CASE 1: POOR BLOOD PRESSURE CONTROL

History - A 56 y/o male (B.M.) with newly-diagnosed hypertension. Patient's physician had ordered hydrochlorthiazide (HCTZ) to control high blood pressure (HBP) of 180s/96-100. After 2 weeks of medication and prior to enrollment into the nurse-managed hypertension clinic (NMHC), the patient took himself off HCTZ. Health assessment revealed several cardiovascular risk factors including heavy tobacco use (105 pack years - 2-3pks/day for 35 years), beer consumption of 3 cases per week, sedentary lifestyle, hypercholesteremia (244 mg/dL), hypertriglyceridemia (196 mg/dL), HDL/LDL ratio 42:164, and overweight (205 lbs., 5'10''). Patient was adamant about three things: staying off HBP medication; continued heavy beer consumption; and continued heavy tobacco use.

Actions - As part of the management, patients are asked to set their own goals. Patient's goals included losing 20 lbs. and beginning an exercise program. Another critical part of the management is educating the patient and family member(s) about hypertension, its causes, its risk factors, its management, its monitoring, and its consequences. Thus, Mr. B.M. and his family received one-on-one education as well as printed education materials, tailored to their needs, readiness, and abilities. Mr. B.M. was also referred to the Health and Wellness Center where he learned more about healthy diet (moderate salt, high potassium, moderate fat, etc.)

Each patient in the NMHC was loaned a blood pressure telemonitoring unit with the capability of transmitting all memorized blood pressure (BP) readings through ordinary telephone lines, using a toll-free number (LifeLink Monitoring.) Patient was taught how to monitor BP, how to transmit the readings, and how to keep a diary of activity and symptoms. Patient was asked to transmit the readings weekly. These readings are available to the nurse for review or action the next working day. Blood pressure monitoring at home enables close monitoring of patients' true condition while cutting down clinic visits. If need be, the nurse can follow up by telephone or arrange for a clinic visit. For some patients, not coming into the clinic means 3-4 hours saved per clinic visit. For other patients, not coming into the clinic means they have blood pressure readings much closer to their true pressures.

Outcomes - In three months, Mr. B.M. had dropped 20 lbs. and began his regular exercise of 30 minutes walking 3-4 times per week. After the initial 10 lbs. weight loss, he realized that his HBP dropped slightly, but was still not close to normal. Mr. B.M. decided to stop the beer consumption to see if it made a difference. He continued to monitor his BP at home at least two times per week. Mr. B.M. saw a marked difference as his BP dropped to within normal range (SBP<140, DBP<90). At the next follow-up visit (a month later), Mr. B.M. commented that the home BP monitor allowed him immediate feedback on the effect of the beer on his BP. He had also explored how many beers he could consume without boosting his BP out of normal range.

Overall Outcomes - MR. B.M. has maintained 1) the 20 lbs. weight loss; 2) the exercise program; and 3) normal BP readings without medication (133/61 to 141/70). He only drinks beer in moderation, on occasion. Upon follow-up at 1 year, Mr. B.M. surprised the nurse by stating that he wanted to quit smoking - a topic that had been "off limits". He is currently enrolled in a tobacco cessation program at our facility. When asked how this NMHC had helped him, Mr B.M. replied, "The stuff you've given me and your interest made me realize that I was going down the wrong road and needed to turn around. I feel better now than I have in years."

CASE 2: WHITE COAT RESISTANCE

History - A 64 y/o white male (Mr. K.B.) with hypertension diagnosed in 1998. Mr. K.B. was started on a beta blocker, and BP readings in the clinic were 140-150/85-90. All vital sign readings reported at prior clinic visits showed a pulse rate of 60-80 beats per minute. Mr. K.B. entered into the NMHC in the late spring of 1999. At the time Mr. K.B. did not have any complaints.

Action - Mr. K.B. was given educational information on his HBP medication and on managing HBP. He was also instructed on the use of a home BP telemonitor. During the first 2 weeks of enrollment into the NMHC, Mr. K.B. contacted the nurse on several occasions to report a frequent "Error" message on the pulse reading. The weekly-transmitted logs were showing pulses ranging from 40-52. During the next clinic visit, he was instructed on taking a manual radial pulse. Upon further questioning, it was learned that throughout the day he had to take frequent naps, which bothered him because napping was interfering with taking care of his large vegetable garden. "I've always had a big garden, but I can't hardly keep up with it, or any other work that I've to do around my farm. I get up for a couple of hours, eat breakfast, do a little work and fall asleep in my chair. Then I'm just too tired to go back out in the heat. Guess my age is catching up with me." The next week, Mr. K.B. reported manual pulses ranging from 35-42 beats per minute, although pulses remained greater than 60 in the clinic. An EKG was performed which showed marked sinus bradycardia with a rate of 36 per minute. Holter monitoring showed a low mean heart rate with rare Premature Ventricular Contractions (PVC's). The physician weaned Mr. K.B. off Atenolol and replaced with Norvasc. Mr. K.B. was followed closely in the NMHC weekly for the next 3 weeks and the results were startling.

Outcomes - Mr. K.B.'s mental acuity was markedly sharper, his previous energy level had returned and his BPs remained in the range of 137-140/85-88. The pulse rates had increased to 62-76 beats per minutes. The naps were no longer required and he was working diligently to bring in the garden. Mr. K.B. said, "My wife can't believe the change in me. I didn't realize how bad I felt. I've got my life back and I think my cylinders have quite a few goods years left on them." The home blood pressure monitoring caught the bradycardia that was not seen in the clinic.

CASE 3: WHITE COAT HYPERTENSION

History - A 62-year-old white female (Ms D.H.) enrolled in the NMHC with clinic BP readings consistently 170-180/90-96. She was taking Maxide. Ms D.H. reported fatigue and dizziness at her enrollment visit.

Actions - After educating Ms D.H. and her husband about hypertension and her medication, the nurse instructed Ms D.H. on the use of the home blood pressure telemonitor. Ms D.H. was asked to take her BP at least twice at home: prior to getting out of bed in the morning, and prior to going to sleep at night. The patient was also instructed to download her BP readings by telephone once a week. Home readings showed BPs ranging from 90-110/60-70, but clinic BP readings remained 170-180/90-96. The home blood pressure monitor was consistent with clinic BP monitor when cross-validated in the clinic. Ms D.H. continued to complain of loss of energy. Based on the home blood pressure readings, Ms D.H. was diagnosed with White Coat Syndrome, and taken off Maxide.

Outcomes - Ms D.H. reported increased energy and absence of drying signs/symptoms. She was very pleased that her skin had stopped flaking, the moisture had returned, and she had no more itchiness. Instead of monitoring her BP three times a week, Ms D.H. chose to monitor her BP at least twice a day religiously. Ms D.H. has been followed over the last three months and has maintained BP within normal range (119-126/74-76).