An Opportunity for Prevention

In this issue, Progress in Prevention focuses on a case study of a patient with hypertension (HTN) and presents strategies to integrate the point-of-service recommendations from the Centers for Disease Control/American Heart Association/National Institutes of Health BAction Framework for a Comprehensive Public Health Strategy To Prevent Heart Disease and Stroke. ^ The case is similar to one presented in the New England Journal of Medicine, to which the reader can refer for in-depth discussion of the pathophysiology, differential diagnosis, and medical treatment of resistant HTN. At the time this patient was evaluated, the authors were clinicians in a community-based cardiology practice in an underserved neighborhood. A 76-year-old African American woman with longstanding HTN is referred to the Heart Center by her primary care provider for resistant, difficult-to-control HTN. She is a nonsmoker, does not drink alcohol, is sedentary, and eats a high-fat diet. Blood pressure (BP) is 160Y170/80Y96 mm Hg, body mass index is 33 kg/m, waist circumference is 40 in, and fasting glucose is 115 mg/dL. Optical fundi reveal arteriolar narrowing with otherwise normal cardiovascular examination. The electrocardiogram reveals left ventricular hypertrophy, serum creatinine is 1.1 mg/dL, negative for microabuminuria. She cares for her husband who has Alzheimer’s disease at their home. She has one adult son, with mental retardation who lives in a residential setting. The patient admits to being sociallyisolated. Her current medications include amlodipine (2.5 mg daily), hydrochlorothiazide (12.5 mg daily), lisinopril (40 mg daily), and ibuprofen (600 mg 2 times a day for osteoarthritis). How would you treat this person? Is achieving adequate BP control realistic? This patient meets the criteria for resistant HTN, which is defined as BP 9120/90 mm/Hg on at least 3 medications. Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure guidelines emphasize the importance of considering secondary causes of HTN when BP remains elevated despite multiple medications. Consequently, this patient had undergone an evaluation for possible renal/vascular/endocrine/ sleep abnormalities, which was negative. Medication compliance was assessed and confirmed. Higher doses of amlodipine were poorly tolerated in the past. In summary, this patient has persistent, elevated BP despite 3 medications, with evidence of target-organ injury (left ventricular hypertrophy and arteriolar narrowing). She also has a cluster of associated risk factors and meets criteria for the metabolic syndrome (HTN, waist circumference 935 in, impaired fasting glucose [9100 mg/dL]). Furthermore, she is sedentary, eats an unhealthy diet, serves as the primary caretaker for her husband and son, and is socially isolated. This constellation of interconnected physical and social factors requires modification through a comprehensive therapeutic approach to her BP and health risk profile. Ironically, although older age and African American race are associated with increased prevalence of vascular/metabolic risk factors, provider bias often results in clinicians tolerating higher BPs and other cardiovascular disease risks in these populations despite dire clinical consequences. Not only are risks of stroke and cardiac events especially high in these populations, but cognition and functional capacity can be eroded by uncontrolled BP and cardiovascular disease risks, potentially limiting