Improving compliance in an inner-city hypertensive patient population.

Because hypertension is a "silent" disease process, compliance with therapy is always a problem. In the inner city, where socioeconomic factors such as poverty, illiteracy, and substance abuse raise additional barriers to effective health care, poor compliance with antihypertensive regimens can reach epidemic proportions--as it did in our clinic in the early 1970s. After identifying the major causes of poor compliance in our patients, we instituted measures that led directly to greatly improved compliance and control, among them the expansion of clinic hours, the expediting of laboratory services, and the training of nurse-therapists to assume many of the responsibilities of running the clinic. In recent years a number of new antihypertensive agents have been introduced, and these new drugs have afforded patients better blood pressure control through less complex drug regimens with fewer serious side effects. Indeed, we observed a strong correlation between patient compliance and the administration of agents with longer dosing intervals and improved side effects profiles. This observation led us to consider whether transdermal clonidine--which requires weekly, rather than daily, administration--might not be an especially effective means of controlling blood pressure in inner-city patients. To test this hypothesis, we enrolled 20 patients, all of them blacks, in a pilot study of this unique delivery system. Blood pressure was adequately controlled in all 18 patients who completed the study, and patients were uniformly enthusiastic about this alternative to daily dosing. As a result, compliance with this mode of therapy was excellent.

Centrally acting alpha-2 agonists, peripherally acting adrenergic-blocking drugs, and direct vasodilators in the treatment of mild and moderate essential hypertension.

The experience with three groups of antihypertensive agents in a large hypertension clinic serving a black patient population is reported. A retrospective review of clinic records was undertaken to determine the efficacy and adverse effects of the centrally acting adrenergic agonists methyldopa and clonidine, the alpha-1 antagonist prazosin, and the direct vasodilator hydralazine in patients with mild and moderate hypertension. Treatment with methyldopa, clonidine, or prazosin, usually in combination with a diuretic produced a 30 to 38 mmHg decrease in systolic blood pressure, and a 24 to 28 mmHg reduction in diastolic blood pressure. Similar declines in blood pressure levels occurred when hydralazine was used with an alpha-2 adrenergic agonist or beta-adrenoceptor blocking agent. Evidence of clinical efficacy, defined as a decrease in systolic blood pressure to below 140 mmHg and in diastolic blood pressure to below 90 mmHg, was observed in 80% or more of the patients. An 88% efficacy rate was seen with methyldopa. Effective doses of the drugs varied considerably; most patients, however, responded at a dose close to the average dose for each agent. The most serious adverse effect observed was elevation of hepatic enzyme levels in patients receiving methyldopa, which necessitated withdrawal of the drug. Two patients treated with 0.4 mg clonidine twice a day experienced "rebound" hypertension when the drug was abruptly discontinued. Overall, good clinical efficacy and patient acceptance were found with these three groups of antihypertensive agents.