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  1. 1. Clinical Cornerstone HYPERTENSION IN HISPANICS Vol. 6, No. 3 C A S E S T U D I E S Treatment of Hypertension in the Hispanic Community: Cultural Case Studies 0 5 , 20 c Juan M. Aranda, Jr, MD, FACC Jose A. Orcasita-Ng, MD Gainesville, Florida In Hialeah, Florida c a Lupu,l , Viorel a MD i i rc ed Julian Marquez, MD Hialeah, Florida Taylor, Michigan p ta e m on M er m i Ex C o u t INTRODUCTION c uncontrolled hypertension, obesity, dyslipidemia, and ib People of Hispanic origin are the fastest growing ethnic osteoarthritis. This is the first time she presented with t © or r minority in the United States and often have hyperten- neurological symptoms; there is no history of cere- rig t f i s t h sion and other comorbidities that contribute to athero- brovascular accident. She took garlic pills to improve op N o sclerosis.1 Despite this observation, the Sixth and y her health, included grapefruit juice in her diet, and C D Seventh Reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of maintained a low-salt diet. The patient believed that “strong emotions” played a role in her illness. High Blood Pressure (JNC-VI, JNC-VII) acknowledge a difference in prevalence and blood pressure (BP) con- Physical Examination and Laboratory Studies trol rates among minority populations; however, no spe- Physical examination revealed an elderly, obese His- cific treatment recommendations are made for Hispanic panic woman. Electrocardiogram and Holter monitor patients.2,3 indicated a supraventricular arrhythmia; an echocardio- The Hispanic Advisory Board for Hypertension gram showed decreased left ventricular compliance and Working Group was created in 2003 to bring together left ventricular hypertrophy. Doppler imaging revealed experienced Hispanic physicians representing dif- 25% to 30% stenosis of the carotid arteries. A chemistry ferent regions of the United States with the goal of panel, complete blood count, and urinalysis were with- identifying differences in awareness, educational in normal limits, however, lipid panel abnormalities language, and cultural practice patterns that lead to included elevations of total cholesterol (312 mg/dL) and the undertreatment of hypertension in the Hispanic low-density lipoprotein cholesterol (216 mg/dL). community. The following case presentations begin to identify the challenges and issues that are involved Diagnosis and Specific Treatment in the treatment of hypertension in Hispanics. Recommendations The patient’s diagnoses were left-sided heart failure CASE ONE and carotid atherosclerosis compatible with malignant, Presentation and History uncontrolled hypertension, and presumed cerebro- An 84-year-old widowed, Cuban housewife and 30- vascular accident. The patient’s BP goal was set at year resident of the United States presented with acute 120/80 mm Hg. She was instructed to reduce the fat neurological symptoms of headache, dizziness, blurred in her diet, to keep her salt intake low, and to reduce vision, and unstable gait, accompanied by hypertension her overall caloric intake. Amlodipine plus benazepril (BP 170/112 mm Hg). Her medical history included 5 mg/20 mg once daily was prescribed to control hypertension. Additional medical therapy included (Clinical Cornerstone. 2004;6[3]:71–75) clopidogrel 75 mg once daily for secondary prevention Copyright © 2004 Excerpta Medica. of ischemic stroke, a statin for hypercholesterolemia, 71
  2. 2. Clinical Cornerstone HYPERTENSION IN HISPANICS Vol. 6, No. 3 pravachol 40 mg at dinner time, lansoprazole 30 mg contact; however, her daughter used this opportuni- per day for indigestion, and celecoxib 200 mg once ty to reinforce the serious nature of the conse- daily for osteoarthritis. quences of her mother’s noncompliance. The physician—in Spanish—repeated the daughter’s Treatment Strategy (Cultural Issues) appeal for compliance. In the case of a complica- The initial office visit was conducted in Spanish tion such as a stroke or heart attack, the family because the patient spoke very little English. She would be unable to care for her at home and the was accompanied by her daughter. The patient mother’s independence would be lost. The instruc- claimed to be aware that her obesity, inactivity, lipid tions were repeated in both Spanish and English in abnormalities, and history of hypertension con- full to all family members who accompanied her at tributed to her high risk for both cardiovascular and each visit. As more family members became in- neurological disease, yet she had made little prior volved with their mother’s care, they collectively attempt at improving these problems. Both her supported her in taking control over her health and body weight and her osteoarthritis limited her abil- treatment plan. At a subsequent follow-up visit, her ity to exercise. Nevertheless, because of her acute BP was normal, 120/70 mm Hg, despite a small presentation, she was advised by her physician of weight gain. The patient was cautiously optimistic the urgent need to control her hypertension and to about her treatment, given a typical degree of Latino become an active participant in her treatment plan. fatalism that death is unavoidable. Practical strategies used by the office staff included visual tools—in this case, normal and high BP val- Summary ues on a simple chart—to demonstrate normal BP Several cultural aspects of this patient’s case values. She was given an example of a normal BP have implications for the patient’s successful treat- reading to take home and shown how to monitor her ment strategy. The patient had been taking tradi- own BP. Office staff gave her a set of forms to tional herbs in the mistaken belief that they were record her daily BP readings with the understanding sufficient to prevent and control her symptoms of that they would be reviewed later by her physician severe hypertension. Although there is no absolute at the next follow-up. The patient was asked to contraindication to the concomitant use of garlic repeat to the staff what she had been instructed to and clopidogrel by carefully controlled trials, there do to confirm to them her understanding of her care. is a dose-related decrease in platelet aggregation Instructions to the patient were repeated for her with garlic.4 Therefore, it would seem prudent to adult daughter as well. Because of the strong fam- discontinue the garlic. The family bond was strong ily ties between them, the daughter was appointed and the mother, however independent, relied on her as the “supervisor” in her mother’s treatment plan. adult daughter for help in managing lifestyle The mother, although clearly independent, would changes and BP monitoring. The patient’s initial need her daughter’s help to manage her lifestyle noncompliance with medical therapy underscores modifications and medical treatment in order to the need for a simple dosing regimen (with benazapril/ maximize her compliance. The daughter agreed to amlodipine) as a first-line strategy for better com- oversee her mother’s BP reports with the home pliance.5 The patient’s diagnosis and urgent need monitoring system. She encouraged her mother to for treatment were repeatedly reinforced through a be truthful in these daily reports and not to change series of discussions with her daughter and other elevated readings or fail to record them. Only family members in the presence of the physician. through actual readings would the physician be able Once the diagnosis was made and the treatment to evaluate her progress and adjust her regimen. regimen decided, the physician supported the family in the context of their mother’s care. This series of Follow-Up discussions over time was absolutely essential for At the first follow-up visit, her BP was still ele- the patient’s gradual understanding of the serious- vated (160/70 mm Hg). When confronted with this ness of her illness and the efforts she would need finding, the patient became evasive and avoided eye to overcome it. However, it was only through her 72
  3. 3. Clinical Cornerstone HYPERTENSION IN HISPANICS Vol. 6, No. 3 daughter’s appeal that a stroke or heart attack threatened Diagnosis and Specific Treatment her mother’s independence that the patient assumed Recommendations final responsibility for her illness, eventually becoming At the conclusion of the initial visit the patient treatment-compliant and meeting her target BP goal. had been given different visuals and articles dis- cussing BP risk and new goals to stay healthy had CASE TWO been explained to him. When he returned for follow- Presentation and History up after having recorded his BP readings as he had A 65-year-old married, Colombian man who has been advised, he was well aware and, once he found been in the United States for 30 years and is a the BP readings to be persistently above normal, he retired banker paid a return visit to his physician’s was in agreement with the diagnosis of HBP. He office in July of 2004 for follow-up of hypertension. understood the risk he was exposed to as a result of He is not at all proficient with the English language. HBP and he asked to be started on medication. He The patient had been seen once previously and, at was aware that most medications can cause side the time of the initial visit, was noted to have a BP effects that can be serious or affect his quality of reading of 140/92 mm Hg. He was informed at the life. He asked to be treated with a medication that time that he may have high blood pressure (HBP), was among the safest on the market, that would be but the patient was asymptomatic and challenged covered by his health plan, that would not cause the diagnosis. Despite the patient’s skepticism he further deterioration of his sex life, interfere with was trained how to monitor his BP and record the ability to play golf, or adversely affect his lipid pro- readings on a form designed by his physician. The file. He had a family member who had been treated patient was also advised that acceptable readings with an angiotensin-converting enzyme inhibitor for BP are below 140/90 mm Hg and that it would who was coughing, so he preferred not to use this be even better to have readings at the 130/80 mm Hg type of medication. The patient was treated with level to prevent the acute and chronic complica- valsartan with hydrochlorothiazide (80 mg/12.5 mg) tions of HBP. He adopted a low-salt diet; used gar- every morning. lic and savila leaf to treat himself for HBP. At the follow-up visit, the patient’s BP was 160/100 mm Hg Treatment Strategy (Cultural Issues) and the readings he had recorded since his ini- The patient comes alone to his doctor’s visits. tial visit showed that 9 of 13 readings were above He is given a form to record BP and basic informa- 140/90 mm Hg, with the average being 150/98 mm tion, and is able to complete the form without prob- Hg. He denied peripheral edema, palpitations, short- lems. A medical assistant reinforces the informa- ness of breath, or any other problems related to the tion about BP goal targets, staying healthy, and BP. The review of systems was positive for hypo- continuing to monitor his BP. These instructions gonadism and lumbar spine stenosis causing chronic are given to the patient in Spanish. The patient is pain. His current medications were ranitidine, di- asked to verbalize all the information and education phenhydramine, and meloxicam, and his medical he received with the medical assistant prior to leav- history is significant for surgical decompression of ing the office, and the medical assistant indicates to the lumbar spine. the physician that all of the information has been clearly understood by the patient. He continues to Physical Examination and Laboratory Studies use garlic and savila leaf in addition to the doctor- Physical examination revealed a well-developed, prescribed medication. well-nourished, Hispanic man with a healed surgi- cal scar on his back but no signs of muscle atrophy. Follow-Up BP was 160/100 mm Hg. Cardiovascular examina- The patient was back 2 weeks later with BP readings tion was normal. Urinalysis was normal without any ranging from 120/80 to 130/80 on average. He report- evidence of albuminuria. Labs showed no alteration ed no side effects related to the use of the combination except for low testosterone and mildly elevated therapy. The medication was creating no problems with cholesterol with a borderline HDL of 38. his quality of life or his time playing golf. He has had 73
  4. 4. Clinical Cornerstone HYPERTENSION IN HISPANICS Vol. 6, No. 3 an exacerbation of the low back pain and arthritis that ities were noted. Urinalysis was normal without any he has suffered from in the past, but he continues to be evidence of albuminuria. Hemoglobin A1C was normotensive despite large doses of prednisone pre- 6.2%. Hemoglobin was 12.6 g/dL. The electrolytes, scribed by his rheumatologist. total cholesterol, high-density lipoprotein, and low- density lipoprotein were all within normal range. Summary Chest x-ray showed mild-to-moderate emphysema- This patient, despite being in the United States for tous changes with cardiomegaly. The electrocardio- over 3 decades, has limited English proficiency. His gram showed normal sinus rhythm with an occasional ease at understanding instructions given and complet- premature ventricular contraction and evidence of left ing forms at his physician’s office suggests that the ventricular hypertrophy. people at the clinician’s office provide this informa- tion in Spanish. Initially, this patient was in denial, Diagnosis and Specific Treatment refusing to believe that he had a problem with HBP Recommendations and this might be reflective of the Latino concept of This patient had poorly controlled hypertension. “machismo,” where an illness might be perceived A new BP goal of 120/80 mm Hg was set for him. to be a sign of weakness. Although he came to his The combination of losartan + hydrochlorothiazide doctor’s visits alone, he drew on the experiences of 100/25 and amlodipine was discontinued, and the friends and relatives to acknowledge that HBP is a patient was started on furosemide, long-acting serious condition that needs treatment and to help him diltiazem, and continued single agent losartan. The make decisions about the kind of treatment he felt patient had very little insight about the pathophysiol- would be acceptable to him. His wife, though not ogy of hypertension, the risk of complications, and present with him during his doctor encounters, was the importance of treatment at the time. In addition to described as supportive and was helping the patient modifying his medications, he received education maintain a healthy lifestyle through dietary modifica- about the potential complications of hypertension tion. He continued to use herbal remedies even after and the importance of treatment. The visual aids and being prescribed medication for his hypertension; literature used with him was primarily in English, therefore, physicians treating him need to remain alert since the patient was quite proficient in the use of to the potential for drug interactions. The patient was English. The patient was also encouraged to come to optimistic about his prognosis. the office any time, even without an appointment, to have his coagulation status and BP checked. CASE THREE Presentation and History Treatment Strategy (Cultural Issues) A 76-year-old widower who moved from Mexico The most important thing for increasing this to the United States 50 years ago was evaluated patient’s compliance was to make him feel comfort- for complaints of dyspnea on exertion, fatigue, leg able in his interactions with the doctor’s office. He pain, and orthopnea. The patient’s command of the was no longer given appointments, but rather was English language was very good. His medical his- encouraged to come to the office at least once a week tory was noteworthy for the presence of multiple for the first year to have his BP measured, check his thrombotic episodes requiring chronic anticoagula- prothrombin time/international normalized ratio, and tion, chronic obstructive pulmonary disease, and alco- discuss his day-to-day problems. This made the hol abuse. His medications consisted of losartan + patient quite comfortable and occasionally enthusias- hydrochlorothiazide 100/25, temazepam, amlodipine, tic about improving the plan. A clear bond was cre- and warfarin 3 mg and 4 mg on alternating days. ated between the physician and the patient, and the patient and the office staff as well. The patient dis- Physical Examination and Laboratory Studies continued all alcohol intake once he was seeing the Physical examination revealed a well-developed, doctor on a regular basis. Family help was also well-nourished, Hispanic man whose BP was essential and at least once a year the patient brings 190/100 mm Hg. No physical examination abnormal- his daughter for a meeting where the treatment plan 74
  5. 5. Clinical Cornerstone HYPERTENSION IN HISPANICS Vol. 6, No. 3 and compliance issues are discussed with her, her refractory hypertension is inadequate diuresis, often father, and the office team. The patient was also given secondary to reduced glomerular filtration. Since an abundance of literature to review at home that this patient appears to have responded to furo- described the pathophysiology of hypertension and semide over a thiazide diuretic, a 24-hour creatinine expected treatment outcomes. Most of the literature clearance should be performed.6 Second, the glyco- was in English since the patient was quite comfort- hemoglobin was abnormal at 6.2 corresponding to a able with the English language. mean blood glucose of 120. This is strongly suspi- cious for metabolic syndrome, and a waistline Follow-Up measurement should be obtained. If this patient is His BP has been decreasing steadily and at the time overweight, a 5% weight loss could reduce this of his last office visit it was 124/82 mm Hg. The patient patient’s chance of developing diabetes by 58%.7 has faithfully been taking his medication as instructed. He is able to walk approximately 2 to 3 blocks without REFERENCES any shortness of breath. His lipid profile and other labs 1. The Hispanic Population in the United States. March have remained normal, and his chest x-ray is stable with 2002. US Census Bureau. no sign of any acute disease processes. 2. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;57:2413– Summary 2475. This patient had good command of English, 3. Chobanian AV, Bakris GL, Black HR, et al. Seventh so most of the interactions and teaching that he par- Report of the Joint National Committee on Prevention, ticipated in was conducted in English. Over time, Detection, Evaluation, and Treatment of High Blood the patient developed a very good relationship with Pressure. Hypertension. 2003;42:1206–1252. the doctor’s office and relied on that relationship to 4. Cooperative Group for Essential Oil of Garlic. The support making changes that would ensure he was effect of essential oil of garlic on hyperlidemia and maintaining good health. The involvement of the platelet inhibition—an analysis of 308 cases. J Tradit patient’s daughter was absolutely essential, since he Chin Med. 1986;6:117–120. had started drinking and neglecting his health fol- 5. Schroeder K, Fahey T, Ebrahim S. How can we improve lowing the death of his wife. Involving his daugh- adherence to blood pressure-lowering medication in ter in the treatment plan gave him someone else ambulatory care? Arch Intern Med. 2004;164:722–732. 6. Setaro JF, Black HR. Refractory hypertension, N Engl outside of the office on whom he could rely for J Med. 1992;327:543–547. guidance and support, and so that she, in turn, could 7. Knowler WC, Barrett-Connor E, Fowler SE, et al, for oversee his compliance with the plan. the Diabetes Prevention Program Research Group. Two other issues deserve mention. First, drug- Reduction in the incidence of type 2 diabetes with resistant hypertension is defined as BP >140/90 mm Hg lifestyle intervention or metformin. N Engl J Med. 2002; on 3 or more medications. One of the causes of 346:393–403. 75