Review Article
Hypertension in diverse populations: a New York State Medicaid clinical guidance document

https://doi.org/10.1016/j.jash.2011.05.003Get rights and content

Abstract

The New York State Medicaid Prescriber Education Program (PEP) is a partnership between the Department of Health and state academic institutions that provides prescribers with an evidence-based, noncommercial source of the latest objective information about pharmaceuticals. This article, detailing treatment of uncomplicated hypertension in diverse populations, represents one of the first large-scale PEP initiatives. The main risk factors for hypertension are age and obesity. Disparities in hypertension risk and outcomes among diverse populations are now believed to be more a function of personal habits, socioeconomic status and psychosocial factors rather than race, ethnicity, or genetics. Blood pressure is controllable in most patients, and all patients should be treated according to best practices. Lifestyle modification, especially diet and exercise, should be encouraged, but most patients will require more than one antihypertensive medication to control blood pressure. Combination therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker plus thiazide-type diuretic or dihydropyridine calcium channel blocker is largely universal in efficacy. Improved provider-patient partnership and communication is important to blood pressure lowering success, and cultural sensitivity should be taken into account where applicable.

Introduction

The purpose of this report is to summarize relevant current information to help clinicians optimize the treatment of hypertension in patients of varied racial and ethnic backgrounds. This advisory statement represents the collective effort of a working group of academic physicians and pharmacists, public health professionals, and other interested parties charged by the New York State Department of Health to respond to a clinical need. As with the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),1 the document is a science-based expert consensus that integrates basic and clinical information.

Section snippets

National Trends

Recent data from the National Health and Nutrition Examination Survey (NHANES) show that the overall prevalence of hypertension in the United States is about 29%. Estimated prevalence of hypertension in New York State is lower than the national average (about 27%),2 and in New York City, the prevalence is about 26%.3 Among Americans being treated for hypertension, about 31% are not well-controlled,4 but in New York City, more than 35% are not well-controlled.3 This latter group presents an

Traditional Hypertension Risk Factors

There are several factors that contribute to the development of hypertension, especially age, obesity, physical activity profiles, and dietary composition.

Age

Age is the most important predictor of CHD mortality; the prevalence of fatal ischemic cardiac events is 64 times higher in a population of 80-year-old patients than in 40 year olds.17 Men with stage 1 hypertension (SBP 140–159 mm Hg) have a 63% increase in age-adjusted CVD mortality compared with those with controlled hypertension (SBP <140

Diagnosis and Classification

There are many factors in the clinical setting that can influence BP measurement and affect the diagnosis and classification of hypertension. Recent trends include the use of office and nonoffice BP values.

BP Goals and Targets

Although BP is continuously distributed in the population, practical considerations dictate the use of arbitrary cutoffs for the diagnosis and treatment of hypertension. These cutoffs have been the source of much recent consideration, both in terms of public health policy and practice guidelines.

Management of Hypertension

Effective management of hypertension includes both nonpharmacologic (lifestyle modification) and pharmacologic therapy for most individuals.

Potential Barriers to Treatment and Control in Diverse Populations

In general, the barriers to BP control in minorities are the same as those present in the population at large. However, certain attitudes and beliefs about hypertension and its treatment vary across different races. Practitioners should be sensitive to the culture and beliefs of each patient and should work to overcome any barriers that may diminish care quality.

Conclusion

The main risk factors for hypertension are age and obesity. Disparities in hypertension risk and outcomes among diverse populations are more dependent on acquired characteristics socioeconomic status, and psychosocial factors rather than race, ethnicity, or genetic background. All patients should be treated according to best practices; using race or ethnicity as a marker for goal-setting or treatment options is not scientifically justified. For most patients with hypertension, blood pressure

Acknowledgments

This article was developed as a background clinical guidance document for the New York State Medicaid Prescriber Education Program, a partnership between the New York State Department of Health and state academic institutions that provides prescribers with an evidence-based, noncommercial source of the latest objective information about pharmaceuticals. More information about this program can be found online at: http://nypep.nysdoh.suny.edu/home and //www.health.state.ny.us/health_care/medicaid/program/prescriber_education/presc-educationprog

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