Antihypertensive Therapy in African Americans: Findings From an Inner-City Ambulatory Clinic

Diuretic use in black patients with uncontrolled hypertension

BACKGROUND

Highly publicized recommendations favor the use of diuretics as a first-line or add-on agent in the management of hypertension, particularly among black patients and patients with resistant hypertension. Failure to follow such guidelines might contribute to high rates of uncontrolled hypertension. This study assessed diuretic prescribing patterns in a sample of black patients with uncontrolled hypertension who were identified from a population of home care recipients.

METHODS

The study was conducted in an urban home health organization. Participants were black, aged 21 to 80 years, and had a diagnosis of hypertension. Participants with uncontrolled hypertension were identified, and in-home interviewers collected information on prescribed antihypertensive medications.

RESULTS

Of 658 participants, 5.5% were not prescribed any antihypertensives, and only 46% were prescribed a diuretic. Participants who were not taking a diuretic were taking fewer antihypertensive medications (1.7 vs. 2.9; P < 0.0001), had a higher mean diastolic blood pressure (89.2 vs. 85.5; P = 0.0005), and were more likely to have a systolic blood pressure ≥160mm Hg (57.6% vs. 49.0%; P = 0.04). The adjusted mean systolic and diastolic blood pressures were 5 and 4mm Hg lower, respectively, in patients who were taking a diuretic.

CONCLUSIONS

In this sample of black patients with uncontrolled hypertension, despite wide publicizing of the recommendations for use of diuretics, a majority are still not receiving a diuretic. This important issue merits continued attention.

Hyperinsulinemia euglycemia therapy for calcium channel blocker overdose: a case report

We report the case of a patient with calcium channel blocker toxicity who was treated successfully with hyperinsulinemia euglycemia therapy, without prior use of vasopressors. The patient was a 60-year-old man with schizoaffective disorder who presented with severe hemodynamic compromise after an intentional overdose of 5,400 mg of extended-release diltiazem. He had been admitted to the hospital twice before for attempted suicide with diltiazem and nifedipine, respectively. During the previous admissions, conventional treatments were used, and complications included hemodynamic compromise, ischemic bowel requiring ileostomy, and a prolonged hospital stay. During the current admission, the patient's clinical condition failed to improve after treatment with charcoal, fluid resuscitation, calcium, and glucagon. Eight hours after admission, hyperinsulinemia euglycemia therapy was initiated; 3 hours later, the patient's hemodynamic status showed sustained improvement. His bradycardia and hypotension resolved without cardiac pacing or vasopressors. Hyperinsulinemia euglycemia therapy is a potentially life-saving treatment for calcium channel blocker toxicity. We suggest that such therapy should be considered early, in conjunction with conventional therapy, for the treatment of calcium channel blocker overdose in patients not responding to initial treatment.

Older blood pressure medications-do they still have a place?

Hypertension is a major risk factor for cardiovascular disease, but control of hypertension remains inadequate, often because of poor patient adherence to prescribed medical regimens that are viewed as poorly tolerated and expensive. Physicians have largely stopped using some older blood pressure medications in favor of newer agents, mostly because of a presumed more favorable side effect profile. The investigators reviewed the pharmacologic properties and the evidence supporting the effectiveness and tolerability of several older blood pressure drugs: sympatholytic agents such as reserpine, methyldopa, and clonidine; diuretics such as chlorthalidone, ethacrynic acid and spironolactone; the vasodilators hydralazine and minoxidil; and others. In conclusion, some of these drugs are well studied and represent alternatives for patients who cannot afford or tolerate newer medications.