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Treatment of hypertension in the hispanic community: Cultural case studies
Clinical Cornerstone
•
HYPERTENSIONIN HISPANICS • Vol. 6, No. 3
Treatment of Hypertension in the Hispanic Community: Cultural Case Studies Juan M. Aranda, Jr, MD, FACC Gainesville, Florida
Jose A. Orcasita-Ng, MD Hialeah, Florida
Julian Marquez, MD Hialeah, Florida
Viorel Lupu, MD Taylor, Michigan
INTRODUCTION People of Hispanic origin are the fastest growing ethnic minority in the United States and often have hypertension and other comorbidities that contribute to atherosclerosis. I Despite this observation, the Sixth and Seventh Reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI, JNC-VII) acknowledge a difference in prevalence and blood pressure (BP) control rates among minority populations; however, no specific treatment recommendations are made for Hispanic patients. 2,3 The Hispanic Advisory Board for Hypertension Working Group was created in 2003 to bring together experienced Hispanic physicians representing different regions of the United States with the goal of identifying differences in awareness, educational language, and cultural practice patterns that lead to the undertreatment of hypertension in the Hispanic community. The following case presentations begin to identify the challenges and issues that are involved in the treatment of hypertension in Hispanics.
uncontrolled hypertension, obesity, dyslipidemia, and osteoarthritis. This is the first time she presented with neurological symptoms; there is no history of cerebrovascular accident. She took garlic pills to improve her health, included grapefruit juice in her diet, and maintained a low-salt diet. The patient believed that "strong emotions" played a role in her illness.
Physical Examination and Laboratory Studies Physical examination revealed an elderly, obese Hispanic woman. Electrocardiogram and Holter monitor indicated a supraventricular arrhythmia; an echocardiogram showed decreased left ventricular compliance and left ventricular hypertrophy. Doppler imaging revealed 25% to 30% stenosis of the carotid arteries. A chemistry panel, complete blood count, and urinalysis were within normal limits, however, lipid panel abnormalities included elevations of total cholesterol (312 mg/dL) and low-density lipoprotein cholesterol (216 mg/dL).
Diagnosis and Specific Treatment Recommendations The patient's diagnoses were left-sided heart failure and carotid atherosclerosis compatible with malignant, uncontrolled hypertension, and presumed cerebrovascular accident. The patient's BP goal was set at 120/80 mm Hg. She was instructed to reduce the fat in her diet, to keep her salt intake low, and to reduce her overall caloric intake. Amlodipine plus benazepril 5 rag/20 mg once daily was prescribed to control hypertension. Additional medical therapy included clopidogrel 75 mg once daily for secondary prevention of ischemic stroke, a statin for hypercholesterolemia,
CASE ONE Presentation and History An 84-year-old widowed, Cuban housewife and 30year resident of the United States presented with acute neurological symptoms of headache, dizziness, blurred vision, and unstable gait, accompanied by hypertension (BP 170/112 mm Hg). Her medical history included (Clinical Cornerstone. 2004;613]:71-75) Copyright © 2004 Excerpta Medica. 71
Clinical Cornerstone
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HYPERTENSION IN HISPANI¢S
pravachol 40 mg at dinner time, lansoprazole 30 mg per day for indigestion, and celecoxib 200 mg once daily for osteoarthritis.
•
Vol. 6, No. 3
contact; however, her daughter used this opportunity to reinforce the serious nature of the consequences of her mother's noncompliance. The physician--in Spanish--repeated the daughter's appeal for compliance. In the case of a complication such as a stroke or heart attack, the family would be unable to care for her at home and the mother's independence would be lost. The instructions were repeated in both Spanish and English in full to all family members who accompanied her at each visit. As more family members became involved with their mother's care, they collectively supported her in taking control over her health and treatment plan. At a subsequent follow-up visit, her BP was normal, 120/70 mm Hg, despite a small weight gain. The patient was cautiously optimistic about her treatment, given a typical degree of Latino fatalism that death is unavoidable.
Treatment Strategy (Cultural Issues) The initial office visit was conducted in Spanish because the patient spoke very little English. She was accompanied by her daughter. The patient claimed to be aware that her obesity, inactivity, lipid abnormalities, and history of hypertension contributed to her high risk for both cardiovascular and neurological disease, yet she had made little prior attempt at improving these problems. Both her body weight and her osteoarthritis limited her ability to exercise. Nevertheless, because of her acute presentation, she was advised by her physician of the urgent need to control her hypertension and to become an active participant in her treatment plan. Practical strategies used by the office staff included visual tools--in this case, normal and high BP values on a simple chart--to demonstrate normal BP values. She was given an example of a normal BP reading to take home and shown how to monitor her own BR Office staff gave her a set of forms to record her daily BP readings with the understanding that they would be reviewed later by her physician at the next follow-up. The patient was asked to repeat to the staff what she had been instructed to do to confirm to them her understanding of her care. Instructions to the patient were repeated for her adult daughter as well. Because of the strong family ties between them, the daughter was appointed as the "supervisor" in her mother's treatment plan. The mother, although clearly independent, would need her daughter's help to manage her lifestyle modifications and medical treatment in order to maximize her compliance. The daughter agreed to oversee her mother's BP reports with the home monitoring system. She encouraged her mother to be truthful in these daily reports and not to change elevated readings or fail to record them. Only through actual readings would the physician be able to evaluate her progress and adjust her regimen.
Summary
Several cultural aspects of this patient's case have implications for the patient's successful treatment strategy. The patient had been taking traditional herbs in the mistaken belief that they were sufficient to prevent and control her symptoms of severe hypertension. Although theie is no absolute contraindication to the concomitant use of garlic and clopidogrel by carefully controlled trials, there is a dose-related decrease in platelet aggregation with garlic. 4 Therefore, it would seem prudent to discontinue the garlic. The family bond was strong and the mother, however independent, relied on her adult daughter for help in managing lifestyle changes and BP monitoring. The patient's initial noncompliance with medical therapy underscores the need for a simple dosing regimen (with benazapril/ amlodipine) as a first-line strategy for better compliance. 5 The patient's diagnosis and urgent need for treatment were repeatedly reinforced through a series of discussions with her daughter and other family members in the presence of the physician. Once the diagnosis was made and the treatment regimen decided, the physician supported the family in the context of their mother's care. This series of discussions over time was absolutely essential for the patient's gradual understanding of the seriousness of her illness and the efforts she would need to overcome it. However, it was only through her
Follow-Up
At the first follow-up visit, her BP was still elevated (160/70 mm Hg). When confronted with this finding, the patient became evasive and avoided eye
72
Clinical Cornerstone
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HYPERTENSION IN HISPANICS •
Vol. 6, No. 3
Diagnosis and Specific T r e a t m e n t Recommendations At the conclusion of the initial visit the patient had been given different visuals and articles discussing BP risk and new goals to stay healthy had been explained to him. When he returned for followup after having recorded his BP readings as he had been advised, he was well aware and, once he found the BP readings to be persistently above normal, he was in agreement with the diagnosis of HBR He understood the risk he was exposed to as a result of HBP and he asked to be started on medication. He was aware that most medications can cause side effects that can be serious or affect his quality of life. He asked to be treated with a medication that was among the safest on the market, that would be covered by his health plan, that would not cause further deterioration of his sex life, interfere with ability to play golf, or adversely affect his lipid profile. He had a family member who had been treated with an angiotensin-converting enzyme inhibitor who was coughing, so he preferred not to use this type of medication. The patient was treated with valsartan with hydrochlorothiazide (80 rag/12.5 rag) every morning.
daughter's appeal that a stroke or heart attack threatened her mother's independence that the patient assumed final responsibility for her illness, eventually becoming treatment-compliant and meeting her target BP goal.
CASE T W O Presentation and History A 65-year-old married, Colombian man who has been in the United States for 30 years and is a retired banker paid a return visit to his physician's office in July of 2004 for follow-up of hypertension. He is not at all proficient with the English language. The patient had been seen once previously and, at the time of the initial visit, was noted to have a BP reading of 140/92 mm Hg. He was informed at the time that he may have high blood pressure (HBP), but the patient was asymptomatic and challenged the diagnosis. Despite the patient's skepticism he was trained how to monitor his BP and record the readings on a form designed by his physician. The patient was also advised that acceptable readings for BP are below 140/90 mm Hg and that it would be even better to have readings at the 130/80 mm Hg level to prevent the acute and chronic complications of HBR He adopted a low-salt diet; used garlic and savila leaf to treat himself for HBR At the follow-up visit, the patient's BP was 160/100 mm Hg and the readings he had recorded since his initial visit showed that 9 of 13 readings were above 140/90 mm Hg, with the average being 150/98 mm Hg. He denied peripheral edema, palpitations, shortness of breath, or any other problems related to the BE The review of systems was positive for hypogonadism and lumbar spine stenosis causing chronic pain. His current medications were ranitidine, diphenhydramine, and meloxicam, and his medical history is significant for surgical decompression of the lumbar spine.
T r e a t m e n t Strategy (Cultural Issues) The patient comes alone to his doctor's visits. He is given a form to record BP and basic information, and is able to complete the form without problems. A medical assistant reinforces the information about BP goal targets, staying healthy, and continuing to monitor his BE These instructions are given to the patient in Spanish. The patient is asked to verbalize all the information and education he received with the medical assistant prior to leaving the office, and the medical assistant indicates to the physician that all of the information has been clearly understood by the patient. He continues to use garlic and savila leaf in addition to the doctorprescribed medication.
Physical Examination and Laboratory Studies Physical examination revealed a well-developed, well-nourished, Hispanic man with a healed surgical scar on his back but no signs of muscle atrophy. BP was 160/100 mm Hg. Cardiovascular examination was normal. Urinalysis was normal without any evidence of albuminuria. Labs showed no alteration except for low testosterone and mildly elevated cholesterol with a borderline HDL of 38.
Follow-Up The patient was back 2 weeks later with BP readings ranging from 120/80 to 130/80 on average. He reported no side effects related to the use of the combination therapy. The medication was creating no problems with his quality of fife or his time playing golf. He has had
73
Clinical Cornerstone
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HYPERTENSIONIN HISPANICS •
an exacerbation of the low back pain and arthritis that he has suffered from in the past, but he continues to be normotensive despite large doses of prednisone prescribed by his rheumatologist.
Vol. 6, No. 3
ities were noted. Urinalysis was normal without any evidence of albuminuria. Hemoglobin A1C was 6.2%. Hemoglobin was 12.6 g/dL. The electrolytes, total cholesterol, high-density lipoprotein, and lowdensity lipoprotein were all within normal range. Chest x-ray showed mild-to-moderate emphysematous changes with cardiomegaly. The electrocardiogram showed normal sinus rhythm with an occasional premature ventricular contraction and evidence of left ventricular hypertrophy.
Summary This patient, despite being in the United States for over 3 decades, has limited English proficiency. His ease at understanding instructions given and completing forms at his physician's office suggests that the people at the clinician's office provide this information in Spanish. Initially, this patient was in denial, refusing to believe that he had a problem with HBP and this might be reflective of the Latino concept of "machismo," where an illness might be perceived to be a sign of weakness. Although he came to his doctor's visits alone, he drew on the experiences of friends and relatives to acknowledge that HBP is a serious condition that needs treatment and to help him make decisions about the kind of treatment he felt would be acceptable to him. His wife, though not present with him during his doctor encounters, was described as supportive and was helping the patient maintain a healthy lifestyle through dietary modification. He continued to use herbal remedies even after being prescribed medication for his hypertension; therefore, physicians treating him need to remain alert to the potential for drug interactions. The patient was optimistic about his prognosis.
Diagnosis and Specific Treatment Recommendations This patient had poorly controlled hypertension. A new BP goal of 120/80 mm Hg was set for him. The combination of losartan + hydrochlorothiazide 100/25 and amlodipine was discontinued, and the patient was started on furosemide, long-acting diltiazem, and continued single agent losartan. The patient had very little insight about the pathophysiology of hypertension, the risk of complications, and the importance of treatment at the time. In addition to modifying his medications, he received education about the potential complications of hypertension and the importance of treatment. The visual aids and literature used with him was primarily in English, since the patient was quite proficient in the use of English. The patient was also encouraged to come to the office any time, even without an appointment, to have his coagulation status and BP checked.
CASE T H R E E Presentation and History A 76-year-old widower who moved from Mexico to the United States 50 years ago was evaluated for complaints of dyspnea on exertion, fatigue, leg pain, and orthopnea. The patient's command of the English language was very good. His medical history was noteworthy for the presence of multiple thrombotic episodes requiring chronic anticoagulation, chronic obstructive pulmonary disease, and alcohol abuse. His medications consisted of losartan + hydrochlorothiazide 100/25, temazepam, amlodipine, and warfarin 3 mg and 4 mg on alternating days.
Treatment Strategy (Cultural Issues) The most important thing for increasing this patient's compliance was to make him feel comfortable in his interactions with the doctor's office. He was no longer given appointments, but rather was encouraged to come to the office at least once a week for the first year to have his BP measured, check his prothrombin time/international normalized ratio, and discuss his day-to-day problems. This made the patient quite comfortable and occasionally enthusiastic about improving the plan. A clear bond was created between the physician and the patient, and the patient and the office staff as well. The patient discontinued all alcohol intake once he was seeing the doctor on a regular basis. Family help was also essential and at least once a year the patient brings his daughter for a meeting where the treatment plan
Physical Examination and Laboratory Studies Physical examination revealed a well-developed, well-nourished, Hispanic man whose BP was 190/100 mm Hg. No physical examination abnormal-
74
Clinical Cornerstone
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HYPERTENSION IN HISPANICS •
Vol. 6, No. 3
refractory hypertension is inadequate diuresis, often
and compliance issues are discussed with her, her father, and the office team. The patient was also given an abundance of literature to review at home that described the pathophysiology of hypertension and expected treatment outcomes. Most of the literature was in English since the patient was quite comfortable with the English language.
secondary to reduced glomerular filtration. Since this patient appears to have responded to furosemide over a thiazide diuretic, a 24-hour creatinine clearance should be performed. 6 Second, the glycohemoglobin was abnormal at 6.2 corresponding to a mean blood glucose of 120. This is strongly suspicious for metabolic syndrome, and a waistline measurement should be obtained. If this patient is overweight, a 5% weight loss could reduce this patient's chance of developing diabetes by 58%. 7
Follow-Up His BP has been decreasing steadily and at the time
of his last office visit it was 124/82 mm Hg. The patient has faithfully been taking his medication as instructed. He is able to walk approximately 2 to 3 blocks without any shortness of breath. His lipid profile and other labs have remained normal, and his chest x-ray is stable with no sign of any acute disease processes.
REFERENCES 1. The Hispanic Population in the United States. March 2002. US Census Bureau. 2. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;57:24132475. 3. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252. 4. Cooperative Group for Essential Oil of Garlic. The effect of essential oil of garlic on hyperlidemia and platelet inhibition--an analysis of 308 cases. J Tradit Chin Med. 1986;6:117-120. 5. Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Arch Intern Med. 2004; 164:722-732. 6. Setaro JE Black HR. Refractory hypertension, N Engl J Med. 1992;327:543-547. 7. Knowler WC, Barrett-Connor E, Fowler SE, et al, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEngl JMed. 2002; 346:393-403.
Summary This patient had good command of English,
so most of the interactions and teaching that he participated in was conducted in English. Over time, the patient developed a very good relationship with the doctor's office and relied on that relationship to support making changes that would ensure he was maintaining good health. The involvement of the patient's daughter was absolutely essential, since he had started drinking and neglecting his health following the death of his wife. Involving his daughter in the treatment plan gave him someone else outside of the office on whom he could rely for guidance and support, and so that she, in turn, could oversee his compliance with the plan. Two other issues deserve mention. First, drugresistant hypertension is defined as BP >140/90 mm Hg on 3 or more medications. One of the causes of
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HYPERTENSIONIN HISPANICS • Vol. 6, No. 3
Treatment of Hypertension in the Hispanic Community: Cultural Case Studies Juan M. Aranda, Jr, MD, FACC Gainesville, Florida
Jose A. Orcasita-Ng, MD Hialeah, Florida
Julian Marquez, MD Hialeah, Florida
Viorel Lupu, MD Taylor, Michigan
INTRODUCTION People of Hispanic origin are the fastest growing ethnic minority in the United States and often have hypertension and other comorbidities that contribute to atherosclerosis. I Despite this observation, the Sixth and Seventh Reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI, JNC-VII) acknowledge a difference in prevalence and blood pressure (BP) control rates among minority populations; however, no specific treatment recommendations are made for Hispanic patients. 2,3 The Hispanic Advisory Board for Hypertension Working Group was created in 2003 to bring together experienced Hispanic physicians representing different regions of the United States with the goal of identifying differences in awareness, educational language, and cultural practice patterns that lead to the undertreatment of hypertension in the Hispanic community. The following case presentations begin to identify the challenges and issues that are involved in the treatment of hypertension in Hispanics.
uncontrolled hypertension, obesity, dyslipidemia, and osteoarthritis. This is the first time she presented with neurological symptoms; there is no history of cerebrovascular accident. She took garlic pills to improve her health, included grapefruit juice in her diet, and maintained a low-salt diet. The patient believed that "strong emotions" played a role in her illness.
Physical Examination and Laboratory Studies Physical examination revealed an elderly, obese Hispanic woman. Electrocardiogram and Holter monitor indicated a supraventricular arrhythmia; an echocardiogram showed decreased left ventricular compliance and left ventricular hypertrophy. Doppler imaging revealed 25% to 30% stenosis of the carotid arteries. A chemistry panel, complete blood count, and urinalysis were within normal limits, however, lipid panel abnormalities included elevations of total cholesterol (312 mg/dL) and low-density lipoprotein cholesterol (216 mg/dL).
Diagnosis and Specific Treatment Recommendations The patient's diagnoses were left-sided heart failure and carotid atherosclerosis compatible with malignant, uncontrolled hypertension, and presumed cerebrovascular accident. The patient's BP goal was set at 120/80 mm Hg. She was instructed to reduce the fat in her diet, to keep her salt intake low, and to reduce her overall caloric intake. Amlodipine plus benazepril 5 rag/20 mg once daily was prescribed to control hypertension. Additional medical therapy included clopidogrel 75 mg once daily for secondary prevention of ischemic stroke, a statin for hypercholesterolemia,
CASE ONE Presentation and History An 84-year-old widowed, Cuban housewife and 30year resident of the United States presented with acute neurological symptoms of headache, dizziness, blurred vision, and unstable gait, accompanied by hypertension (BP 170/112 mm Hg). Her medical history included (Clinical Cornerstone. 2004;613]:71-75) Copyright © 2004 Excerpta Medica. 71
Clinical Cornerstone
•
HYPERTENSION IN HISPANI¢S
pravachol 40 mg at dinner time, lansoprazole 30 mg per day for indigestion, and celecoxib 200 mg once daily for osteoarthritis.
•
Vol. 6, No. 3
contact; however, her daughter used this opportunity to reinforce the serious nature of the consequences of her mother's noncompliance. The physician--in Spanish--repeated the daughter's appeal for compliance. In the case of a complication such as a stroke or heart attack, the family would be unable to care for her at home and the mother's independence would be lost. The instructions were repeated in both Spanish and English in full to all family members who accompanied her at each visit. As more family members became involved with their mother's care, they collectively supported her in taking control over her health and treatment plan. At a subsequent follow-up visit, her BP was normal, 120/70 mm Hg, despite a small weight gain. The patient was cautiously optimistic about her treatment, given a typical degree of Latino fatalism that death is unavoidable.
Treatment Strategy (Cultural Issues) The initial office visit was conducted in Spanish because the patient spoke very little English. She was accompanied by her daughter. The patient claimed to be aware that her obesity, inactivity, lipid abnormalities, and history of hypertension contributed to her high risk for both cardiovascular and neurological disease, yet she had made little prior attempt at improving these problems. Both her body weight and her osteoarthritis limited her ability to exercise. Nevertheless, because of her acute presentation, she was advised by her physician of the urgent need to control her hypertension and to become an active participant in her treatment plan. Practical strategies used by the office staff included visual tools--in this case, normal and high BP values on a simple chart--to demonstrate normal BP values. She was given an example of a normal BP reading to take home and shown how to monitor her own BR Office staff gave her a set of forms to record her daily BP readings with the understanding that they would be reviewed later by her physician at the next follow-up. The patient was asked to repeat to the staff what she had been instructed to do to confirm to them her understanding of her care. Instructions to the patient were repeated for her adult daughter as well. Because of the strong family ties between them, the daughter was appointed as the "supervisor" in her mother's treatment plan. The mother, although clearly independent, would need her daughter's help to manage her lifestyle modifications and medical treatment in order to maximize her compliance. The daughter agreed to oversee her mother's BP reports with the home monitoring system. She encouraged her mother to be truthful in these daily reports and not to change elevated readings or fail to record them. Only through actual readings would the physician be able to evaluate her progress and adjust her regimen.
Summary
Several cultural aspects of this patient's case have implications for the patient's successful treatment strategy. The patient had been taking traditional herbs in the mistaken belief that they were sufficient to prevent and control her symptoms of severe hypertension. Although theie is no absolute contraindication to the concomitant use of garlic and clopidogrel by carefully controlled trials, there is a dose-related decrease in platelet aggregation with garlic. 4 Therefore, it would seem prudent to discontinue the garlic. The family bond was strong and the mother, however independent, relied on her adult daughter for help in managing lifestyle changes and BP monitoring. The patient's initial noncompliance with medical therapy underscores the need for a simple dosing regimen (with benazapril/ amlodipine) as a first-line strategy for better compliance. 5 The patient's diagnosis and urgent need for treatment were repeatedly reinforced through a series of discussions with her daughter and other family members in the presence of the physician. Once the diagnosis was made and the treatment regimen decided, the physician supported the family in the context of their mother's care. This series of discussions over time was absolutely essential for the patient's gradual understanding of the seriousness of her illness and the efforts she would need to overcome it. However, it was only through her
Follow-Up
At the first follow-up visit, her BP was still elevated (160/70 mm Hg). When confronted with this finding, the patient became evasive and avoided eye
72
Clinical Cornerstone
•
HYPERTENSION IN HISPANICS •
Vol. 6, No. 3
Diagnosis and Specific T r e a t m e n t Recommendations At the conclusion of the initial visit the patient had been given different visuals and articles discussing BP risk and new goals to stay healthy had been explained to him. When he returned for followup after having recorded his BP readings as he had been advised, he was well aware and, once he found the BP readings to be persistently above normal, he was in agreement with the diagnosis of HBR He understood the risk he was exposed to as a result of HBP and he asked to be started on medication. He was aware that most medications can cause side effects that can be serious or affect his quality of life. He asked to be treated with a medication that was among the safest on the market, that would be covered by his health plan, that would not cause further deterioration of his sex life, interfere with ability to play golf, or adversely affect his lipid profile. He had a family member who had been treated with an angiotensin-converting enzyme inhibitor who was coughing, so he preferred not to use this type of medication. The patient was treated with valsartan with hydrochlorothiazide (80 rag/12.5 rag) every morning.
daughter's appeal that a stroke or heart attack threatened her mother's independence that the patient assumed final responsibility for her illness, eventually becoming treatment-compliant and meeting her target BP goal.
CASE T W O Presentation and History A 65-year-old married, Colombian man who has been in the United States for 30 years and is a retired banker paid a return visit to his physician's office in July of 2004 for follow-up of hypertension. He is not at all proficient with the English language. The patient had been seen once previously and, at the time of the initial visit, was noted to have a BP reading of 140/92 mm Hg. He was informed at the time that he may have high blood pressure (HBP), but the patient was asymptomatic and challenged the diagnosis. Despite the patient's skepticism he was trained how to monitor his BP and record the readings on a form designed by his physician. The patient was also advised that acceptable readings for BP are below 140/90 mm Hg and that it would be even better to have readings at the 130/80 mm Hg level to prevent the acute and chronic complications of HBR He adopted a low-salt diet; used garlic and savila leaf to treat himself for HBR At the follow-up visit, the patient's BP was 160/100 mm Hg and the readings he had recorded since his initial visit showed that 9 of 13 readings were above 140/90 mm Hg, with the average being 150/98 mm Hg. He denied peripheral edema, palpitations, shortness of breath, or any other problems related to the BE The review of systems was positive for hypogonadism and lumbar spine stenosis causing chronic pain. His current medications were ranitidine, diphenhydramine, and meloxicam, and his medical history is significant for surgical decompression of the lumbar spine.
T r e a t m e n t Strategy (Cultural Issues) The patient comes alone to his doctor's visits. He is given a form to record BP and basic information, and is able to complete the form without problems. A medical assistant reinforces the information about BP goal targets, staying healthy, and continuing to monitor his BE These instructions are given to the patient in Spanish. The patient is asked to verbalize all the information and education he received with the medical assistant prior to leaving the office, and the medical assistant indicates to the physician that all of the information has been clearly understood by the patient. He continues to use garlic and savila leaf in addition to the doctorprescribed medication.
Physical Examination and Laboratory Studies Physical examination revealed a well-developed, well-nourished, Hispanic man with a healed surgical scar on his back but no signs of muscle atrophy. BP was 160/100 mm Hg. Cardiovascular examination was normal. Urinalysis was normal without any evidence of albuminuria. Labs showed no alteration except for low testosterone and mildly elevated cholesterol with a borderline HDL of 38.
Follow-Up The patient was back 2 weeks later with BP readings ranging from 120/80 to 130/80 on average. He reported no side effects related to the use of the combination therapy. The medication was creating no problems with his quality of fife or his time playing golf. He has had
73
Clinical Cornerstone
•
HYPERTENSIONIN HISPANICS •
an exacerbation of the low back pain and arthritis that he has suffered from in the past, but he continues to be normotensive despite large doses of prednisone prescribed by his rheumatologist.
Vol. 6, No. 3
ities were noted. Urinalysis was normal without any evidence of albuminuria. Hemoglobin A1C was 6.2%. Hemoglobin was 12.6 g/dL. The electrolytes, total cholesterol, high-density lipoprotein, and lowdensity lipoprotein were all within normal range. Chest x-ray showed mild-to-moderate emphysematous changes with cardiomegaly. The electrocardiogram showed normal sinus rhythm with an occasional premature ventricular contraction and evidence of left ventricular hypertrophy.
Summary This patient, despite being in the United States for over 3 decades, has limited English proficiency. His ease at understanding instructions given and completing forms at his physician's office suggests that the people at the clinician's office provide this information in Spanish. Initially, this patient was in denial, refusing to believe that he had a problem with HBP and this might be reflective of the Latino concept of "machismo," where an illness might be perceived to be a sign of weakness. Although he came to his doctor's visits alone, he drew on the experiences of friends and relatives to acknowledge that HBP is a serious condition that needs treatment and to help him make decisions about the kind of treatment he felt would be acceptable to him. His wife, though not present with him during his doctor encounters, was described as supportive and was helping the patient maintain a healthy lifestyle through dietary modification. He continued to use herbal remedies even after being prescribed medication for his hypertension; therefore, physicians treating him need to remain alert to the potential for drug interactions. The patient was optimistic about his prognosis.
Diagnosis and Specific Treatment Recommendations This patient had poorly controlled hypertension. A new BP goal of 120/80 mm Hg was set for him. The combination of losartan + hydrochlorothiazide 100/25 and amlodipine was discontinued, and the patient was started on furosemide, long-acting diltiazem, and continued single agent losartan. The patient had very little insight about the pathophysiology of hypertension, the risk of complications, and the importance of treatment at the time. In addition to modifying his medications, he received education about the potential complications of hypertension and the importance of treatment. The visual aids and literature used with him was primarily in English, since the patient was quite proficient in the use of English. The patient was also encouraged to come to the office any time, even without an appointment, to have his coagulation status and BP checked.
CASE T H R E E Presentation and History A 76-year-old widower who moved from Mexico to the United States 50 years ago was evaluated for complaints of dyspnea on exertion, fatigue, leg pain, and orthopnea. The patient's command of the English language was very good. His medical history was noteworthy for the presence of multiple thrombotic episodes requiring chronic anticoagulation, chronic obstructive pulmonary disease, and alcohol abuse. His medications consisted of losartan + hydrochlorothiazide 100/25, temazepam, amlodipine, and warfarin 3 mg and 4 mg on alternating days.
Treatment Strategy (Cultural Issues) The most important thing for increasing this patient's compliance was to make him feel comfortable in his interactions with the doctor's office. He was no longer given appointments, but rather was encouraged to come to the office at least once a week for the first year to have his BP measured, check his prothrombin time/international normalized ratio, and discuss his day-to-day problems. This made the patient quite comfortable and occasionally enthusiastic about improving the plan. A clear bond was created between the physician and the patient, and the patient and the office staff as well. The patient discontinued all alcohol intake once he was seeing the doctor on a regular basis. Family help was also essential and at least once a year the patient brings his daughter for a meeting where the treatment plan
Physical Examination and Laboratory Studies Physical examination revealed a well-developed, well-nourished, Hispanic man whose BP was 190/100 mm Hg. No physical examination abnormal-
74
Clinical Cornerstone
•
HYPERTENSION IN HISPANICS •
Vol. 6, No. 3
refractory hypertension is inadequate diuresis, often
and compliance issues are discussed with her, her father, and the office team. The patient was also given an abundance of literature to review at home that described the pathophysiology of hypertension and expected treatment outcomes. Most of the literature was in English since the patient was quite comfortable with the English language.
secondary to reduced glomerular filtration. Since this patient appears to have responded to furosemide over a thiazide diuretic, a 24-hour creatinine clearance should be performed. 6 Second, the glycohemoglobin was abnormal at 6.2 corresponding to a mean blood glucose of 120. This is strongly suspicious for metabolic syndrome, and a waistline measurement should be obtained. If this patient is overweight, a 5% weight loss could reduce this patient's chance of developing diabetes by 58%. 7
Follow-Up His BP has been decreasing steadily and at the time
of his last office visit it was 124/82 mm Hg. The patient has faithfully been taking his medication as instructed. He is able to walk approximately 2 to 3 blocks without any shortness of breath. His lipid profile and other labs have remained normal, and his chest x-ray is stable with no sign of any acute disease processes.
REFERENCES 1. The Hispanic Population in the United States. March 2002. US Census Bureau. 2. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;57:24132475. 3. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252. 4. Cooperative Group for Essential Oil of Garlic. The effect of essential oil of garlic on hyperlidemia and platelet inhibition--an analysis of 308 cases. J Tradit Chin Med. 1986;6:117-120. 5. Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Arch Intern Med. 2004; 164:722-732. 6. Setaro JE Black HR. Refractory hypertension, N Engl J Med. 1992;327:543-547. 7. Knowler WC, Barrett-Connor E, Fowler SE, et al, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEngl JMed. 2002; 346:393-403.
Summary This patient had good command of English,
so most of the interactions and teaching that he participated in was conducted in English. Over time, the patient developed a very good relationship with the doctor's office and relied on that relationship to support making changes that would ensure he was maintaining good health. The involvement of the patient's daughter was absolutely essential, since he had started drinking and neglecting his health following the death of his wife. Involving his daughter in the treatment plan gave him someone else outside of the office on whom he could rely for guidance and support, and so that she, in turn, could oversee his compliance with the plan. Two other issues deserve mention. First, drugresistant hypertension is defined as BP >140/90 mm Hg on 3 or more medications. One of the causes of
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