One of the most important things that many physicians neglect to do for their hypertensive patients is set a blood pressure goal and inform the patient of that goal, Hill says. Its hard to meet a goal that hasnt been set and for which there is no feedback. You have to be aware of the fact that its the patients daily life that will make the ultimate difference. The day-to-day work is the patients, so you have to involve them in the decision making.
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One complicating factor in treating hypertension is that the same strategy wont work for every patient. Researchers at the University of Maryland have identified four distinct types of hypertensive patients based on lifestyle choices and the ability to adhere to medication protocols, and they say that tailoring treatment to each group may improve your chances of success.
Matthew Weir, MD, professor of medicine in the division of nephrology at the University of Maryland in Baltimore, and his colleagues interviewed 727 hypertensive patients by telephone about their beliefs and behaviors surrounding the management of their disease. They weighted the composition of the cohort to match the age and sex distribution of hypertensive patients in the 1992 National Health Interview Survey. The researchers found four distinct groups that need different management strategies:.sup.1
Group A. Patients use an effective mix of medication and lifestyle regimens to control blood pressure. These patients need positive reinforcement, such as monthly telephone contact by nurses and encouragement to gradually adopt more aggressive healthy lifestyle goals.
Group B. Patients are most likely to depend on medication and have high adherence rates, but they also have high rates of smoking (29%) and alcohol use (an average of 104 times per year) and are less likely to exercise regularly. This group needs more aggressive medical management and needs to take small steps toward a more active lifestyle.
Group C. Patients are most likely to forget to take medication, are likely to be obese, and find it most difficult to comply with lifestyle changes (except for very low rates of smoking and alcohol use). They need a simplified medication schedule with care taken to minimize side effects. They also need encouragement to incorporate easy physical activity such as taking the stairs or taking a 10-minute walk during lunch, into their daily life.
Group D. Patients are least likely to take medication, most likely to change or stop medication without consulting their physician (20%), most likely to smoke (40%), and least likely to control diet (29%). This group needs strategies to make it easier for them to take their medications and increased frequency of patient contact through a case manager.
Weir and his colleagues are planning another trial to test the hypothesis that tailoring treatment in those ways would reduce the incidence of high blood pressure. They suggest caregivers need a hypertension lifestyle assessment instrument that would identify the subgroup into which an individual falls, as well as clinical management protocols that are tailored for members of each group.
Congestive heart failure has increased in the last five years partly because hypertension is not well-controlled, Weir says. Anything we can do to improve hypertension would improve heart failure as well. We need to be more aggressive to get intensified control of hypertension.
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One way providers can become more aggressive is through the use of combination drug therapy, says Joel Neutel, MD, chief of clinical pharmacology and hypertension at the Veterans Affairs Medical Center in Long Beach, CA, and assistant clinical professor of medicine at the University of California, Irvine.
Because hypertension is a multifaceted disease, it is extremely difficult to get to goal blood pressure using only one drug, Neutel says. He recommends that physicians consider using low-dose combination therapy earlier in the treatment process.
Combining two drugs in one tablet is more likely to reduce blood pressure and makes compliance easier for patients. Theres been somewhat of a reluctance to using combination therapy, but now with the new low-dose products that are available, you are much more likely to get control, he says. Some are concerned that there might be more side effects, but when you compare studies in which patients are started on low-dose combination therapy to those on monotherapy, there are really no differences in the side-effect profile. In almost all patients, it is possible to find a treatment regimen that would not have side effects. You have to do that if you want your patients to comply.
The step-care approach has been ingrained in doctors as the right approach to treating hypertension, and thats not necessarily a bad thing as long as blood pressure is controlled, Neutel says. But by virtue of the fact that in 75% of patients were not getting to control, the system is somehow breaking down. We have to be more aggressive with combination therapy earlier on in the treatment of hypertension, which is something that is not taught at medical school. Physicians have to constantly change their approach.