. The goal of this review is to assist researchers and policy makers in choosing methodologies to assess the effects of uninsurance. It provides a compendium of methods that have been used to examine the health consequences of uninsurance, the populations in which these methods have been used, and the strengths and weaknesses of different approaches. The review highlights the need for more longitudinal studies that focus on community-based samples of the uninsured.

Hypertensive vascular disease as a cause of death in blacks versus whites: autopsy findings in 587 adults

Cardiovascular disease is the major cause of excess mortality among urban US blacks, but autopsy data comparing black-white differences in underlying pathological causes of cardiovascular death are lacking. We reviewed all 720 adult cases autopsied in 1991 in the New York City Medical Examiner's Office in which the coded cause of death was cardiovascular disease (International Classification of Diseases, 9th Revision, codes 391, 393 to 398, 401 to 404, 410, 411, 414 to 417, 420 to 438, and 440 to 444). After exclusion of 133 cases because race was missing or coded as other than black or white, gender was not coded, or there was an unusual circumstances of death or extreme obesity, 587 cases were available for analysis. There were 314 black and 273 white subjects. Black women were younger than white women at time of death (mean age, 54.7 versus 61.5 years; P<.001), whereas black and white men did not differ in mean age at death. Hypertensive vascular disease was the autopsy cause of death in 42% of blacks compared with 23% of whites (P<.001). Conversely, atherosclerotic heart disease was the autopsy cause of death in 64% of white subjects but only 38% of blacks. These patterns were consistent in both sexes and after adjustment for age. Hypertensive vascular disease was far more common than atherosclerotic heart disease as the cause of death at autopsy among blacks compared with whites in New York City, whereas atherosclerotic heart disease was more common in whites. These findings suggest that ineffective control of hypertension is a major factor contributing to excess cardiovascular mortality among urban blacks.

Undertreatment of hypertension in older Mexican Americans

OBJECTIVE

To identify the prevalence of hypertension and factors associated with nontreatment and poor control of hypertension in Mexican Americans aged 65 years and older.

DESIGN

A population-based survey of older Mexican Americans conducted in 1993-1994.

SETTING

Subjects residing in five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California.

PARTICIPANTS

An area probability sample of 3050 noninstitutionalized Mexican American men and women aged 65 and older took part in a 90-minute in-home interview, which included review of all medications taken and two sitting blood pressure measurements.

OUTCOME MEASURES

Measured were previous diagnoses of hypertension, current medication for hypertension, and current blood pressure

RESULTS

Sixty-one percent of older Mexican-Americans were hypertensive, and 51% of those with hypertension were taking antihypertensive medications. Only 25% of hypertensive subjects (18% of males and 30% of females) were in good blood pressure control (i.e., systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg). In multivariate analyses, factors associated with increased likelihood of treatment included female gender (OR = 1.9), history of heart disease (OR = 2.4), possessing a regular source of health care (OR = 2.7), and having seen a physician two or more times in the previous year (OR = 3.8). These were also independent predictors of good blood pressure control.

CONCLUSION

Nontreatment of hypertension is still a major public health concern in older Mexican Americans. We estimate that adequate blood pressure control in this population would prevent approximately 30,000 adverse cardiovascular events over 10 years, affecting approximately 6% of the entire Mexican American older population.

Insurance or a regular physician: which is the most powerful predictor of health care?

OBJECTIVES

This study compared the relative effects on access to health care of relationship with a regular physician and insurance status.

METHODS

The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5 academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year.

RESULTS

After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit [OR] = 4.5%, 95% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician.

CONCLUSIONS

Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care.

Blood pressure measurement and antihypertensive treatment in a low-income African-American population

OBJECTIVES

The purpose of this study was to describe blood pressure measurement and hypertension treatment in an inner-city African-American community.

METHODS

A random-digit dialing telephone survey of adults more than 18 years of age was carried out in 12 predominantly African-American zip code areas in Houston, Texas.

RESULTS

More than 90% of subjects reported a blood pressure measurement within the past 2 years, and 87% of known hypertensives reported current medication use.

CONCLUSIONS

Further improvements in hypertension control among African Americans in this country are likely to depend primarily on changes in diagnosis and management practices of health care providers and on maintaining primary care access for all socioeconomic groups.

Use of the ED as a regular source of care: associated factors beyond lack of health insurance

STUDY OBJECTIVE

To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care.

METHODS

We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED.

RESULTS

Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than $30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a $25 copayment were in effect.

CONCLUSION

Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

Controlling tuberculosis in an urban emergency department: a rapid decision instrument for patient isolation

OBJECTIVES

This study examined whether data routinely available in emergency departments could be used to improve isolation decisions for tuberculosis patients.

METHODS

In a large emergency department in New York City, we compared the exposure histories of tuberculosis culture-positive and culture-negative patients and used these data to develop a rapid decision instrument to predict culture-positive tuberculosis. The screen used only data that are routinely available to emergency physicians.

RESULTS

The method had high sensitivity (.96) and moderate specificity (.54).

CONCLUSIONS

The method is easily adaptable for a broad range of settings and illustrates the potential benefits of applying basic epidemiologic methods in a clinical setting.

Cigarette smoking and severe uncontrolled hypertension in inner-city African Americans

PURPOSE

Although over the past 2 decades great strides have been made in increasing the awareness, detection, and treatment of hypertension (HTN), actual control of blood pressure is far from optimal. We hypothesized that current cigarette smoking, by acting as a marker for poor health related behavioral patterns, would be significantly associated with uncontrolled blood pressure (BP).

PATIENTS AND METHODS

Over a 3-month period in 1994, all patients who presented to a public hospital medical walk-in clinic were screened, and had their BP measured if they had been prescribed BP medication within 1 year and were aware of their diagnosis of HTN. Patients were defined as controlled hypertensives if both systolic BP and diastolic BP were < or = 140/90 mm Hg. Severe uncontrolled hypertensives were those with either systolic BP > or = 180 mm Hg or diastolic BP was > or = 110 mm Hg.

RESULTS

Of the 221 patients meeting all inclusion criteria (1 refusal), 86 had uncontrolled HTN (mean BP = 192/106 mm Hg), 130 were controlled (mean BP = 130/80 mm Hg), and 5 were not African American. Severe uncontrolled hypertensives, when compared with controlled hypertensives, were significantly more likely to be current (versus former) smokers (odds ratio [OR] = 4.17; 95% confidence interval [CI]: 1.8 to 9.5), and be less compliant with medications (OR = 2.33; 95% CI: 1.3 to 4.1). Age, gender, alcohol use, marital status, education, and comorbidity were not associated with HTN control. In an adjusted logistic regression model, both current and never-smokers when compared with former smokers were significantly more likely to have uncontrolled HTN in compliant patients (OR = 14.4; 95% CI: 3.3 to 63.3 and OR = 5.7; 95% CI: 1.5 to 21.7, respectively). In noncompliant patients, smoking status was not associated with uncontrolled HTN.

CONCLUSION

In disadvantaged African-American patients who report good medication compliance, former smoking status is strongly associated with HTN control. Physicians may need to be especially vigilant of BP control in patients who smoke.

Observations on sleeping position and essential hypertension

A hypertensive black male, at risk for episodic attacks of pseudo-malignant hypertension and self-induced atrial fibrillation, seeks to discover possible clues to the pathogeneses of these strange disorders through self-study and concludes they might be associated with impaired oxygen intake, secondary to sleeping position in bed.

Awareness, treatment and control of hyperlipidaemia, hypertension and diabetes mellitus in a selected population of southern Italy

The purpose of the present study was to assess the degree of awareness, treatment and control of hyperlipidaemia compared with hypertension and diabetes mellitus in a selected population of southern Italy. All participants to a cardiovascular disease prevention campaign examined between April 1994 and July 1995 were screened for hyperlipidaemia, hypertension and diabetes mellitus. Subjects received also ECG, echo-Doppler of carotid arteries and filled in a questionnaire concerning personal and familial cardiovascular diseases, smoking habit and drug consumption. Of the 742 participants, 327 were found to have hypertension, 73 to have diabetes mellitus, 287 to have mild hyperlipidaemia and 322 to have moderate-severe hyperlipidaemia. Among hypertensive subjects, 60.2% were aware of their condition, 53.5% were treated and 15.6% had their blood pressure controlled at the recommended level (< 140/90 mmHg). Among diabetic subjects, 76.7% were aware, 64.4% treated and 19.2% reached fasting blood glucose level of less than 7.77 mmol/l (140 mg/dl). Only 24.0% of subjects with mild hyperlipidaemia were aware of their condition. Of the subjects found to have moderate-severe hyperlipidaemia, 64.9% were aware, 32.3% were treated and 9.0% had plasma cholesterol and triglycerides concentration of less than 6.45 and 5.65 mmol/l (250 and 500 mg/dl), respectively (cutoffs chosen to separate mild from moderate-severe hyperlipidaemia). These results show that mild hyperlipidaemia is almost neglected whereas awareness of moderave-severe hyperlipidaemia is quite widespread and comparable to that of hypertension and diabetes mellitus. Prevalence of treatment and control of moderate-severe hyperlipidaemia is, however, much lower than that of hypertension and diabetes.

Factors contributing to the hospitalization of patients with congestive heart failure

OBJECTIVES

This study identifies acute precipitants of hospitalization and evaluates utilization of angiotension-converting enzyme inhibitors in patients admitted with congestive heart failure.

METHODS

Cross-sectional chart-review study was done of 435 patients admitted nonelectively from February 1993 to February 1994 to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure.

RESULTS

The most common identifiable abnormalities associated with clinical deterioration prior to admission were acute anginal chest pain (33%), respiratory infection (16%), uncontrolled hypertension with initial systolic blood pressure > or = 180 mm Hg (15%), atrial arrhythmia with heart rate > or = 120 (8%), and noncompliance with medications (15%) or diet (6%); in 34% of patients, no clear cause could be identified. After exclusion of those who were already on a different vasodilator or who had relative contraindications, 18 (32%) of the patients with ejection fractions < or = 0.35 measured prior to admission were not taking an angiotensin-converting enzyme inhibitor on presentation to the hospital.

CONCLUSIONS

Interventions to improve compliance, the control of hypertension, and the appropriate use of angiotensin-converting enzyme inhibitors may prevent many hospitalizations of heart-failure patients.

History of hypertension in patients treated for end-stage renal disease

OBJECTIVES

To describe patterns of hypertension history in patients with various types of end-stage renal disease (ESRD) and in persons with normal kidney function; and to identify risk factors for the diagnosis 'hypertensive ESRD'.

DESIGN

A case-control study.

SETTING

Population-based.

PARTICIPANTS

Patients with ESRD due to hypertension (n = 214), diabetes (n = 239), other specified causes (n = 181), unknown causes (n = 82) and control subjects drawn from the general population (n = 361).

MAIN OUTCOME MEASURES

Participants' history of hypertension.

RESULTS

The prevalence of hypertension was 90% in ESRD patients and 27% in controls. Only 6% of patients with hypertensive ESRD had a history of malignant hypertension. Patients with hypertensive ESRD were more likely to have been hospitalized because of hypertension (36%) than were other ESRD patients (18%) or controls (5%). ESRD of any cause was more strongly associated with hypertension of > or = 25 years duration (odds ratio 51.0, compared with normal blood pressure) than it was with hypertension of shorter duration (15-25 years: odds ratio 31.8, 5-15 years: odds ratio 16.0, < 5 years: odds ratio 21.2). Among patients who had both hypertension and ESRD, the diagnosis of 'hypertensive ESRD' was associated independently with a long duration of hypertension, greater severity of hypertension, the absence of diabetes, black race, and limited education.

CONCLUSIONS

Hypertension is common among patients with ESRD. The risk of ESRD from any cause increases progressively with the duration of hypertension, and with indicators of severe hypertension. This result supports the hypothesis that nonmalignant hypertension of long duration may cause renal insufficiency. The criteria used to diagnose hypertensive ESRD are consistent with pathophysiologic and epidemiologic evidence.

Using the hospital emergency department as a regular source of care

OBJECTIVES

to evaluate the proportion of the patients who report the emergency department as their regular source of care and to describe the demographics and health status of this population.

DESIGN

A cross-sectional study was performed at the emergency department in two hospitals (around 12,000 visits per year each). Subjects were interviewed using a standardised questionnaire, before and after the emergency department visit.

SETTING

The medical emergency department of two university hospitals, one in Paris and one in Besançon (France).

SUBJECTS

Each patient aged 15 and more attending the emergency department for a visit during forty randomly selected periods of 12 hours was included.

MAIN OUTCOME MEASURES

Self report of the utilization of the emergency department as a regular source of care.

RESULTS

Fourteen percent of the patients cited the emergency department as a regular source of care in Paris, and 3.3% in Besançon. In Paris, young age, being born outside of France, homelessness or precarious housing, lack of social support in case of illness and lack of health insurance were independently associated with this health care utilization behavior.

CONCLUSIONS

From a public health point of view, the patients reported to use the emergency department as a primary health care structure should not be considered as 'inappropriate' or 'abusers'. Specific health needs have been found, which would require some continuity of care, a task for which the emergency department is not organised nowadays.

Non-urgent care in the hospital medical emergency department in France: how much and which health needs does it reflect?

OBJECTIVES

The goal was to describe the use of the medical emergency department as a source of non-urgent medical care in order to assess unmet health care needs among its users. The specific objectives were thus to assess the proportion of emergency department visits for non-urgent medical care and to describe those who used the department for this reason.

DESIGN

A cross sectional study was performed at the emergency department in two hospitals (around 12,000 visits per year each). Subjects were interviewed before and after the visit using a standardised questionnaire.

SETTING

The medical emergency department of two university hospitals, one in Paris and one in Besançon (France).

SUBJECTS

Each patient aged 15 and more attending the emergency department for a visit during 40 randomly selected periods of 12 hours was included.

MAIN OUTCOME MEASURES

A definition of urgent care was adopted before the beginning of the study. Four expert judgments were then used for each case to determine whether the reason for the visit was urgent or not.

RESULTS

Altogether 594 patients in the Paris emergency department and 614 in the Besançon one were included. In Besançon, the patients were older, a general practitioner was more often cited as the regular source of care, and the percentage of subsequent hospital admission was higher than in Paris (71% versus 34%). The non-urgent visits were estimated to account for 35% and 29% of the visits in Paris and Besançon respectively. Patients using the emergency department for a non-urgent visit were younger than other patients. More of them were unemployed, homeless, born outside of France, and without health insurance.

CONCLUSIONS

Non-urgent use of the emergency department was observed in about one third of the visits. Groups using the department for primary care and/or non-urgent care were mostly young and socially fragile, with no regular source of health care. Their poor health condition suggests that there is a need for a structure providing primary care both inside and outside 'normal' working hours.

Primary care and receipt of preventive services

OBJECTIVE

To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services.

DESIGN

A cross-sectional telephone survey.

SETTING

Population based.

PARTICIPANTS

Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California.

INTERVENTIONS

Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication.

MEASUREMENTS AND MAIN RESULTS

In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p < .0001). Having health insurance (p < .001) and receiving optimal primary care from the regular place of care (p < .01) further significantly increased the likelihood of receiving preventive care services.

CONCLUSION

A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care.

Primary care: specialists or generalists

A critical appraisal of the literature on the cost and quality trade-offs of primary care provided by specialists in comparison with that provided by generalists is presented.

Correlates of health care satisfaction in inner-city patients with hypertension and chronic renal insufficiency

Barriers to effective health care are potential contributors to the increased prevalence of hypertension and hypertension-related renal disease observed in black patients. We have enrolled 333 primarily elderly (mean age 69 years) black (87%) patients with hypertension and chronic renal insufficiency into a prospective randomized trial testing the effect of intense multidisciplinary management on progression of chronic renal insufficiency. These patients have an average 6 years of education and $400-$800 monthly household income: 57% have diabetes. Our baseline data include the Patient Satisfaction Questionnaire administered by home interviewers who also recorded sociodemographic data, medications and questionnaires regarding medication compliance and symptoms related to anti-hypertensive drugs. Inpatient and outpatient vital signs, test results and diagnoses came from patients' computerized medical records. We used multiple linear regression to identify correlates of overall satisfaction. We also analyzed three subscales: access to care, financial aspects and interpersonal manner of physicians. We included only variables with univariate correlations (P < 0.05) in the models. Decreased overall satisfaction correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01), and higher diastolic blood pressure (P = 0.08). Decreased satisfaction with access to care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001) and decreased medication compliance (P = 0.08). Decreased satisfaction with financial aspects of care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01) and more proteinuria (P = 0.02). Finally, decreased satisfaction with interpersonal manner of physicians correlated with lower medication compliance (P < 0.001), lower albumin (P = 0.01) and sodium (P = 0.04), and higher diastolic blood pressure (P = 0.04). These cross-sectional baseline data describe a group of mostly black inner-city patients with hypertension and chronic renal insufficiency in whom decreased satisfaction with care correlates with decreased medication compliance, increased symptoms related to anti-hypertensive drug therapy, higher diastolic blood pressure and more proteinuria. Our prospective study may help determine whether improving satisfaction improves compliance and blood pressure control, and forestalls complications in this high-risk population.

Management of hypertensive urgencies and emergencies

Hypertensive emergency is a condition in which there is elevation of both systolic and diastolic blood pressure with the presence of acute target organ disease. Hypertensive urgency is a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease. Hypertensive emergencies are best managed with parenteral drugs and careful intraarterial blood pressure monitoring. Hydralazine has been widely used in treatment of hypertension in eclampsia and preeclampsia, and its safety has been demonstrated in these patients. Sodium nitroprusside (SNP) has the most reliable antihypertensive activity, which begins immediately after its administration and ends when the infusion is stopped. As with diazoxide, it should be used with caution in patients with impaired cerebral flow. SNP is the preferred drug in obtaining controlled hypotension in patients undergoing neurovascular surgery. Intravenous nitroglycerin is useful in patients prone to myocardial ischemia, but should be avoided in patients with increased intracranial pressure. Esmolol is effective in controlling both supraventricular tachyarrhythmias and severe hypertension. Its short onset of duration of action make it useful in the emergent setting, but because of its negative inotropic effect its use should be avoided in patients with low cardiac output. Verapamil should not be used in patients with preexisting conduction abnormalities. Nicardipine is a potent arteriolar vasodilator without a significant direct depressant effect on myocardium. As with other afterload reducing agents, it should not be used in patients with severe aortic stenosis. Because angiotensin-converting enzyme (ACE) inhibitors generally cause cerebral vasodilatation, enalaprilat may be particularly beneficial for patients who are at high risk of developing cerebral hypotensive episodes secondary to impaired cerebral circulation. Fenoldopam, a selective post-synaptic dopaminergic receptor (DA1) has been shown to be effective in treating severe hypertension with a lower incidence of side effects than SNP. Hypertensive urgencies can usually be managed with oral agents. Oral nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine have all been shown to be effective in these situations.

Southwestern Internal Medicine Conference: difficult-to-treat hypertension

In this article, the author identifies the major causes of difficult-to-treat hypertension and provides guidelines for its management. The data were obtained from multiple clinical series of patients with hypertension resistant to therapy, reports of over-sensitivity to antihypertensive drugs, and the effects of anxiety-induced hyperventilation. As many as 15% of patients are resistant to antihypertensive therapy. Of the multiple possible causes for resistance, volume overload is the most common. Volume overload, in turn, is related to multiple factors, with inadequate diuretic therapy playing a major role. Many patients may experience tissue hypoperfusion when given usual doses of antihypertensive therapy, making their hypertension difficult to treat. In the author's experience, an even larger number of patients have psychosomatic symptoms, usually attributable to anxiety-induced hyperventilation, that often are blamed on their therapy. Therefore, hypertension may be difficult to treat for various reasons. When the cause is recognized, appropriate management almost always can be provided.