Blood pressure modification
in hypertensive patients
in a community-based clinical trial

Raúl Rizo González M..D, Raúl Rizo Rodríguez M.D, Manuel Vázquez Trigo M.D.,
Norca Alvarez Puig M.D.

ABSTRACT: A community-based clinical trial, involving 45 patients with essential hypertension receiving medical attention at the Julián Grimau Polyclinic in Santiago de Cuba, was carried out with the aim of promoting patient understanding of their illness and increased involvement and responsibility for its control. The patients studied were over 15 years of age and of both sexes. Specifically, risk factor and life-style changes were examined together with impact on the control and management of high blood pressure. McNemar's test and the difference of means for matched observations were used to validate the results, which included statistically significant modifications in blood pressure readings.

Subject Headings: HYPERTENSION/ Preventive control; HEALTH PROMOTION; PATIENT EDUCATION/ methods; COMMUNITY HEALTH SERVICES; KNOWLEDGE; ATTITUDES; PRACTICE; PRIMARY HEALTH CARE.

The fact that high blood pressure diminishes life expectancy has been known for over a century.1  It is considered the most important health problem in the developed countries by a number of authors, affecting approximately 20% of the adult population. The onset of complications is directly proportional to the degree of hypertension.2 However, control and management of hypertension is widely recognized as difficult. The problems underlying this phenomenon are diverse and are associated with issues related to lifestyle, educational level and even the physician-patient relationship, to name a few.

The objectives of this clinical trial included providing hypertensive patients with knowledge about their illness, increasing self-reliance and responsibility for changing noxious habits and lifestyles, and carrying out health promotion and preventive actions aimed at developing generally greater patient consciousness of the condition.

Methods

A community clinical trial involving 45 adult hypertensives receiving attention at Sector No. 22 of Santiago de Cuba's Julián Grimau Community Teaching Polyclinic was carried out. A training program was conducted between November 1994 and April 1995, including three groups with 15, 14 and 16 participants in each.

Each group met for seven weeks, once a week, in two-hour sessions, including the following activities:

First Session: Participant introductions and brief overview of hypertension and group dynamics techniques.

Second Session: Brainstorming on hypertension, risk factors, symptoms and most frequent complications.

Third Session: Group discussion on diet; group dynamics techniques.

Fourth Session: Group discussion on treatment; acupressure and group dynamics techniques.

Fifth Session: Brainstorming on stress; music therapy and group dynamics techniques.

Sixth Session: Group discussion on physical exercise, acupressure and group d ynamics techniques.

Seventh Session: Healthy lifestyles; feedback on the program and individual recommendations; program conclusion.

At the beginning and at the end of each session, the patients' blood pressure was measured and recorded. The blood pressure readings obtained at the first and seventh sessions were compared by using the difference of means for matched observations test and the McNemar test.

Results

Table 1 shows that after the clinical trial the number of patients with mild hypertension increased from 12 to 27 (60.0%) and those with moderate hypertension from 9 to 18 (40.0%), since patients initially classified as severe or very severe responded positively to treatment and moved to the mild or moderate categories.

Table 1. Classification of Patients According to Degree of High Blood Pressure Comparison
              Before and After Intervention

Classification Mild Moderate Severe Extremely Severe BEFORE No. 12 9 17 7 % 26.7 20.0 37.8 15.5 AFTER No. 27 18 - - % 60.0 40.0 - -

Comparing blood pressure readings recorded at the first and seventh sessions (see Table 2), average maximum systolic pressure decreased from 160.68 to 140.61, for a mean difference of 17.61 (X= 17.61), which is statistically significant; and average minimum diastolic pressure went from 104.09 at the first session to 92.50 at the seventh session for a mean difference of 11.25 (X= 11.25), also statistically significant.

Table 2. Mean Values of Maximum and Minimum Systolic and Diastolic Pressure Taken at
              the First, Third, Fifth and Seventh Sessions

Figure 1 shows that average diastolic and systolic pressure, both maximum and minumum, decreased over the clinical trial period.

Discussion

It is well known that treatment of hypertension is aimed at controlling blood pressure, at eliminating or reducing symptoms and at enhancing patients' well-being.

In our opinion, the blood pressure reduction attained in these hypertensive patients resulted from the various factors considered throughout the seven sessions. The following are worth mentioning:

1. Active learning about hypertension enabled patients to conciously participate in the control and treatment of their illness.
    
2. Excellent physician-patient relationship made it possible to personalize treatment and to control the onset of side effects related to it.
    
3. Patients' awareness of the harmful effects of stress and importance of acquiring coping mechanisms enabled them to deal with the strains of daily life.4
    
4. Adherence to an adequate diet was promoted, paying attention to salt intake, consumption of animal fat and carbohydrates, all of which contribute to obesity.5
    
5. Emphasis was placed on avoiding nervous system stimulants and urinary tract irritants.6
    
6. Use of relaxation and acupressure techniques during the program enabled patients to continue these techniques at home.7,8

Furthermore, it is important to highlight that we have closely followed the recommendations formulated in the 1993 Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNCU) on long-term anti-hypertensive treatment.9

Through our intervention, the blood pressure readings (both systolic and diastolic) of all program participants decreased in a statistically significant way. Those patients who had been classified as severe or very severe moved to the mild or moderate categories.

Our results indicate that developing a program for hypertensive patients might prove a helpful strategy for managing hypertension.

References

1. Roccella EJ. Consideraciones epidemiológicas para definir la hipertensión. Clin Med Norteam 1987;71:815-31.
2. Freitas JJ. Manual de terapéutica médica. La Habana: Editorial Cientifico-Técnica, 1983: 175-85. (Edición revolucionaria).
3. Morales CF. El estrés psicológico en el riesgo a enfermar. Su atención en el nivel primario. Rev Cubana Med Gen Integr 1991; 7(1):27-47.
4. Hernández Mesa N, Anías Calderón I. Estrés. Rev Cubana Med Gen Integr 1992; 8(3):261-70.
5. Rigol Ricardo O., Pérez Carballas F., Pérez Corral J., Fernández Sacasas JA, Fernández Mirabal JA. Medicina General Integral. La Habana: Editorial Pueblo y Educación, 1997;t1:118-9.
6. Smetnev AC. Enfermedades internas. Moscú: Editorial Mir, 1986;t2:501-2.
7. Núñez de Villavicencio Porro F. Psicología Médica. Santiago de Cuba: Editorial Oriente, 1987;t2:106-7.
8. Rigol Ricardo O. Manual de acupuntura y digitopuntura para el médico de familia. La Habana: Editorial Ciencias Médicas, 1992:85-102.
9. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The Fifth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med 1993;153:154-83.

This article originally appeared in Spanish in the Revista Cubana de Medicina General Integral , Vol. 14, No. 1, (pp. 27-31), January-February, 1998.

 

Copyright (c) 1999, MEDICC - Medical Education Cooperation with Cuba