Leon is an African American, 55-year-old male. He is a non-smoker, is a nondrinker, and has a healthy weight for his height
On weekends, he coaches a youth baseball team in his community and loves to eat hot dogs and nachos with the children after they play. Leon attends a community health clinic to have a routine urinalysis and blood pressure monitored. At his last visit, his blood pressure was 168/92 mm Hg. Although Leon was pleased that "the lower number dropped from 96 to 92," his physician was still concerned. He warned Leon about the dietary choices he was making and reminded him to limit his salt intake. He also renewed Leon's prescription for diuretics and added an ACE inhibitor to Leon's treatment regime.
Speculate how Leon's ethnicity contributes to his hypertension. What other determinants of health contribute to the prevalence of hypertensive disease in this population?
What is the significance of an elevated systolic pressure, even in the absence of diastolic hypertension?
What is the mechanism of action of the two classes of drugs Leon was prescribed for the management of his hypertension?
The reason for the high incidence of hypertension among African Americans is not entirely clear. Salt sensitivity, or the increase of blood pressure in response to a high-sodium diet, has been speculated. This condition is thought to involve an impaired renal sodium transport mechanism. Increased vasomotor tone and abnormal endothelium-dependent vasodilation are other possibilities for the prevalence of hypertension among African Americans.
Barriers to care are noteworthy in this population. There are frequently financial considerations, difficulties in accessing health care, or long wait times for treatment. Furthermore, health education materials may not be culturally sensitive and fail to address the high rate of salt sensitivity, smoking, and obesity among African Americans.
An elevated systolic pressure, even in the absence of diastolic hypertension, carries with it a high risk for cardiovascular disease. Increased systole is associated with left ventricular hypertrophy, increased myocardial demand for oxygen, and subsequent heart failure. An absolute or relative decrease in diastolic pressure limits coronary perfusion. Finally, a widened pulse pressure damages arterial tissues and predisposes an individual to atherosclerosis and aneurysm formation.
Diuretics reduce blood pressure by increasing renal secretion of sodium and water. They reduce cardiac output and with prolonged use, decrease peripheral vascular resistance. ACE inhibitors limit the activity of ACE in converting angiotensin I to angiotensin II. As a result, less circulating angiotensin II is available to trigger aldosterone secretion and vasoconstriction. ACE inhibitors also inhibit bradykinin degradation and stimulate the production of prostaglandins that have a vasodilating effect.
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