|Year : 2006 | Volume
| Issue : 1 | Page : 38-46
|Management of Hypertension in Adults with Diabetes
Department of Nephrology, King Saud University, Riyadh, Saudi Arabia
Click here for correspondence address and email
|How to cite this article:|
Alsuwaida A. Management of Hypertension in Adults with Diabetes. Saudi J Kidney Dis Transpl 2006;17:38-46
| Introduction|| |
Hypertension and diabetes mellitus are common diseases in the Kingdom of Saudi Arabia (KSA), related in part to improved living conditions and increasing rates of obesity. ,,,, One in five adults in the KSA has hypertension  and more than three million adults have diabetes., It is projected that the incidence of diabetes will continue to grow and that the majority of the cases will be type II diabetes. Diabetes Mellitus (DM) is a strong predictor of cardiovascular events., The increased risk of cardiovascular morbidity and mortality is about 2fold in men and 4-fold in women, and cardiovascular disease is the leading cause of death among diabetic patients. DM is also the most important cause of end-stage renal disease in KSA, accounting for almost 40% of the cases. Diabetic retinopathy is one of the major causes of blindness in the general population. Taken together, the health burden of DM is enormous. Hypertension and DM frequently coexist., Among type II diabetics, 40 to 50% have hypertension compared to 20% of matched nondiabetic patients. Also, hypertensive patients have a 2-fold increased risk of developing type II diabetes in their lifetime. The presence of hypertension in diabetic patients dramatically increases the rate of complications. In the United Kingdom Prospective Diabetes Study (UKPDS), for example, the incidence of any aggregate end-point related to diabetes was strongly and linearly associated with systolic blood pressure (BP) and over the range of systolic BP from less than 120 mm Hg to greater than 160 mm Hg the likelyhood of a cardiovascular event increased 2fold. Additionally, the absolute event rate in diabetic patients is substantially higher than that in non-diabetic patients at the same level of BP.
| Clinical trials in hypertensive diabetic patients|| |
Benefits of treatment to control blood pressure
The health benefits of lowering BP in hypertensive diabetic patients are well documented in a large number of clinical trials. Additionally, there is trial evidence of improved outcomes with aggressive treatment to a lower goal pressure than that recommended for uncomplicated hypertension. These findings have led to recommendations that all hypertensive diabetic patients should be treated with antihypertensive medication and the goal of therapy should be to decrease BP to less than 130/80 mm Hg. ,,,,
Choice of pharmacological therapy
All the major classes of antihypertensive agents (diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel antagonists) are highly effective in reducing cardiovascular events in diabetic patients.,,, Although the beneficial effects in hypertensive trials have been attributed to the fall in BP with active therapy, data from HOPE and LIFE trials suggest that agents disrupting the function of the renin-angiotensin system improve outcomes by means beyond their effects on BP. , In the HOPE trial, the addition of the ACE inhibitor, ramipril, to standard therapy significantly reduced the rates of death and major cardiovascular events in a broad range of high-risk patients including those with diabetes and hypertension, despite modest differences in office BP readings compared to placebo. The LIFE trial demonstrated that, despite comparable reductions in BP, angiotensin II receptor blocker (ARB)based treatment with losartan significantly reduced the incidence of the composite endpoint of cardiovascular morbidity and mortality to a greater extent than atenololbased therapy in older (55-80 years) patients with essential hypertension and electrocardiographic left ventricular hypertrophy. On the other hand, the UKPDS trial showed that BP lowering with the ACE inhibitor, captopril, or atenolol-based treatment was equally effective in reducing the incidence of diabetic complications in type-2 diabetic hypertensive patients.
There is considerable evidence supporting the use of specific classes of agents in treating and preventing diabetic nephropathy. Experimental studies provide compelling support for a major role of angiotensin II in the pathogenesis of diabetic renal disease, and these findings have been confirmed in human studies. Starting with the hallmark study in type I diabetic patients with overt nephropathy, there are now many largescaled trials in patients with diabetic renal disease demonstrating the importance of including an ACEi or ARB as initial therapy compared with conventional agents (diuretics/betablocker) or a dihydropyridine antagonist. ,,, These agents, possibly because of their anti-proteinuric action, have a greater relative benefit in patients with significant proteinuria as this abnormality is a strong predictor of decline of glomerular filtration rate. Some studies have demonstrated that the non-dihydropyridine calcium channel antagonists can also reduce urinary protein excretion  but their effectiveness in providing renal protection has not been convincingly shown, particularly in comparison with an ACEi or ARB. There are no head-to-head studies comparing the relative effectiveness of an ACEi and ARB in renal outcomes, and studies of their use in combination are only beginning to appear., Thus, until more information becomes available, it would appear that the choice between an ACEi and an ARB as initial therapy will be based largely on cost and side effect profile.
Multidrug therapy in hypertensive diabetic patients
To achieve the desired reduction in BP (<130/80), over 80% of hypertensive diabetic patients will require two or more antihyper-tensive drugs. Data from several major recent trials demonstrate that attainment of such low levels of BP is virtually impossible to achieve with monotherapy.,,,, An appropriate combination of therapy generally includes ACEi or ARB, diuretic and calcium channel blocker, supplemented often with a betablocker or possibly an alpha-adrenergic blocker.
Achieving good blood pressure control
A major challenge in managing hypertensive patients is not whether to initiate treatment or use a specific therapeutic agent, but rather the failure to treat patients aggressively enough to achieve the desired BP goal. Community-based epidemiological studies have repeatedly found poor BP control in treated hypertensive patients. Reasons for this discouraging observation include patient-related factors such as noncompliance, difficulties in accessing care, financial barriers, failure to understand the consequences of the disease, and adverse events during therapy. Equally important, however, are physician-related factors. Physicians are often not aggressive enough in managing hypertensive patients. They fail to follow recommended guidelines in initiating antihypertensive therapy in patients who would benefit from treatment and increasing the dose and types of BP lowering agents until good BP has been achieved. Several studies have shown that physicians fail to intensify therapy in as much as two-thirds of the visits when the patients present with BP values above the desired goal.
Several physician-related barriers may contribute to their reluctance to follow guidelines including the lack of awareness or knowledge of the guidelines, disagreement with consensus statements, lack of selfefficacy and outcome expectancy and inertia of previous practice. In a recent study, the most frequently cited reason for noninitiation or change in therapy was related to the physician being satisfied with the current BP even though it was above the guideline recommended level.,
Home blood pressure monitoring
The BP can be monitored at the office and at home using conventional or ambulatory BP monitors (ABPM). Measurement of BP outside the office setting may allay physicians' concerns about a possible "white-coat syndrome". There is a sizeable body of literature showing the superiority of ABPM over casual office measurement for predicting prognosis, ,,, but this type of monitoring has not been used to make ongoing treatment decisions largely because of cost, inconvenience and poor patient acceptance of repeated measurements. Having patients measure their own BP regularly at home has proven to be an acceptable alternative. Home BP monitoring is relatively cheap and convenient. Multiple readings can be obtained over a prolonged period of time, thereby better defining true pressure and eliminating the 'white-coat' effect. Home BP monitoring may also be used to increase patient compliance with medications, improve BP control, reduce the number of office visits related to hypertension and decrease the cost of care.
Health care professionals are often concerned about using patient-measured readings to make treatment decisions. Home BP readings are often inaccurate because of the use of faulty devices or inadequate training of the patients. Moreover, patients may select the readings that they report to the physician. In addition there is limited prospective data relating home BP readings to health outcomes; consequently, there is a lack of consensus on reference values to guide decision-making. Despite these limitations, most organizations providing recommendations on hypertension management advocate the use of home BP monitoring, undoubtedly encouraged by the finding that home readings correlate more closely with cardiovascular mortality than do those recorded in the clinic.
Disease management may be defined as "a systematic, population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical and other outcomes"., It can be divided into strategies that are designed to facilitate usual care with their primary care physician and those that are planned as alternative means of managing patients such as multidisciplinary teams or specialized clinics. Several trials have examined various strategies to facilitate usual care to improve BP control including appointment reminders, home BP monitoring, written treatment protocols and computer assisted feedback on hypertension management. Although these strategies often improve elements of the process of care such as better clinic attendance, in general they have failed to improve BP control. Similarly, in metaanalysis of heart failure studies, McAlister et al showed that there was no effect on morbidity or mortality of programs designed to increase patient attendance with their primary care physicians. 
There are many examples of alternative ways of managing hypertension, ranging from limited interventions to programs involving multiple health-care workers. Most multidisciplinary programs have shown benefit, but generally they are very expensive to establish and maintain. The key, therefore, to their acceptance is to develop a model that is clinically effective, safe and costeffective.
Technologies are available that may be used to collect, transmit and store data on patients with chronic health problems. They provide opportunities for outreach models and can be used for patient self-monitoring at home and to disseminate this information to health care providers and medical laboratories. Studies using first generation systems in patients with essential hypertension achieved a greater reduction in BP than usual care. , However, the magnitude of the change in BP was modest and the proportion of patients achieving a prespecified treatment goal was not assessed. The principal focus of these systems was home BP monitoring, and physicians and patients were provided with a printed version of the results. Other capabilities of computerized systems such as trend analysis, application of treatment algorithms and internet communications were not exploited. Past studies of home BP monitoring have shown that monitoring alone is not an effective method to improve hypertension control.
The Internet has generated unprecedented opportunities to enhance patient-provider communication and improve the provision of health related services. A recent systematic review on comparative studies evaluating internet-mediated communication,, reported better health outcomes in a variety of conditions  and other reviews have described better quality of care and increased patient satisfaction. Its use can also improve access to services and coordination of activities by clinicians. Studies have demonstrated that informed patients gain control of their conditions, reduce their anxiety levels, improve medication and treatment compliance, create realistic expectations, promote self-care and participation, and generate feelings of safety and security. Moreover, satisfaction with information has been shown to correlate with quality of life. Patients who feel satisfied with the adequacy of information given are more likely to feel happy with their level of participation in the overall process of decision-making.  To date, there are no studies assessing the role of the internet for type II diabetic patients with uncontrolled hypertension.
Goal-oriented, protocol-driven treatment of hypertension
Beginning in the 1970s, several clinical trials (Hypertension Detection and Followup Program [HDFP], Systolic Hypertension in the Elderly Program [SHEP], Controlled Onset Verapamil Investigation of Cardiovascular Events [CONVINCE], Hypertension Optimal Treatment [HOT] study and the Antihypertensive Lipid Lowering Trial to Prevent Heart Attack [ALLHAT]) used a BP treatment algorithm to treat hypertensive patients and achieved better BP control than those reported in national surveys. ,,,, In the CONVINCE trial, for example, the proportion achieving goal pressures stabilized around 70% during 2.5 years of follow-up, whereas only 20% of the participants taking drug therapy for hypertension at the time of enrolment had their BP under good control. The findings in these trials, while impressive, cannot readily be generalized, since only highly compliant patients are recruited in these trials and cost was not a constraint to the delivery of care.
Logan and colleagues used a similar paradigm to treat patients with uncomplicated hypertension at the worksite. They found that hypertensive workers, randomly allocated to receive protocol-driven treatment delivered by a specially trained nurse working under physician supervision, were significantly more likely to be put on antihypertensive medications (94.7% vs. 62.7%), reach goal BP in the first six months of therapy (48.5% vs. 27.5%) and take medicine as prescribed (67.6% vs. 49.1%), compared to those receiving standard care provided by general practitioners. The improved BP control was attributed to convenience of the site for the delivery of care, more vigorous application of therapy and better compliance with therapy. Others have reported similar results. , While the cost of delivering care was higher in the nurse-managed group in the study of Logan et al, it was also more costeffective.
Recently, Singer et al observed that physicians trained in hypertension management achieved better control of BP among patients referred to a specialty referral clinic by primary care physicians, because of difficult-to-manage hypertension.  Overall, 63% achieved systolic BP goal, 86%, the diastolic BP goal and 59% both systolic and diastolic goals. The results of the subgroup with diabetes, however, were much less impressive with only 15% reaching the <130/80 mm Hg goal set by and Canadian Hypertension Society (CHS) and American Diabetes Association/National Kidney Foundation (ADA/NKF).,, Treating physicians in this study, while encouraged to treat to a specific BP goal, were not required to follow a formal drug treatment algorithm. Moreover, the study lacked a control group with which to make direct comparisons.
| Conclusion|| |
Chronic illness accounts for significant proportion of national health care expenditures. The majority of patients with such chronic health problems as hypertension, diabetes mellitus or hyperlipidemia are inadequately treated. Increasingly, illness and death are due to chronic disorders in which an abnormal blood value or clinical measurement may be the only manifestation of disease. Good management of these conditions requires physicians to respond in a timely fashion to indicators of inadequate or ineffective treatment, particularly in the absence of symptoms. Most importantly, patients need to take a more active role in managing their personal health care.
| References|| |
|1.||Al-Mahroos F, Al-Roomi K. Overweight and obesity in the Arabian Peninsula: an overview. J R Soc Health 1999; 119: 251-3. [PUBMED] |
|2.||Al-Nuaim A, Bamgboye E, Al-Rubeaan K, Al-Mazron Y. Overweight and obesity in Saudi Arabian adult population, role of sociodemographic variables. J Comm Health 1997; 22: 211-23. |
|3.||Renal Data System. USRDS 2000 annual data report. Bethesda, Md.: National Institute of Diabetes and Digestive and Kidney Diseases, 2001. |
|4.||European Dialysis and Transplant Association. Report on management of renal failure in Europe, XXVI, 1995. Nephrol Dial Transplant 1996; 11:Suppl 7:1-32. |
|5.||Harris MI, Hadden WC, Knowler WC, Bennett PH. Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in U.S. population aged 2074 yr. Diabetes1987; 36:523-34. |
|6.||Al-Nozha M, Ali MS, Osman AK. Arterial Hypertension in Saudi Arabia. Ann Saudi Med 1997;17(2):170-4. |
|7.||Al-Nuaim AR, Al-Rubean K, Al-Mazrou Y, Khoja T, Al-Attas O, Al-Daghri. Prevalence of diabetes mellitus, obesity and hypercholesterolemia in Saudi Arabia: national chronic disease survey. Riyadh: Ministry of Health and King Saud University; 1995. ISBN: 9960-603-01-6. |
|8.||El-Hazmi MA, Warsy AS, Al-Swailem AM, Sulaimani R, Al-Meshari A. Diabetes mellitus and impaired glucose tolerance in Saudi Arabia. Ann Saudi Med 1996;4:381-5. |
|9.||Joffres MR, Ghadirian P, Fodor JG, et al. Awareness, treatment, and control of hypertension in Canada. Am J Hypertens 1997;10:1097-102. [PUBMED] [FULLTEXT]|
|10.||Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: an update. Hypertension 2001; 37: 1053-59. [PUBMED] [FULLTEXT]|
|11.||Jondeby M, Delos Santos G, Al-Ghamdi A. et al. Caring for haemodialysis patients in Saudi Arabia-past, present and future. Saudi Med J 2001;22:199-204. |
|12.||Klein R, Klein BE, Moss SE, Cruickshanks KJ. Association of ocular disease and mortality in a diabetic population. Arch Ophthalmol 1999; 117:1487-95. [PUBMED] [FULLTEXT]|
|13.||Diabetes in Canada: national statistics and opportunities for improved surveillance, prevention, and control. Ottawa: Health Canada, 1999. Cat.no H49-121/1999. |
|14.||Mogensen CE. Microalbuminuria, blood pressure and diabetic renal disease: origin and development of ideas. In: Mogensen CE, ed. The kidney and hypertension in diabetes mellitus. 5th ed. Boston: Kluwer, 2000:655-706. |
|15.||UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998; 317:713-20. [PUBMED] [FULLTEXT]|
|16.||Weidmann P, Boehlen LM, de Courten M. Pathogenesis and treatment of hypertension associated with diabetes mellitus. Am Heart J 1993; 125:1498-513. [PUBMED] |
|17.||The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997; 157:2413-46. [PUBMED] |
|18.||Guidelines Subcommittee. World Health Organization - International Society of Hypertension Guidelines for the management of hypertension. J Hypertens 1999; 17:151-83. [PUBMED] [FULLTEXT]|
|19.||McAlister FA, Zarnke KB, Campbell NR, et al. The 2001 Canadian recommendations for the management of hypertension: Part one. Can J Cardiol 2002; 18:604-24. [PUBMED] |
|20.||McAlister FA, Zarnke KB, Campbell NR, et al. The 2001 Canadian recommendations for the management of hypertension: Part two. Can J Cardiol 2002;18:625-41. [PUBMED] |
|21.||Curb JD, Pressel SL, Cutler JA, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996;276:1886-92. |
|22.||Staessen JA, Fagard R, Thijs L, et al. Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (SystEur) Trial Investigators. Lancet 1997; 350:757-64. |
|23.||Tatti P, Pahor M, Byington RP, et al. Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. Diabetes Care 1998; 21:597-603. [PUBMED] [FULLTEXT]|
|24.||Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000; 355:253-9. [PUBMED] [FULLTEXT]|
|25.||Lindholm LH, Ibsen H, Dahlof B, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359:1004-10. [PUBMED] [FULLTEXT]|
|26.||Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-convertingenzyme inhibition on diabetic nephropathy. N Engl J Med 1993; 329:1456-62. [PUBMED] [FULLTEXT]|
|27.||Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345:861-9. [PUBMED] [FULLTEXT]|
|28.||Parving HH, Lehnert H, BrochnerMortensen J, Gomis R, Andersen S, Arner P. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001; 345:870-8. |
|29.||Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensinreceptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001; 345:851-60. [PUBMED] [FULLTEXT]|
|30.||Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med 1998; 338:645-52. |
|31.||Jafar TH, Schmid CH, Landa M, et al. Angiotensin-converting enzme inhibitors and progression of nondiabetic renal disease. A meta-analysis of patient-level data. Ann Intern Med 2001; 135:73-87. |
|32.||Bakris GL, Copley JB, Vicknair N, Sadler R, Leurgans S. Calium channel blockers versus other antihypertensive therapies on progression of non-insulin-dependent diabetes mellitus associated nephropathy. Kidney Int 1996; 56:1641-50. |
|33.||McKelvie RS, Yusuf S, Pericak D, et al. Comparison of candesartan, enalapril and their combination in congestive heart failure. Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) pilot study. Circulation, 1999;100:1056-64. |
|34.||Mimran A, Ruilope L, Kerwin L, et al. A randomized, double-blind comparison of the angiotensin II receptor antagonist, irbesartan, with the full dose range of enalapril for the treatment of mild-tomoderate hypertension. J Hum Hyperten 1998;12:203-8. |
|35.||Singer GM, Izhar M, Black HR. Goaloriented hypertension management. Translating clinical trials to practice. Hypertension 2002; 40:464-9. |
|36.||Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282:1458-65. |
|37.||Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999; 281:1900-5. |
|38.||Campbell NR. New Canadian hypertension recommendations- so what? Can Fam Physician 2000; 46:1413-6. [PUBMED] |
|39.||American College of Physicians. Automated ambulatory blood pressure and self-measured blood pressure monitoring devices: their role in the diagnosis and management of hypertension. Ann Intern Med 1993; 118:889-92. [PUBMED] [FULLTEXT]|
|40.||Zachariah PK, Sheps SG, Smith RL. Role of self-monitoring and ambulatory monitoring in diagnosis and evaluation of hypertension. Practical Cardiol 1988;14:1-7. |
|41.||Mancia G, Sega R, Bravi C, et al. Ambulatory blood pressure normality: results from the PAMELA study. J Hypertens 1995;13(12, pt 1):1377-90. |
|42.||Staessen JA, Thijs L, Fagard R, et al. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. JAMA 1999; 282:539-46. [PUBMED] [FULLTEXT]|
|43.||Soghikian K, Casper SM, Fireman BH, et al. Home blood pressure monitoring. Effect on use of medical services and medical care costs. Med Care 1992;30:855-65. |
|44.||Ohkubo T, Imai Y, Tsuji I, et al. Home blood pressure measurement has a stronger predictive power for mortality than does screening blood pressure measurement: a population-based observation in Ohasama, Japan. J Hypertens 1998;16:971-5. [PUBMED] [FULLTEXT]|
|45.||Hunter DJ, Fairfield G. Disease management. BMJ 1997; 315:50-3. [PUBMED] [FULLTEXT]|
|46.||Epstein RS, Sherwood LM. From outcomes research to disease management: a guide for the perplexed. Ann Intern Med 1996; 124:832-7. [PUBMED] [FULLTEXT]|
|47.||Burns H. Disease management and the drug industry: carve out or carve up? Lancet 1996; 347:1021-23. [PUBMED] |
|48.||McAlister FA, Lawson FM, Toe KK, Armstrong PW. A systemic review of randomized trials of disease management programs in heart failure. Am J Med 2001; 110:374-84. |
|49.||Friedman RH, Kazis LE, Jette A, et al. A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens 1996;9: 285-92. |
|50.||Rogers M, Small D, Buchan D, et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. Ann Intern Med 2001; 134: 1024-32. |
|51.||Boulware LE, Daumit GL, Frick KD, Minkovitz CS, Lawrence RS, Powe NR. An evidence-based review of patientcentered behavioral interventions for hypertension. Am J Prev Med 2001; 21:221-32. [PUBMED] [FULLTEXT]|
|52.||Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:757-62. [PUBMED] [FULLTEXT]|
|53.||Bessell TL, McDonald S, Silagy CA, Anderson JN, Hiller JE, Sansom LN. Do internet interventions cause more harm than good? A systematic review. Health Expectations 2002; 5:28-37. |
|54.||Balas EA, Jaffrey F, Kuperman GJ, et al. Electronic communication with patients. Evaluation of distance medicine technology. JAMA 1997; 278:152-9 |
|55.||Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995; 152:1423-33. [PUBMED] [FULLTEXT]|
|56.||Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer Prev Control 1999; 3:25-30. [PUBMED] |
|57.||Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000; 320:1246-50. [PUBMED] [FULLTEXT]|
|58.||Five year findings of the hypertension detection and follow up program. 1. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group. JAMA 1979; 242:2562-71. |
|59.||Black HR, Elliott WJ, Neaton JD, et al. Baseline characteristics and early blood pressure control in the CONVINCE Trial. Hypertension 2001;37:12-8. [PUBMED] [FULLTEXT]|
|60.||Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 1998; 351:1755-62. [PUBMED] [FULLTEXT]|
|61.||ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2000; 283:1967. [PUBMED] [FULLTEXT]|
|62.||Logan AG, Milne BJ, Achber C, et al. Work-site treatment of hypertension at work site. Lancet 1979; 2:1175-8. [PUBMED] |
|63.||Reichgott MJ, Pearson S, Hill MN. The nurse practitioner's role in complex patient management:Hypertensoin. J Natl Med Assoc 1983; 75:1197-204. [PUBMED] |
|64.||Perry HM, Schnapner JW, Meyer G, Swatzell R. Clinical progran for screening and treatment of hypertension in veterans. J Natl Med Assoc 1982; 74:433-44. |
|65.||Logan AC, Milne BJ, Flanagan PT, Hayens RB. Clinical effectiveness and cost effectiveness of monitoring of blood pressure of hypertensive employees at work. Hypertension 1983;5:828-36. |
|66.||Singer GM, Izhar M, Black HR. Goaloriented hypertension management. Translating clinical trials to practice. Hypertension 2002;40:464-9. |
|67.||American Diabetes Association (Position Statement). Standards of Medical Care for Patients with Diabetes Mellitus. Diabetes Care 2001;24(Supplement 1):S33-43. |
Department of Nephrology King Saud University, P.O. Box 1388, Riyadh 11321
| Article Access Statistics|
| Viewed||3566 |
| Printed||53 |
| Emailed||0 |
| PDF Downloaded||423 |
| Comments ||[Add] |