Introduction
The number of patients with hypertension has been on the rise and is likely to continue rising as the population grows older. The condition despite affecting a large population of Americans and being the most common reason for visits to the physicians has not been adequately managed. Data from a recent survey indicates that only about 27 per cent of the American population with hypertension has their blood pressure under control (Kaplan, 1998). This indicates ineffective treatment and management. Hypertension, often called the silent killer because of its asymptomatic nature, can range from essential, the mild form, to malignant, a severe form. In essential hypertension there is no specific medical cause to explain the patient’s condition while malignant or secondary hypertension is usually caused by another condition for example a tumor or kidney disease (Nursing Practice Guidelines, 2005). Hypertension is a risk factor for strokes, arterial aneurysms, heart failure and is among the leading causes of chronic renal failure.
A consistent systolic blood pressure of 140mmHg or greater and or diastolic blood pressure above 90mm/Hg indicates that a client has hypertension (Nursing Practice Guidelines, 2005). As of 2004, mortality due to hypertension was at 23,016 and the percentage of non-institutionalized adults above 20 years was 20% for the years 2001-2004 (CDC, 2005). Hypertension generally strains the health sector and early detection with proper management is important if this strain is to be reduced.
Research question
How can hypertension be managed and treated to ensure adequate control o f blood pressure among America’s population of hypertensive patients?
Purpose Statement
This research study will describe treatment and management of hypertension with the aim of providing information that will provide options for greater control of blood pressures among hypertensive patients.
Hypothesis
Treatment and management of hypertension is currently inadequate for most hypertensive Americans.
The main treatment of hypertension involves medication. Long term therapy for an asymptomatic condition gives insight into the problem of failure to control blood pressure among hypertensive patients. This is especially a problem when therapy interferes with the patient’s quality of life and the immediate benefits of the therapy are not obvious to the patient. Kaplan reports that this problem led the Joint National Committees of Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNCVI) to set new guidelines that would improve the standard of cure of hypertension (JNCVI, 1997).
Diagnosis is an integral part of management. This involves careful documentation, evaluation of the courses of hypertension and evaluation of cardiovascular risk. This need for careful documentation arises form the phenomenon of “white coat” effect where an estimated 30 per cent of patients have been found to have readings above 140/90mmHg in the physicians office but when the same reading are done out of the office values below 130/85mmHg are found. White coat hypertension has a long-term course whose explanation is currently unknown. There has been little change in patents noted to show this response (Nursing Best Practice Guidelines, 2005). These patients should be put under surveillance and also be encouraged to change their lifestyles appropriately. This will reduce their tendency towards increased blood pressure. In addition, where there are no other conditions Krukoff and Phillips assert that patients who are hypertensive in the physician’s office only should not be treated for hypertension rather they should be given advice on lifestyle modifications that will decrease their tendency toward high blood pressure.(Krakoff and Phillips, 1996)
Determining overall risk profile is an important aspect of diagnosis that will determine the treatment and management a patient will undergo. These risks include weight, age, coexisting cardiovascular disease and organ damage. The Framingham Heart study indicated that the 20 year risk of developing hypertension was more that 90 per cent for men and women who were not yet hypertensive at 55 to 65 years (Vasan et al, 2002). This points to the relationship between age and hypertension. For a patient with concomitant conditions the goal of treatment changes while their management is different. The National Kidney foundation, American Diabetes Association and JVCI all agree that those patients with chronic renal disease or disease ought to have a lower goal of treatment 130/90mmHg, which is lower than that for other patients with hypertension (140/90mmHg). (National Kidney Foundations in 2002; Arauz-pacheco, Parrot and Raskin, 2003). A patient with a high body mass also has high cardiovascular risk and a greater part of their management will involve lifestyle modification with changes in diet as well as physical activity (Rosendorff et al, 2007) a low risk individual may not require medication but only change in their lifestyle while those people who have a higher cardiovascular risk, for example the elderly who may also have other significant risk factors may receive the most benefit form drug treatment (Gueyffier, Froment and Garton, 1996).
An example of lifestyle intervention is the DASH diet which was investigated as a means of managing hypertension. Volmer and colleagues studied 412 adults with systolic blood pressure ranging from 120 to 160mmHg and diastolic blood pressure from 80 t0 95 mmHg. A typical US diet or a Dietary Approaches to Stop Hypertension (DASH) diet was randomly assigned to every one of the subjects. The DASH diet placed emphasis on vegetables, fruit, low fat dairy goods, poultry, fish and whole grains. All the foods were provided as part of the study. The participants ate the assigned foods for 90 days and for these 90 days they were also randomly assigned varied intakes of sodium of 1.2g, 2.3g or 3.5g for each 30 day period of feeding. The results were such that the DASH did and salt restriction lowered pressure compared to the typical US diet and normal salt intake of 3.5g. Further the DASH diet when combined with salt restriction, lowered blood pressure than when either method was used alone. The decrease in blood pressure from reduced salt intake was noted in all subgroups. These subgroups were men, women, African-Americans, Non-African Americans, normotensive and hypertensive subjects as well as people younger and older than 45years (Volmer et al, 2007). Other randomized trials, have shown that a salt restricted diet may reduce blood pressure and also reduce the need for antihypertensive medication. However, for most trials these effects seem to be short term since most o f the trials have short periods of follow-up of about a month. When the trials are longer-term, the results begin to conflict with some research suggesting a diminished or minimal effect at 12 months (Mulrow, 2001)
A low salt diet can be achieved by eating fresh fruit and vegetables, refraining from adding salt at the table, and avoiding over processed food. This would result in a sodium intake of about 2.4g, the level currently recommended by guidelines. (JNCVI, 1997) However, the very low salt intake of 1.2g such as the one tested by Volmer and colleagues would not be feasible among the American population where the typical American diet accounts for 3.5g of sodium intake due to the content and nature of processing the food (Mulrow, 2007).
Other lifestyle interventions include increasing physical exercise to achieve weight loss. Lifestyle changes are the common management methods for patients with hypertension. (JNVI, 2004). The relationship between caloric restriction, weight loss and decreased incidence of hypertension has been documented for a long time. An analysis of 12 prospective studies including 5 randomized clinical trials share that an average 1 kilogram decrease in body weight in an obese hypertensive individual could be associated with a decrease in systolic blood pressure of 2.4mmHg and diastolic blood pressure of 1.5mmHg (Mulrow et al, 1998). Mulrow and associates analyzed six trials where participants were subjected to a weight reducing diet and others to a normal diet. The data from these studies showed that there was a weight loss ranging from 4 per cent to 8 percent, there was also a decrease in blood pressure ranging around 3mmHg systolic and diastolic. In other trials where a weight reducing diet was compared to antihypertensive medication, there was greater decrease in blood pressure where antihypertensive medication was used. For those trials that allowed participants to adjust their regimens of drugs therapy, the results suggested that patients following a weight reduction diet required les intensive drug therapy (Mulrow et al, 1998).
When lifestyle modifications fail to control blood pressure due to present risk factors or evidence of target-organ damage, pharmacological therapy is necessary. Pharmacological therapy has however, for a long time been the quick fix for the problem of hypertension. This though understandable due to the time constraints involved when seeing patients in the office should not be the case. The effort in helping a client realize the need for changes in lifestyle and the effort required in modifying lifestyles are worthwhile because in the end they protect the patients form cardiovascular disease as well as reduce cost and drugs and the incidence of side effects from drugs (Miller, 2004).
Randomized place to controlled trials of beta-adrenergic blockers and diuretics show that these drugs are most beneficial to patients below 65 years who have uncomplicated hypertension. In certain circumstance, specific drugs are required. Hypertensive patients with diabetic nephropathy will require ACE inhibitors. Those with congestive heart failure will require ACE inhibitors and diuretics and long acting dihydropividine calcium antagonists are necessary for elderly people with systolic hypertension. The need for these specific drugs is well recognized and evident following the systolic Hypertension in Europe Trial where 4600 patients above 65 years with an average blood pressure of 174/85mmHg were either given placebo treatment or active therapy with nitrendipine ( along acting calcium antagonist). Those patients receiving nitrendipine had a 42 per cent reduction in stroke events (Staessen et al, 1997)
JNCVI guidelines for treatment of patients with diabetes or renal insufficiency target a blood pressure below 130/85mmHg. Often blood pressure is under controlled and consequently the patients are left under protected (Kaplan, 1998). To solve this Kaplan (1998) suggests choosing a long acting formulation of drugs so that a single dose in a day provides sufficient 24 hour protection. This will not only improve compliance but also the cost of therapy since fewer pills will be required. Further the risk of cardiovascular catastrophe is avoided especially during the early morning when there is a blood pressure surge following arising from bed (Kaplan 1998)
High rates of blood pressure controls are attainable with compliance to treatment regimes. When patients were monitored by nurses in a home health setting the blood pressure readings were considerably reduced as shown by a study conducted by Tobe and associates with the nurses assessing patients readings and reporting to physicians, it was possible for earlier interventions to be started (Tobe et al, 2006) Non compliance has been a limiting factor in hypertensive therapy. Not every patient will have nurses available to them. If they are not in a healthcare facility noncompliance among patients can be explained partly by the fact that hypertension is asymptomatic while patients view it as symptomatic. A cross-sectional study of outpatients attending a hypertension clinic, assessed veterans to evaluate their understanding of the condition, hypertension history, co morbidities and refills of hypertension medications (Hill and Miller, 1998). Studies show that most patients view hypertension as symptomatic. However, symptoms did not have a significant association with compliance with pharmacy refills. This indicates that when managing a hypertensive patient it is necessary to assess medication compliance during follow up and also include in formation on compliance which can be used to detect noncompliance and also motivate the client to comply with their treatment regime. A team approach is necessary to achieve this. Though the tradition of face to face visits with the physician is deep rooted, research has shown that it is less effective in ensuring compliance and behavior change among patients. A multidisciplinary approach is more effective and here the role of nurses becomes very significant (Hill and Miller, 1998).
When reasonable doses of the first choice drug are not achieved, a drug from another class ought to be given. This should be coupled with a low dosage diuretic if a diuretic was not the initial agent (Kaplan, 1998) Randomized trials of hypertensive patients with type 2 diabetes showed that ACE inhibits and calcium channel blocks did not differ significantly in their effectiveness of reducing blood pressures (UKPD, 1998). This points to the fact that an individual profile is necessary in establishing an appropriate management protocol for each individual hypertensive patient. Some drugs may cause uncomfortable side effects in one person or be ineffective while in another they are effective with serious adverse effects.
For patients with severe and resistant hypertension, high dosages of potent diuretics may be necessary. Short-acting loop diuretics may be given twice or twice a day but long acting agents are preferable. When the case remains hard to control referral to a hypertension specialist is necessary (Kaplan, 1998).
With proper identification, treatment and monitoring the long term effects of hypotension can be kept under control. Organ damage from hypertension can be avoided or at lease delayed and more importantly life expectancy can be increased.
Potential for further research
An area that needs further research as far as treatment management of hypertension is concerned is the issue of patients’ compliance with pharmacological therapy, the factors influencing compliance to pharmacological therapy as well as the ways which compliance among patients of different subgroups can be enhanced.
References
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