Type A, Race, Anger, Forgiveness, Plus Stroke, HRT, and Hydralazine - The Bad, the Good, and the To-Be-Avoided

November 14, 2003

In This Article

First Study of Intensive Intervention Targeting High-Risk, Young Urban African-American Men

A comprehensive intervention conducted at the community level by a multidisciplinary healthcare team among young African-American men has demonstrated the benefits of a more intensive approach toward blood pressure control among this group.[12]

Researchers from Johns Hopkins University (Baltimore, Maryland) conducted a randomized clinical trial in 309 urban African-American men living in an inner city area of Baltimore described as "one of the most impoverished urban environments in the US." The men were aged 21-54 years and all were hypertensive (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg). Just over half (53%) were taking antihypertensive medication(s) and approximately one fifth (19%) had controlled blood pressure (< 140/90 mm Hg). Rates of smoking, obesity, cigarette smoking, excess alcohol consumption, and illicit drug use were high among this cohort, as were unemployment, low income, and lack of health insurance.

Of the 309 men, 157 were randomized to receive a more intensive comprehensive educational-behavioral/pharmacologic intervention by a nurse practitioner/community health worker physician team and 152 to a less intensive education and referral intervention in controlling blood pressure. The more intensive care group received individual attention from a community health worker who made home visits and provided social services that included referrals, job training, and housing assistance, and a physician who was available for consultation. These men also received free antihypertensive medication, including progressive titration of losartan (50-100 mg) and losartan/hydrochlorothiazide (50/12.5 to 100/25 mg). This was further individualized according to the Sixth Report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure[13] guidelines. The men in the less intensive group received referral to sources of hypertension care within the community and a phone call twice a year to provide counseling. Men in both groups were seen annually at the Outpatient General Clinical Research Center, where blood pressure, left ventricular mass (LVM), serum creatinine, total cholesterol, and HDL cholesterol were measured and diabetes testing and illicit drug screening performed.

At 36 months, the proportion of men with controlled blood pressure was significantly higher in the more intensive group compared with the less intensive group (44% vs 31%, P = .045). LVM increased in both groups at follow-up, but was significantly lower in the more intensive group at 36 months than in the less intensive group (274 g vs 311 g, P < .004). The more intensive group showed a trend toward slowing of progression of renal insufficiency (incidence of 50% increase in serum creatinine) compared with the less intense group (5.2% vs 8.0%, P = .08). Over time, both groups showed significant decreases in the proportions of men who reported smoking or eating salty food "all or most of the time" and who had low serum HDL-cholesterol. The high rates of obesity and illicit drug use remained unchanged at 36 months, however.

According to principal investigator Martha N Hill, PhD, RN, this is the first study to specifically target high-risk, young, urban African-American men, who are underserved by the healthcare system. She noted that for many of the men who participated in the study, it was the first time that they had contact with formal healthcare, and they were pleased to take part in the research and improve their health. The team approach was key to achieving control of hypertension and to retaining more than 90% of the men in the study protocol over 3 years, she stressed. She and her colleagues believe that culturally appropriate outreach efforts and individualized care are needed to attain blood pressure reductions in this high-risk population.


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