Hypertensive men living in a southern city: is it a recipe for disaster?

Hypertension affects over 65 million Americans; nearly 30% of the adult population, with the highest prevalence in the southeastern part of the United States. (1) Furthermore, this region has higher complication rates of hypertension-related diseases, such as stroke, cardiovascular events, and kidney failure. (1) It has been well documented that effective control of blood pressure (BP) reduces the rate of complications, yet studies have persistently shown that only about three in ten adult Americans with hypertension have blood pressure values that are controlled to the goal of <140/90 mmHg. (2)

The high prevalence of uncontrolled hypertension in the southeastern US has been generally attributed to the large population of African Americans living in this area, as well as limited access to medical care and low socioeconomic status due to the largely rural population. In this issue of the Journal, King and Crisp (3) challenge this assumption and report that male sex and urban living in the southeastern part of United States are strongly associated with uncontrolled hypertension. The investigators audited 300 outpatient medical records of patients with hypertension, 100 each from an urban university family practice center, an urban residency practice, and a rural private practice. They collected demographic information, comorbid conditions, treatment factors, and assessed adherence to the treatment regimen. Their analysis showed that male gender was associated with a twofold increased risk of uncontrolled hypertension and residence in urban areas was associated with a more than threefold increase in risk. Age, race, total number of medications, number of visits, and the number of comorbidities were not significantly associated with poor blood pressure control.

There have been conflicting reports on rural-urban differences in hypertension prevalence. One study showed higher hypertension prevalence for men in the nonmetropolitan areas of the southern regions of the US compared with other regions (4) while another did not find any differences. (5)

Hypertension is a complex disease with many nonbiological factors affecting BP control. These factors may be related to the patient, provider practice, or to the healthcare delivery system. Patient-related factors include age, gender, race/ethnicity, SES, disease severity, adherence, availability of insurance, physician trust, and health beliefs, including misperceptions of the seriousness of the problem. (6) Provider-related factors include therapeutic inertia, lack of knowledge and skills, and inadequate communication with patients about their plan of care. (7) System issues include access to care, the cost of treatment, and possibly, lack of financial incentives for better care. (6) Since this study was performed in one geographic area of the United States, it is difficult to generalize their observations to other areas of the US where these factors may be quite different. Regardless, physicians practicing in the urban southeast should take careful note of these findings.

The findings reported in this issue of Journal emphasize the need for specific research and intervention efforts directed toward men living in the southern cities. Why do men living in southern cities have a higher risk of uncontrolled hypertension while women living in the same area do not? What factors are responsible for uncontrolled hypertension in the urban areas?

References

1. Hall WD, Ferrario CM, Moore MA, et al. Hypertension-related morbidity and mortality in the southeastern United States. Am J Med Sci 1997;313:195-209.

2. Borzecki AM, Wong AT, Hickey EC, et al. Hypertension control. How well are we doing? Arch Intern Med 2003;163:2705-2711.

3. King D, Crisp J. Rural-urban differences in factors associated with poor blood pressure control among outpatients. South Med J 2006:99:1221-1223.

4. Roccella EJ, Lenfant C. Regional and racial differences among stroke victims in the United States. Clin Cardiol 1989;12(Suppl 14):IV18-IV22.

5. Gillum RF, Mussolino ME, Madans JH. Relation between region of residence in the United States and hypertension incidence-the NHANES I epidemiologic follow-up study. J Natl Med Assoc 2004;96:625-634.

6. Rehman SU, Hutchison FN, Hendrix K, et al. Ethnic differences in blood pressure control among men at Veterans Affairs clinics and other health care sites. Arch Intern Med 2005;165:1041-1047.

7. Okonofua EC, Simpson KN, Jesri A, et al. Blood pressure control goals therapeutic inertia is an impediment to achieving the Healthy People 2010. Hypertension 2006;47:345-351.

Shakaib U. Rehman, MD, and Florence N. Hutchison, MD

From the Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, SC.

Reprint requests to Shakaib U. Rehman, MD, Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee Street (11C), Charleston, SC 29401. Email: [e-mail]

This work was supported in part by Department of Veterans Affairs Research Service (Drs. Rehman & Hutchison).

Accepted June 16, 2006.