Article Abstract:
A total of 241 physicians delivering at least 10 percent of primary care services in the upper Midwest were surveyed in 1987 and again in 1989 about how they managed major risk factors for cardiovascular disease. Specifically, they were asked how they counseled their patients and treated hypertension, hypercholesterolemia (elevated cholesterol in the blood), physical inactivity, and cigarette smoking. Between 1987 and 1989, the practices of many of the physicians had changed significantly. The most dramatic change was in their management of hypercholesterolemia. The average cut-off level they used to decide that a patient's cholesterol level was abnormal dropped from 226 milligrams per deciliter (mg/dL) to 210 mg/dL. The cholesterol level at which they initiated treatment with cholesterol-lowering drugs dropped from 284 to 253 mg/dL. In diagnosing and treating hypertension, most of the physicians were still using the same cut-off point: 140 to 149 systolic and 90 to 94 diastolic blood pressures. The most significant change was the choice of antihypertensive drug. By 1989, only 32 percent of the physicians chose a diuretic as the first treatment, down from 60 percent in 1987. Instead of diuretics, the doctors used a variety of drugs, including ACE inhibitors and beta-blockers. ACE inhibitors showed the most dramatic increase in use, with almost 30 percent of doctors prescribing them in 1989, compared with 5 percent in 1987. As far as encouraging their patients to exercise, no changes occurred over the two-year period; most doctors recommended exercising for at least 30 minutes three or four times a week. Rather than discussing smoking cessation only when asked, more doctors were routinely advising their patients to stop smoking. In 1989, 98 percent of the doctors had some type of nonsmoking policy in their offices. The physicians who participated in the survey have clearly changed their practice with regard to preventing cardiovascular disease in their patients. The most significant change occurred in the diagnosis and treatment of hypercholesterolemia, with the physicians apparently moving toward compliance with the recommendations of the National Cholesterol Education Program. (Consumer Summary produced by Reliance Medical Information, Inc.)
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Article Abstract:
Malignant hypertension, the most severe type of high blood pressure, requires immediate treatment with antihypertensive drugs. Antihypertensive drugs can be administered orally or intravenously. Intravenous (IV) infusion of nitroprusside appears to offer the best blood pressure-lowering effect, but the continuous patient monitoring required is demanding. The search for other antihypertensive drugs has led to the reassessment of oral agents for rapid blood pressure control. Physicians generally prefer to have immediate reductions in blood pressure before sending the patient home with maintenance therapy. Popular oral hypertensive agents include clonidine, which may take a few hours for effects to be seen; captopril; and more recently, nifedipine. The benefits of oral antihypertensive agents are that the results can be rapid, IV facilities are not needed, the transition from acute to long-term therapy is easier, the cost is less, and professional time and resources are saved. However, the underlying cause of the high blood pressure may be masked by immediate drug response. Blood pressures may be reduced too far and patients released a few hours after the initial intervention, leaving the patient prematurely unmonitored. There are times when IV therapy is definitely indicated, as in the control of hypertension before some types of surgery, during surgery, in the recovery room, with patients with vascular disease and patients who have had a heart attack. In the December 1989 issue of Archives of Internal Medicine, two articles discuss the efficacy of dilevalol and nicardipine for IV hypertensive drug therapy. The results of these studies suggest IV nicardipine therapy may replace nitroprusside as the drug of choice for the treatment of hypertensive emergencies.
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Article Abstract:
A report is presented from a working group composed of representatives from a large number of professional medical and health care organizations concerning the relationship between high blood pressure (hypertension) and chronic renal (kidney) failure. End-stage renal disease (ESRD; irreversible kidney failure) is a significant health problem in the US, with the number of new cases increasing each year by almost 8 percent. Two factors that place patients at greatly increased risk for ESRD are diabetes and hypertension. The report discusses the pathology and pathophysiology of hypertension, which can lead to chronic kidney failure. The effects of long-term use of drugs to combat hypertension have not been well documented. The medical literature concerning these agents is briefly reviewed. It is concluded that the best way to protect the kidney from hypertension-associated damage is to control blood pressure effectively; in general, reduction of blood pressure to levels below 140/90 should reduce the incidence of ESRD. Four groups are at particular risk from hypertension: blacks; people with chronic renal failure; diabetics; and the elderly. These groups need special attention to attain blood pressure control. Well-designed clinical trials are needed to determine which antihypertensive drugs are most effective. In addition, more efforts should be made to improve patient compliance with drug regimens, an essential component of effective treatment of hypertension. (Consumer Summary produced by Reliance Medical Information, Inc.)
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