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Clinical Decisionmaking

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Following protocols for managing hypertension and metabolic syndrome can reduce cardiovascular risk factors

Obesity is driving the growing prevalence of risk and disease from hypertension and metabolic syndrome. Using a treatment protocol based on research evidence to manage hypertension and metabolic syndrome (which includes abdominal obesity, hypertension, diabetes mellitus, and high levels of cholesterol and triglycerides) can reduce blood pressure, low-density lipoprotein cholesterol (LDL-C), and blood sugar to target levels among a majority of primary care patients. These are the findings of a recent study by researchers at the Low Country Medical Group, Beaufort, SC, and the Medical University of South Carolina in Charleston. Their work was supported in part by the Agency for Healthcare Research and Quality (HS10871).

The researchers obtained longitudinal data on three cardiovascular risk factors: blood pressure, LDL-C (so-called "bad" cholesterol because it builds up and clogs arteries), and hemoglobin A1C (HbA1c, an indicator of blood-sugar levels), as well as coexisting cardiovascular and renal disease and treatment medications on study participants. Data were gathered on all 817 hypertensive patients (55 percent of whom were considered high-risk) seen from January 1, 2000, to June 30, 2003, in a rural primary care practice. Most patients were managed in quarterly office visits of 15 to 25 minutes each.

The physician changed therapy at every visit if any risk factor was not at goal, beginning with the medication recommended at the top of the list for each risk factor. Patients received educational materials on diet, exercise, medications, and insulin titration. This approach achieved better rates of cardiovascular risk factor control than are generally reported in primary care practices. Blood pressure was less than 140/90 mm Hg in 77 percent of all patients. Among the high-risk patients, mean blood pressure was 126/71 on 2.8 antihypertensive medications. Among those with hypertension and high cholesterol, LDL-C was controlled to less than 130 mg/dL in 84 percent of patients overall and to less than 100 mg/dL in 70 percent of patients in the high-risk group. Among those patients with both diabetes and hypertension, the mean HbA1c was 6.8 percent, and 64 percent were less than the target 7 percent.

For more details, see "A systematic approach to managing hypertension and the metabolic syndrome in primary care," by William H. Bestermann, M.D., Daniel T. Lackland, Dr.P.H., Jessica E. Riehle, and Brent M. Egan, M.D., in the October 2004 Southern Medical Journal 97(10), pp. 933-938.

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