case study of htn

• Search Menu
• Advance articles
• Editor's Choice
• Graphical Abstracts and Tidbit
• Author Guidelines
• Submission Site
• Open Access
• About American Journal of Hypertension
• Editorial Board
• Board of Directors
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• AJH Summer School
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

• < Previous
• Article contents
• Figures & tables
• Supplementary Data

Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

• Permissions Icon Permissions

Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

1. Joint National Committee : The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med 1997 ; 24 157 : 2413 – 2446 .

Google Scholar

2. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg . JAMA 1967 ; 202 : 116 – 122 .

3. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg . JAMA 1970 ; 213 : 1143 – 1152 .

4. Pooling Project Research Group : Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to the incidence of major coronary events: Final report of the pooling project . J Chronic Dis 1978 ; 31 : 201 – 306 .

5. Hypertension Detection and Follow-Up Program Cooperative Group : Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension . JAMA 1979 ; 242 : 2562 – 2577 .

6. Kannel WB , Dawber TR , McGee DL : Perspectives on systolic hypertension: The Framingham Study . Circulation 1980 ; 61 : 1179 – 1182 .

7. Hypertension Detection and Follow-Up Program Cooperative Group : The effect of treatment on mortality in “mild” hypertension: Results of the Hypertension Detection and Follow-Up Program . N Engl J Med 1982 ; 307 : 976 – 980 .

8. Burt VL , Whelton P , Roccella EJ et al.  : Prevalence of hypertension in the US adult population: Results from the third National Health and Nutrition Examination Survey, 1988–1991 . Hypertension 1995 ; 25 : 305 – 313 .

9. Klag MJ , Whelton PK , Randall BL et al.  : End-stage renal disease in African-American and white men: 16-year MRFIT findings . JAMA 1997 ; 277 : 1293 – 1298 .

10. Neaton JD , Kuller LH , Wentworth D et al.  : Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J 1984 ; 3 : 759 – 769 .

11. Gillum RF , Grant CT : Coronary heart disease in black populations II: Risk factors . Heart J 1982 ; 104 : 852 – 864 .

12. M’Buyamba-Kabangu JR , Amery A , Lijnen P : Differences between black and white persons in blood pressure and related biological variables . J Hum Hypertens 1994 ; 8 : 163 – 170 .

13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al.  : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

15. Weinberger MH : Racial differences in antihypertensive therapy: evidence and implications . Cardiovasc Drugs Ther 1990 ; 4 ( suppl 2 ): 379 – 392 .

16. Materson BJ , Reda DJ , Cushman WC et al.  : Single-drug therapy for hypertension in men: A comparison of six antihypertensive agents with placebo . N Engl J Med 1993 ; 328 : 914 – 921 .

17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

• hypertension
• blood pressure
• african american

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1941-7225
• Copyright © 2024 American Journal of Hypertension, Ltd.
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Patient Case Presentation

Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%.  Glucose  180 mg/dL (fasting).  FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.

Past medical history

Diagnosed with diabetes (type 2) at 32 years old

Overweight, BMI of 31

Had a cholecystomy at 38 years old

Diagnosed with dyslipidemia at 32 years old

Past family history

Mother alive, diagnosed diabetic at 42 years old 

Father alive with Hypertension diagnosed at 55 years old

Brother alive and well at 45 years old

Sister alive and obese at 34 years old 

Pertinent social history

Social drinker on occasion

Smokes a pack of cigarettes per day

Works full time as an IT technician and is in graduate school

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 6:  10 Real Cases on Hypertensive Emergency and Pericardial Disease: Diagnosis, Management, and Follow-Up

Niel Shah; Fareeha S. Alavi; Muhammad Saad

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Case review, case discussion.

• Clinical Symptoms
• Diagnostic Evaluation
• Full Chapter
• Supplementary Content

Case 1: Management of Hypertensive Encephalopathy

A 45-year-old man with a 2-month history of progressive headache presented to the emergency department with nausea, vomiting, visual disturbance, and confusion for 1 day. He denied fever, weakness, numbness, shortness of breath, and flulike symptoms. He had significant medical history of hypertension and was on a β-blocker in the past, but a year ago, he stopped taking medication due to an unspecified reason. The patient denied any history of tobacco smoking, alcoholism, and recreational drug use. The patient had a significant family history of hypertension in both his father and mother. Physical examination was unremarkable, and at the time of triage, his blood pressure (BP) was noted as 195/123 mm Hg, equal in both arms. The patient was promptly started on intravenous labetalol with the goal to reduce BP by 15% to 20% in the first hour. The BP was rechecked after an hour of starting labetalol and was 165/100 mm Hg. MRI of the brain was performed in the emergency department and demonstrated multiple scattered areas of increased signal intensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in both the occipital and posterior parietal lobes. There were also similar lesions in both hemispheres of the cerebellum (especially the cerebellar white matter on the left) as well as in the medulla oblongata. The lesions were not associated with mass effect, and after contrast administration, there was no evidence of abnormal enhancement. In the emergency department, his BP decreased to 160/95 mm Hg, and he was transitioned from drip to oral medications and transferred to the telemetry floor. How would you manage this case?

The patient initially presented with headache, nausea, vomiting, blurred vision, and confusion. The patient’s BP was found to be 195/123 mm Hg, and MRI of the brain demonstrated scattered lesions with increased intensity in the occipital and posterior parietal lobes, as well as in cerebellum and medulla oblongata. The clinical presentation, elevated BP, and brain MRI findings were suggestive of hypertensive emergency, more specifically hypertensive encephalopathy. These MRI changes can be seen particularly in posterior reversible encephalopathy syndrome (PRES), a sequela of hypertensive encephalopathy. BP was initially controlled by labetalol, and after satisfactory control of BP, the patient was switched to oral antihypertensive medications.

Hypertensive emergency refers to the elevation of systolic BP >180 mm Hg and/or diastolic BP >120 mm Hg that is associated with end-organ damage; however, in some conditions such as pregnancy, more modest BP elevation can constitute an emergency. An equal degree of hypertension but without end-organ damage constitutes a hypertensive urgency, the treatment of which requires gradual BP reduction over several hours. Patients with hypertensive emergency require rapid, tightly controlled reductions in BP that avoid overcorrection. Management typically occurs in an intensive care setting with continuous arterial BP monitoring and continuous infusion of antihypertensive agents.

Sign in or create a free Access profile below to access even more exclusive content.

With an Access profile, you can save and manage favorites from your personal dashboard, complete case quizzes, review Q&A, and take these feature on the go with our Access app.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

• Previous Article
• Next Article

Presentation

Clinical pearls, case study: treating hypertension in patients with diabetes.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Cite Icon Cite
• Get Permissions

Evan M. Benjamin; Case Study: Treating Hypertension in Patients With Diabetes. Clin Diabetes 1 July 2004; 22 (3): 137–138. https://doi.org/10.2337/diaclin.22.3.137

Download citation file:

• Ris (Zotero)
• Reference Manager

L.N. is a 49-year-old white woman with a history of type 2 diabetes,obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side,with her weight fluctuating between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A 1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

What are the effects of controlling BP in people with diabetes?

What is the target BP for patients with diabetes and hypertension?

Which antihypertensive agents are recommended for patients with diabetes?

Diabetes mellitus is a major risk factor for cardiovascular disease (CVD). Approximately two-thirds of people with diabetes die from complications of CVD. Nearly half of middle-aged people with diabetes have evidence of coronary artery disease (CAD), compared with only one-fourth of people without diabetes in similar populations.

Patients with diabetes are prone to a number of cardiovascular risk factors beyond hyperglycemia. These risk factors, including hypertension,dyslipidemia, and a sedentary lifestyle, are particularly prevalent among patients with diabetes. To reduce the mortality and morbidity from CVD among patients with diabetes, aggressive treatment of glycemic control as well as other cardiovascular risk factors must be initiated.

Studies that have compared antihypertensive treatment in patients with diabetes versus placebo have shown reduced cardiovascular events. The United Kingdom Prospective Diabetes Study (UKPDS), which followed patients with diabetes for an average of 8.5 years, found that patients with tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg) had lower rates of myocardial infarction (MI), stroke, and peripheral vascular events. In the UKPDS, each 10-mmHg decrease in mean systolic BP was associated with a 12% reduction in risk for any complication related to diabetes, a 15% reduction for death related to diabetes, and an 11% reduction for MI. Another trial followed patients for 2 years and compared calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors,with or without hydrochlorothiazide against placebo and found a significant reduction in acute MI, congestive heart failure, and sudden cardiac death in the intervention group compared to placebo.

The Hypertension Optimal Treatment (HOT) trial has shown that patients assigned to lower BP targets have improved outcomes. In the HOT trial,patients who achieved a diastolic BP of < 80 mmHg benefited the most in terms of reduction of cardiovascular events. Other epidemiological studies have shown that BPs > 120/70 mmHg are associated with increased cardiovascular morbidity and mortality in people with diabetes. The American Diabetes Association has recommended a target BP goal of < 130/80 mmHg. Studies have shown that there is no lower threshold value for BP and that the risk of morbidity and mortality will continue to decrease well into the normal range.

Many classes of drugs have been used in numerous trials to treat patients with hypertension. All classes of drugs have been shown to be superior to placebo in terms of reducing morbidity and mortality. Often, numerous agents(three or more) are needed to achieve specific target levels of BP. Use of almost any drug therapy to reduce hypertension in patients with diabetes has been shown to be effective in decreasing cardiovascular risk. Keeping in mind that numerous agents are often required to achieve the target level of BP control, recommending specific agents becomes a not-so-simple task. The literature continues to evolve, and individual patient conditions and preferences also must come into play.

While lowering BP by any means will help to reduce cardiovascular morbidity, there is evidence that may help guide the selection of an antihypertensive regimen. The UKPDS showed no significant differences in outcomes for treatment for hypertension using an ACE inhibitor or aβ-blocker. In addition, both ACE inhibitors and angiotensin II receptor blockers (ARBs) have been shown to slow the development and progression of diabetic nephropathy. In the Heart Outcomes Prevention Evaluation (HOPE)trial, ACE inhibitors were found to have a favorable effect in reducing cardiovascular morbidity and mortality, whereas recent trials have shown a renal protective benefit from both ACE inhibitors and ARBs. ACE inhibitors andβ-blockers seem to be better than dihydropyridine calcium-channel blockers to reduce MI and heart failure. However, trials using dihydropyridine calcium-channel blockers in combination with ACE inhibitors andβ-blockers do not appear to show any increased morbidity or mortality in CVD, as has been implicated in the past for dihydropyridine calcium-channel blockers alone. Recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in high-risk hypertensive patients,including those with diabetes, demonstrated that chlorthalidone, a thiazide-type diuretic, was superior to an ACE inhibitor, lisinopril, in preventing one or more forms of CVD.

L.N. is a typical patient with obesity, diabetes, and hypertension. Her BP control can be improved. To achieve the target BP goal of < 130/80 mmHg, it may be necessary to maximize the dose of the ACE inhibitor and to add a second and perhaps even a third agent.

Diuretics have been shown to have synergistic effects with ACE inhibitors,and one could be added. Because L.N. has migraine headaches as well as diabetic nephropathy, it may be necessary to individualize her treatment. Adding a β-blocker to the ACE inhibitor will certainly help lower her BP and is associated with good evidence to reduce cardiovascular morbidity. Theβ-blocker may also help to reduce the burden caused by her migraine headaches. Because of the presence of microalbuminuria, the combination of ARBs and ACE inhibitors could also be considered to help reduce BP as well as retard the progression of diabetic nephropathy. Overall, more aggressive treatment to control L.N.'s hypertension will be necessary. Information obtained from recent trials and emerging new pharmacological agents now make it easier to achieve BP control targets.

Hypertension is a risk factor for cardiovascular complications of diabetes.

Clinical trials demonstrate that drug therapy versus placebo will reduce cardiovascular events when treating patients with hypertension and diabetes.

A target BP goal of < 130/80 mmHg is recommended.

Pharmacological therapy needs to be individualized to fit patients'needs.

ACE inhibitors, ARBs, diuretics, and β-blockers have all been documented to be effective pharmacological treatment.

Combinations of drugs are often necessary to achieve target levels of BP control.

ACE inhibitors and ARBs are agents best suited to retard progression of nephropathy.

Evan M. Benjamin, MD, FACP, is an assistant professor of medicine and Vice President of Healthcare Quality at Baystate Medical Center in Springfield, Mass.

Email alerts

• Online ISSN 1945-4953
• Print ISSN 0891-8929
• Diabetes Care
• Clinical Diabetes
• Diabetes Spectrum
• Standards of Medical Care in Diabetes
• Scientific Sessions Abstracts
• BMJ Open Diabetes Research & Care
• ShopDiabetes.org
• ADA Professional Books

Clinical Compendia

• Clinical Compendia Home
• Latest News
• DiabetesPro SmartBrief
• Special Collections
• DiabetesPro®
• Diabetes Food Hub™
• Insulin Affordability
• Know Diabetes By Heart™
• About the ADA
• Journal Policies
• For Reviewers
• Advertising in ADA Journals
• Reprints and Permission for Reuse
• Copyright Notice/Public Access Policy
• ADA Professional Membership
• ADA Member Directory
• Diabetes.org
• X (Twitter)
• Cookie Policy
• Accessibility
• Terms & Conditions
• Get Adobe Acrobat Reader
• © Copyright American Diabetes Association

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This website is intended for healthcare professionals

• { $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Abegaz TM, Shehab A, Gebreyohannes EA, Bhagavathula AS, Elnour AA. Nonadherence to antihypertensive drugs. Medicine (Baltimore). 2017; 96:(4) https://doi.org/10.1097/MD.0000000000005641

Armitage LC, Davidson S, Mahdi A Diagnosing hypertension in primary care: a retrospective cohort study to investigate the importance of night-time blood pressure assessment. Br J Gen Pract. 2023; 73:(726)e16-e23 https://doi.org/10.3399/BJGP.2022.0160

Barratt J. Developing clinical reasoning and effective communication skills in advanced practice. Nurs Stand. 2018; 34:(2)48-53 https://doi.org/10.7748/ns.2018.e11109

Bostock-Cox B. Nurse prescribing for the management of hypertension. British Journal of Cardiac Nursing. 2013; 8:(11)531-536

Bostock-Cox B. Hypertension – the present and the future for diagnosis. Independent Nurse. 2019; 2019:(1)20-24 https://doi.org/10.12968/indn.2019.1.20

Chakrabarti S. What's in a name? Compliance, adherence and concordance in chronic psychiatric disorders. World J Psychiatry. 2014; 4:(2)30-36 https://doi.org/10.5498/wjp.v4.i2.30

De Mauri A, Carrera D, Vidali M Compliance, adherence and concordance differently predict the improvement of uremic and microbial toxins in chronic kidney disease on low protein diet. Nutrients. 2022; 14:(3) https://doi.org/10.3390/nu14030487

Demosthenous N. Consultation skills: a personal reflection on history-taking and assessment in aesthetics. Journal of Aesthetic Nursing. 2017; 6:(9)460-464 https://doi.org/10.12968/joan.2017.6.9.460

Diamond-Fox S. Undertaking consultations and clinical assessments at advanced level. Br J Nurs. 2021; 30:(4)238-243 https://doi.org/10.12968/bjon.2021.30.4.238

Diamond-Fox S, Bone H. Advanced practice: critical thinking and clinical reasoning. Br J Nurs. 2021; 30:(9)526-532 https://doi.org/10.12968/bjon.2021.30.9.526

Donnelly M, Martin D. History taking and physical assessment in holistic palliative care. Br J Nurs. 2016; 25:(22)1250-1255 https://doi.org/10.12968/bjon.2016.25.22.1250

Fawcett J. Thoughts about meanings of compliance, adherence, and concordance. Nurs Sci Q. 2020; 33:(4)358-360 https://doi.org/10.1177/0894318420943136

Fisher NDL, Curfman G. Hypertension—a public health challenge of global proportions. JAMA. 2018; 320:(17)1757-1759 https://doi.org/10.1001/jama.2018.16760

Green S. Assessment and management of acute sore throat. Pract Nurs. 2015; 26:(10)480-486 https://doi.org/10.12968/pnur.2015.26.10.480

Harper C, Ajao A. Pendleton's consultation model: assessing a patient. Br J Community Nurs. 2010; 15:(1)38-43 https://doi.org/10.12968/bjcn.2010.15.1.45784

Hitchings A, Lonsdale D, Burrage D, Baker E. The Top 100 Drugs; Clinical Pharmacology and Practical Prescribing, 2nd edn. Scotland: Elsevier; 2019

Hobden A. Strategies to promote concordance within consultations. Br J Community Nurs. 2006; 11:(7)286-289 https://doi.org/10.12968/bjcn.2006.11.7.21443

Ingram S. Taking a comprehensive health history: learning through practice and reflection. Br J Nurs. 2017; 26:(18)1033-1037 https://doi.org/10.12968/bjon.2017.26.18.1033

James A, Holloway S. Application of concepts of concordance and health beliefs to individuals with pressure ulcers. British Journal of Healthcare Management. 2020; 26:(11)281-288 https://doi.org/10.12968/bjhc.2019.0104

Jamison J. Differential diagnosis for primary care. A handbook for health care practitioners, 2nd edn. China: Churchill Livingstone Elsevier; 2006

History and Physical Examination. 2021. https://patient.info/doctor/history-and-physical-examination (accessed 26 January 2023)

Kumar P, Clark M. Clinical Medicine, 9th edn. The Netherlands: Elsevier; 2017

Matthys J, Elwyn G, Van Nuland M Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2009; 59:(558)29-36 https://doi.org/10.3399/bjgp09X394833

McKinnon J. The case for concordance: value and application in nursing practice. Br J Nurs. 2013; 22:(13)766-771 https://doi.org/10.12968/bjon.2013.22.13.766

McPhillips H, Wood AF, Harper-McDonald B. Conducting a consultation and clinical assessment of the skin for advanced clinical practitioners. Br J Nurs. 2021; 30:(21)1232-1236 https://doi.org/10.12968/bjon.2021.30.21.1232

Moulton L. The naked consultation; a practical guide to primary care consultation skills.Abingdon: Radcliffe Publishing; 2007

Medicine adherence; involving patients in decisions about prescribed medications and supporting adherence.England: NICE; 2009

National Institute for Health and Care Excellence. How do I control my blood pressure? Lifestyle options and choice of medicines patient decision aid. 2019. https://www.nice.org.uk/guidance/ng136/resources/patient-decision-aid-pdf-6899918221 (accessed 25 January 2023)

National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. NICE guideline NG136. 2022. https://www.nice.org.uk/guidance/ng136 (accessed 15 June 2023)

Nazarko L. Healthwise, Part 4. Hypertension: how to treat it and how to reduce its risks. Br J Healthc Assist. 2021; 15:(10)484-490 https://doi.org/10.12968/bjha.2021.15.10.484

Neighbour R. The inner consultation.London: Radcliffe Publishing Ltd; 1987

The Code. professional standards of practice and behaviour for nurses, midwives and nursing associates.London: NMC; 2018

Nuttall D, Rutt-Howard J. The textbook of non-medical prescribing, 2nd edn. Chichester: Wiley-Blackwell; 2016

O'Donovan K. The role of ACE inhibitors in cardiovascular disease. British Journal of Cardiac Nursing. 2018; 13:(12)600-608 https://doi.org/10.12968/bjca.2018.13.12.600

O'Donovan K. Angiotensin receptor blockers as an alternative to angiotensin converting enzyme inhibitors. British Journal of Cardiac Nursing. 2019; 14:(6)1-12 https://doi.org/10.12968/bjca.2019.0009

Porth CM. Essentials of Pathophysiology, 4th edn. Philadelphia: Wolters Kluwer; 2015

Rae B. Obedience to collaboration: compliance, adherence and concordance. Journal of Prescribing Practice. 2021; 3:(6)235-240 https://doi.org/10.12968/jprp.2021.3.6.235

Rostoft S, van den Bos F, Pedersen R, Hamaker ME. Shared decision-making in older patients with cancer - What does the patient want?. J Geriatr Oncol. 2021; 12:(3)339-342 https://doi.org/10.1016/j.jgo.2020.08.001

Schroeder K. The 10-minute clinical assessment, 2nd edn. Oxford: Wiley Blackwell; 2017

Thomas J, Monaghan T. The Oxford handbook of clinical examination and practical skills, 2nd edn. Oxford: Oxford University Press; 2014

Vincer K, Kaufman G. Balancing shared decision-making with ethical principles in optimising medicines. Nurse Prescribing. 2017; 15:(12)594-599 https://doi.org/10.12968/npre.2017.15.12.594

Waterfield J. ACE inhibitors: use, actions and prescribing rationale. Nurse Prescribing. 2008; 6:(3)110-114 https://doi.org/10.12968/npre.2008.6.3.28858

Weiss M. Concordance, 6th edn. In: Watson J, Cogan LS Poland: Elsevier; 2019

Williams H. An update on hypertension for nurse prescribers. Nurse Prescribing. 2013; 11:(2)70-75 https://doi.org/10.12968/npre.2013.11.2.70

Adherence to long-term therapies, evidence for action.Geneva: WHO; 2003

Young K, Franklin P, Franklin P. Effective consulting and historytaking skills for prescribing practice. Br J Nurs. 2009; 18:(17)1056-1061 https://doi.org/10.12968/bjon.2009.18.17.44160

Newly diagnosed hypertension: case study

Angela Brown

Trainee Advanced Nurse Practitioner, East Belfast GP Federation, Northern Ireland

View articles · Email Angela

The role of an advanced nurse practitioner encompasses the assessment, diagnosis and treatment of a range of conditions. This case study presents a patient with newly diagnosed hypertension. It demonstrates effective history taking, physical examination, differential diagnoses and the shared decision making which occurred between the patient and the professional. It is widely acknowledged that adherence to medications is poor in long-term conditions, such as hypertension, but using a concordant approach in practice can optimise patient outcomes. This case study outlines a concordant approach to consultations in clinical practice which can enhance adherence in long-term conditions.

Hypertension is a worldwide problem with substantial consequences ( Fisher and Curfman, 2018 ). It is a progressive condition ( Jamison, 2006 ) requiring lifelong management with pharmacological treatments and lifestyle adjustments. However, adopting these lifestyle changes can be notoriously difficult to implement and sustain ( Fisher and Curfman, 2018 ) and non-adherence to chronic medication regimens is extremely common ( Abegaz et al, 2017 ). This is also recognised by the National Institute for Health and Care Excellence (NICE) (2009) which estimates that between 33.3% and 50% of medications are not taken as recommended. Abegaz et al (2017) furthered this by claiming 83.7% of people with uncontrolled hypertension do not take medications as prescribed. However, leaving hypertension untreated or uncontrolled is the single largest cause of cardiovascular disease ( Fisher and Curfman, 2018 ). Therefore, better adherence to medications is associated with better outcomes ( World Health Organization, 2003 ) in terms of reducing the financial burden associated with the disease process on the health service, improving outcomes for patients ( Chakrabarti, 2014 ) and increasing job satisfaction for professionals ( McKinnon, 2013 ). Therefore, at a time when growing numbers of patients are presenting with hypertension, health professionals must adopt a concordant approach from the initial consultation to optimise adherence.

Great emphasis is placed on optimising adherence to medications ( NICE, 2009 ), but the meaning of the term ‘adherence’ is not clear and it is sometimes used interchangeably with compliance and concordance ( De Mauri et al, 2022 ), although they are not synonyms. Compliance is an outdated term alluding to paternalism, obedience and passivity from the patient ( Rae, 2021 ), whereby the patient's behaviour must conform to the health professional's recommendations. Adherence is defined as ‘the extent to which a person's behaviour, taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’ ( Chakrabarti, 2014 ). This term is preferred over compliance as it is less paternalistic ( Rae, 2021 ), as the patient is included in the decision-making process and has agreed to the treatment plan. While it is not yet widely embraced or used in practice ( Fawcett, 2020 ), concordance is recognised, not as a behaviour ( Rae, 2021 ) but more an approach or method which focuses on the equal partnership between patient and professional ( McKinnon, 2013 ) and enables effective and agreed treatment plans.

NICE last reviewed its guidance on medication adherence in 2019 and did not replace adherence with concordance within this. This supports the theory that adherence is an outcome of good concordance and the two are not synonyms. NICE (2009) guidelines, which are still valid, show evidence of concordant principles to maximise adherence. Integrating the theoretical principles of concordance into this case study demonstrates how the trainee advanced nurse practitioner aimed to individualise patient-centred care and improve health outcomes through optimising adherence.

Patient introduction and assessment

Jane (a pseudonym has been used to protect the patient's anonymity; Nursing and Midwifery Council (NMC) 2018 ), is a 45-year-old woman who had been referred to the surgery following an attendance at an emergency department. Jane had been role-playing as a patient as part of a teaching session for health professionals when it was noted that her blood pressure was significantly elevated at 170/88 mmHg. She had no other symptoms. Following an initial assessment at the emergency department, Jane was advised to contact her GP surgery for review and follow up. Nazarko (2021) recognised that it is common for individuals with high blood pressure to be asymptomatic, contributing to this being referred to as the ‘silent killer’. Hypertension is generally only detected through opportunistic checking of blood pressure, as seen in Jane's case, which is why adults over the age of 40 years are offered a blood pressure check every 5 years ( Bostock-Cox, 2013 ).

Consultation

Jane presented for a consultation at the surgery. Green (2015) advocates using a model to provide a structured approach to consultations which ensures quality and safety, and improves time management. Young et al (2009) claimed that no single consultation model is perfect, and Diamond-Fox (2021) suggested that, with experience, professionals can combine models to optimise consultation outcomes. Therefore, to effectively consult with Jane and to adapt to her individual personality, different models were intertwined to provide better person-centred care.

The Calgary–Cambridge model is the only consultation model that places emphasis on initiating the session, despite it being recognised that if a consultation gets off to a bad start this can interfere throughout ( Young et al, 2009 ). Being prepared for the consultation is key. Before Jane's consultation, the environment was checked to minimise interruptions, ensuring privacy and dignity ( Green, 2015 ; NMC, 2018 ), the seating arrangements optimised to aid good body language and communication ( Diamond-Fox, 2021 ) and her records were viewed to give some background information to help set the scene and develop a rapport ( Young et al, 2009 ). Being adequately prepared builds the patient's trust and confidence in the professional ( Donnelly and Martin, 2016 ) but equally viewing patient information can lead to the professional forming preconceived ideas ( Donnelly and Martin, 2016 ). Therefore, care was taken by the trainee advanced nurse practitioner to remain open-minded.

During Jane's consultation, a thorough clinical history was taken ( Table 1 ). History taking is common to all consultation models and involves gathering important information ( Diamond-Fox, 2021 ). History-taking needs to be an effective ( Bostock-Cox, 2019 ), holistic process ( Harper and Ajao, 2010 ) in order to be thorough, safe ( Diamond-Fox, 2021 ) and aid in an accurate diagnosis. The key skill for taking history is listening and observing the patient ( Harper and Ajao, 2010 ). Sir William Osler said:‘listen to the patient as they are telling you the diagnosis’, but Knott and Tidy (2021) suggested that patients are barely given 20 seconds before being interrupted, after which they withdraw and do not offer any new information ( Demosthenous, 2017 ). Using this guidance, Jane was given the ‘golden minute’ allowing her to tell her ‘story’ without being interrupted ( Green, 2015 ). This not only showed respect ( Ingram, 2017 ) but interest in the patient and their concerns.

Once Jane shared her story, it was important for the trainee advanced nurse practitioner to guide the questioning ( Green 2015 ). This was achieved using a structured approach to take Jane's history, which optimised efficiency and effectiveness, and ensured that pertinent information was not omitted ( Young et al, 2009 ). Thomas and Monaghan (2014) set out clear headings for this purpose. These included:

• The presenting complaint
• Past medical history
• Drug history
• Social history
• Family history.

McPhillips et al (2021) also emphasised a need for a systemic enquiry of the other body systems to ensure nothing is missed. From taking this history it was discovered that Jane had been feeling well with no associated symptoms or red flags. A blood pressure reading showed that her blood pressure was elevated. Jane had no past medical history or allergies. She was not taking any medications, including prescribed, over the counter, herbal or recreational. Jane confirmed that she did not drink alcohol or smoke. There was no family history to note, which is important to clarify as a genetic link to hypertension could account for 30–50% of cases ( Nazarko, 2021 ). The information gathered was summarised back to Jane, showing good practice ( McPhillips et al, 2021 ), and Jane was able to clarify salient or missing points. Green (2015) suggested that optimising the patient's involvement in this way in the consultation makes her feel listened to which enhances patient satisfaction, develops a therapeutic relationship and demonstrates concordance.

During history taking it is important to explore the patient's ideas, concerns and expectations. Moulton (2007) refers to these as the ‘holy trinity’ and central to upholding person-centredness ( Matthys et al, 2009 ). Giving Jane time to discuss her ideas, concerns and expectations allowed the trainee advanced nurse practitioner to understand that she was concerned about her risk of a stroke and heart attack, and worried about the implications of hypertension on her already stressful job. Using ideas, concerns and expectations helped to understand Jane's experience, attitudes and perceptions, which ultimately will impact on her health behaviours and whether engagement in treatment options is likely ( James and Holloway, 2020 ). Establishing Jane's views demonstrated that she was eager to engage and manage her blood pressure more effectively.

Vincer and Kaufman (2017) demonstrated, through their case study, that a failure to ask their patient's viewpoint at the initial consultation meant a delay in engagement with treatment. They recognised that this delay could have been avoided with the use of additional strategies had ideas, concerns and expectations been implemented. Failure to implement ideas, concerns and expectations is also associated with reattendance or the patient seeking second opinions ( Green, 2015 ) but more positively, when ideas, concerns and expectations is implemented, it can reduce the number of prescriptions while sustaining patient satisfaction ( Matthys et al, 2009 ).

Physical examination

Once a comprehensive history was taken, a physical examination was undertaken to supplement this information ( Nuttall and Rutt-Howard, 2016 ). A physical examination of all the body systems is not required ( Diamond-Fox, 2021 ) as this would be extremely time consuming, but the trainee advanced nurse practitioner needed to carefully select which systems to examine and use good examination technique to yield a correct diagnosis ( Knott and Tidy, 2021 ). With informed consent, clinical observations were recorded along with a full cardiovascular examination. The only abnormality discovered was Jane's blood pressure which was 164/90 mmHg, which could suggest stage 2 hypertension ( NICE, 2019 ; 2022 ). However, it is the trainee advanced nurse practitioner's role to use a hypothetico-deductive approach to arrive at a diagnosis. This requires synthesising all the information from the history taking and physical examination to formulate differential diagnoses ( Green, 2015 ) from which to confirm or refute before arriving at a final diagnosis ( Barratt, 2018 ).

Differential diagnosis

Hypertension can be triggered by secondary causes such as certain drugs (non-steroidal anti-inflammatory drugs, steroids, decongestants, sodium-containing medications or combined oral contraception), foods (liquorice, alcohol or caffeine; Jamison, 2006 ), physiological response (pain, anxiety or stress) or pre-eclampsia ( Jamison, 2006 ; Schroeder, 2017 ). However, Jane had clarified that these were not contributing factors. Other potential differentials which could not be ruled out were the white-coat syndrome, renal disease or hyperthyroidism ( Schroeder, 2017 ). Further tests were required, which included bloods, urine albumin creatinine ratio, electrocardiogram and home blood pressure monitoring, to ensure a correct diagnosis and identify any target organ damage.

Joint decision making

At this point, the trainee advanced nurse practitioner needed to share their knowledge in a meaningful way to enable the patient to participate with and be involved in making decisions about their care ( Rostoft et al, 2021 ). Not all patients wish to be involved in decision making ( Hobden, 2006 ) and this must be respected ( NMC, 2018 ). However, engaging patients in partnership working improves health outcomes ( McKinnon, 2013 ). Explaining the options available requires skill so as not to make the professional seem incompetent and to ensure the patient continues to feel safe ( Rostoft et al, 2021 ).

Information supported by the NICE guidelines was shared with Jane. These guidelines advocated that in order to confirm a diagnosis of hypertension, a clinic blood pressure reading of 140/90 mmHg or higher was required, with either an ambulatory or home blood pressure monitoring result of 135/85 mmHg or higher ( NICE, 2019 ; 2022 ). However, the results from a new retrospective study suggested that the use of home blood pressure monitoring is failing to detect ‘non-dippers’ or ‘reverse dippers’ ( Armitage et al, 2023 ). These are patients whose blood pressure fails to fall during their nighttime sleep. This places them at greater risk of cardiovascular disease and misdiagnosis if home blood pressure monitors are used, but ambulatory blood pressure monitors are less frequently used in primary care and therefore home blood pressure monitors appear to be the new norm ( Armitage et al, 2023 ).

Having discussed this with Jane she was keen to engage with home blood pressure monitoring in order to confirm the potential diagnosis, as starting a medication without a true diagnosis of hypertension could potentially cause harm ( Jamison, 2006 ). An accurate blood pressure measurement is needed to prevent misdiagnosis and unnecessary therapy ( Jamison, 2006 ) and this is dependent on reliable and calibrated equipment and competency in performing the task ( Bostock-Cox, 2013 ). Therefore, Jane was given education and training to ensure the validity and reliability of her blood pressure readings.

For Jane, this consultation was the ideal time to offer health promotion advice ( Green, 2015 ) as she was particularly worried about her elevated blood pressure. Offering health promotion advice is a way of caring, showing support and empowerment ( Ingram, 2017 ). Therefore, Jane was provided with information on a healthy diet, the reduction of salt intake, weight loss, exercise and continuing to abstain from smoking and alcohol ( Williams, 2013 ). These were all modifiable factors which Jane could implement straight away to reduce her blood pressure.

Safety netting

The final stage and bringing this consultation to a close was based on the fourth stage of Neighbour's (1987) model, which is safety netting. Safety netting identifies appropriate follow up and gives details to the patient on what to do if their condition changes ( Weiss, 2019 ). It is important that the patient knows who to contact and when ( Young et al, 2009 ). Therefore, Jane was advised that, should she develop chest pains, shortness of breath, peripheral oedema, reduced urinary output, headaches, visual disturbances or retinal haemorrhages ( Schroeder, 2017 ), she should present immediately to the emergency department, otherwise she would be reviewed in the surgery in 1 week.

Jane was followed up in a second consultation 1 week later with her home blood pressure readings. The average reading from the previous 6 days was calculated ( Bostock-Cox, 2013 ) and Jane's home blood pressure reading was 158/82 mmHg. This reading ruled out white-coat syndrome as Jane's blood pressure remained elevated outside clinic conditions (white-coat syndrome is defined as a difference of more than 20/10 mmHg between clinic blood pressure readings and the average home blood pressure reading; NICE, 2019 ; 2022 ). Subsequently, Jane was diagnosed with stage 2 essential (or primary) hypertension. Stage 2 is defined as a clinic blood pressure of 160/100 mmHg or higher or a home blood pressure of 150/95 mmHg or higher ( NICE, 2019 ; 2022 ).

A diagnosis of hypertension can be difficult for patients as they obtain a ‘sick label’ despite feeling well ( Jamison, 2006 ). This is recognised as a deterrent for their motivation to initiate drug treatment and lifestyle changes ( Williams, 2013 ), presenting a greater challenge to health professionals, which can be addressed through concordance strategies. However, having taken Jane's bloods, electrocardiogram and urine albumin:creatinine ratio in the first consultation, it was evident that there was no target organ damage and her Qrisk3 score was calculated as 3.4%. These results provided reassurance for Jane, but she was keen to engage and prevent any potential complications.

Agreeing treatment

Concordance is only truly practised when the patient's perspectives are valued, shared and used to inform planning ( McKinnon, 2013 ). The trainee advanced nurse practitioner now needed to use the information gained from the consultations to formulate a co-produced and meaningful treatment plan based on the best available evidence ( Diamond-Fox and Bone, 2021 ). Jane understood the risk associated with high blood pressure and was keen to begin medication as soon as possible. NICE guidelines ( 2019 ; 2022 ) advocate the use of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blockers in patients under 55 years of age and not of Black African or African-Caribbean origin. However, ACE inhibitors seem to be used as the first-line treatment for hypertensive patients under the age of 55 years ( O'Donovan, 2019 ).

ACE inhibitors directly affect the renin–angiotensin-aldosterone system which plays a central role in regulation of blood pressure ( Porth, 2015 ). Renin is secreted by the juxtaglomerular cells, in the kidneys' nephrons, when there is a decrease in renal perfusion and stimulation of the sympathetic nervous system ( O'Donovan, 2018 ). Renin then combines with angiotensinogen, a circulating plasma globulin from the liver, to form angiotensin I ( Kumar and Clark, 2017 ). Angiotensin I is inactive but, through ACE, an enzyme present in the endothelium of the lungs, it is transformed into angiotensin II ( Kumar and Clark, 2017 ). Angiotensin II is a vasoconstrictor which increases vascular resistance and in turn blood pressure ( Porth, 2015 ) while also stimulating the adrenal gland to produce aldosterone. Aldosterone reduces sodium excretion in the kidneys, thus increasing water reabsorption and therefore blood volume ( Porth, 2015 ). Using an ACE inhibitor prevents angiotensin II formation, which prevents vasoconstriction and stops reabsorption of sodium and water, thus reducing blood pressure.

When any new medication is being considered, providing education is key. This must include what the medication is for, the importance of taking it, any contraindications or interactions with the current medications being taken by the patient and the potential risk of adverse effects ( O'Donovan, 2018 ). Sharing this information with Jane allowed her to weigh up the pros and cons and make an informed choice leading to the creation of an individualised treatment plan.

Jamison (2006) placed great emphasis on sharing information about adverse effects, because patients with hypertension feel well before commencing medications, but taking medication has the potential to cause side effects which can affect adherence. Therefore, the range of side effects were discussed with Jane. These include a persistent, dry non-productive cough, hypotension, hypersensitivity, angioedema and renal impairment with hyperkalaemia ( Hitchings et al, 2019 ). ACE inhibitors have a range of adverse effects and most resolve when treatment is stopped ( Waterfield, 2008 ).

Following discussion with Jane, she proceeded with taking an ACE inhibitor and was encouraged to report any side effects in order to find another more suitable medication and to prevent her hypertension from going untreated. This information was provided verbally and written which is seen as good practice ( Green, 2015 ). Jane was followed up with fortnightly blood pressure recordings and urea and electrolyte checks and her dose of ramipril was increased fortnightly until her blood pressure was under 140/90 mmHg ( NICE, 2019 ; 2022 ).

Conclusions

Adherence to medications can be difficult to establish and maintain, especially for patients with long-term conditions. This can be particularly challenging for patients with hypertension because they are generally asymptomatic, yet acquire a sick label and start lifelong medication and lifestyle adjustments to prevent complications. Through adopting a concordant approach in practice, the outcome of adherence can be increased. This case study demonstrates how concordant strategies were implemented throughout the consultation to create a therapeutic patient–professional relationship. This optimised the creation of an individualised treatment plan which the patient engaged with and adhered to.

• Hypertension is a growing worldwide problem
• Appropriate clinical assessment, diagnosis and management is key to prevent misdiagnosis
• Long-term conditions are associated with high levels of non-adherence to treatments
• Adopting a concordance approach to practice optimises adherence and promotes positive patient outcomes

Case Studies: BP Evaluation and Treatment in Patients with Prediabetes or Diabetes

—the new acc/aha blood pressure guidelines call for a more aggressive diagnostic and treatment approach in most situations..

By Kevin O. Hwang, MD, MPH, Associate Professor, McGovern Medical School, Houston, TX

The following case studies illustrate how the new ACC/AHA guideline specifies a shift in the definition of BP categories and treatment targets.

A 59-year-old man with type 2 diabetes presents with concerns about high blood pressure (BP). At a recent visit to his dentist he was told his BP was high. He was reclining in the dentist’s chair when his BP was taken, but he doesn’t remember the exact reading. He has no symptoms. He has never taken medications for high BP. He takes metformin for type 2 diabetes.

His BP is measured once at 146/95 mm Hg in the left arm while sitting. Physical exam is unremarkable except for obesity. EKG is unremarkable.

BP Measurement

Controlling BP in patients with diabetes reduces the risk of cardiovascular events, but the available data are not sufficient to classify this patient with respect to BP status. The reading taken while reclining in the dentist’s chair was likely inaccurate. A single reading in the medical clinic, even with correct technique, is not adequate for clinical decision-making because individual BP measurements vary in unpredictable or random ways.

The accuracy of BP measurement is affected by patient preparation and positioning, technique, and timing. Before the first reading, the patient should avoid smoking, caffeine, and exercise for at least 30 minutes and should sit quietly in a chair for at least 5 minutes with back supported and feet flat on the floor. An appropriately sized cuff should be placed on the bare upper arm and with the arm supported at heart level. For the first encounter, BP should be recorded in both arms. The arm with the higher reading should be used for subsequent measurements.

It is recommended that one use an average of 2 to 3 readings, separated by 1 to 2 minutes, obtained on 2 to 3 separate visits. Some of those readings should be performed outside of the clinical setting, either with home BP self-monitoring or 24-hour ambulatory BP monitoring, especially when confirming the diagnosis of sustained hypertension. Note that a clinic BP of 140/90 corresponds to home BP values of 135/85. Multiple BP readings in the clinic and at home allow for classification into one of the following categories.

The BP is measured in the office with the correct technique and timing referenced above. The patient is educated on how on to measure BP at home with a validated monitor. He should take at least 2 readings 1 minute apart in the morning and in the evening before supper (4 readings per day). The optimal schedule is to measure BP every day for a week before the next clinic visit, which is set for a month from now. Obtaining multiple clinic and home BP readings on multiple days will support a well-informed assessment of the patient’s BP status and subsequent treatment decisions.

A 62 year old African-American woman with prediabetes presents for her annual physical. She has no complaints. The average of 2 BP readings in her right arm is BP 143/88. Her physical exam is unremarkable except for obesity. She has no history of myocardial infarction, stroke, kidney disease, or heart failure. After the visit, she measures her BP at home and returns 1 month later. The average BP from multiple clinic and home readings is 138/86.

Her total cholesterol is 260 mg/dL, HDL 42 mg/dL, and LDL 165 mg/dL. She does not smoke.

Stage 1 Hypertension

Under the 2017 ACC/AHA guideline, she has stage 1 hypertension (HTN). This guideline uses a uniform BP definition for HTN without regard to patient age or comorbid illnesses, such as diabetes or chronic kidney disease.

In patients with stage 1 HTN and no known atherosclerotic cardiovascular disease (ASCVD) , the new guideline recommends treating with BP-lowering medications if the 10-year risk for ASCVD risk is 10% or greater. With input such as her age, gender, race, lipid profile, and other risk factors, the ACC/AHA Pooled Cohort Equations tool estimates her 10-year risk to be approximately 10.5%.

With stage 1 HTN and 10-year ASCVD risk of 10% or higher, she would benefit from a BP-lowering medication. Thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers are first-line agents for HTN because they reduce the risk of clinical events. In African-Americans, thiazide diuretics and calcium channel blockers are more effective for lowering BP and preventing cardiovascular events compared to ACE inhibitors or ARBs.

Patient-specific factors, such as age, comorbidities, concurrent medications, drug adherence, and out-of-pocket costs should be considered. Shared decision making should drive the ultimate choice of antihypertensive medication(s).

Nonpharmacologic strategies for prediabetes and HTN include dietary changes, physical activity, and weight loss. If clinically appropriate, she should also avoid agents which could elevate BP, such as NSAIDs, oral steroids, stimulants, and decongestants.

A goal BP of 130/80 is recommended. After starting the new BP medication, she should monitor BP at home and return to the clinic in 1 month. If the BP goal is not met at that time despite adherence to treatment, consideration should be given to intensifying treatment by increasing the dose of the first medication or adding a second agent.

A 63 year old man with type 2 diabetes has an average BP of 151/92 over the span of several weeks of measuring at home and in the clinic. He also has albuminuria.

Stage 2 Hypertension:

The BP treatment goal patients with diabetes and HTN is less than 130/80. While some patients can be effectively treated with a single agent, serious consideration should be given to starting with 2 drugs of different classes, especially if BP is more than 20/10 mm Hg above their BP target. Giving both medications as a fixed-dose combination may improve adherence.

In this man with diabetes and HTN, any of the first-line classes of antihypertensive agents (diuretics, ACE inhibitors, ARBs, and CCBs) would be reasonable choices. Given the presence of albuminuria, an ACE inhibitor or ARB would be beneficial for slowing progression of kidney disease. However, an ACE inhibitor and ARB should not be used simultaneously due to an increase in cardiovascular and renal risk observed in clinical trials.

He is started on a fixed-dose combination of an ACE-inhibitor and thiazide diuretic. He purchases a validated BP monitor which can transmit BP readings to his provider’s electronic health records system. Direct transmission of BP data to the provider has been shown to help patients achieve greater reductions in BP compared to self-monitoring without transmission of data. One month follow-up is recommended to determine if the treatment goal has been met.

Published: April 30, 2018

• 2. Final Recommendation Statement: High Blood Pressure in Adults: Screening. U.S. Preventive Services Task Force. September 2017.

More On This Topic

Does cabg owe its success more to sag--or to mag, dvt treatment: home versus hospital, perioperative thromboembolic complications predict long-term vte risk, coronary plaque in people with well-controlled hiv and low ascvd risk, poor neighborhood, poor mi outcome, stroke risk at age 66 to 74 years—with atrial fibrillation but without other risk factors, using cardiovascular biomarkers to diagnose type 2 mi: yea or nay, cardiac rehabilitation: outcomes in south asian patients.

McMaster study reveals long-term heart risks for children with hypertension 

Youth with high blood pressure face significantly higher risks of serious heart conditions, including stroke and heart attack, a study by Rahul Chanchlani shows.

BY Cheryl Crocker, Faculty of Health Sciences

May 6, 2024

Fewer than 25 per cent of children have their blood pressure checked during visits to a family doctor, but that needs to change, a McMaster researcher  says — and he has the evidence to prove it.

Rahul Chanchlani’s research, published in JAMA Pediatrics , analyzed the health records of thousands of Ontario children from 1993 to 2021. The findings revealed that youth with high blood pressure, or hypertension, face significantly increased long-term risks of serious heart conditions, including stroke and heart attack.

While guidelines recommend screening for hypertension in all kids aged 3-18, the practice remains largely absent in primary care, mainly because of a lack of evidence supporting it.

“When I talk to family doctors, they often ask about the long-term data and whether there is any potential harm with not checking kids’ blood pressure” said Chanchlani, an associate professor in the department of pediatrics and a pediatric nephrologist at McMaster Children’s Hospital.

Chanchlani turned to big data for answers. He tracked the outcomes of over 25,000 children with hypertension and compared them to approximately 128,000 children without the condition over a 15-year period.

Youth with hypertension were at twice the risk of major adverse heart events compared to their peers, he found.

What’s the solution?

While the solution may seem straightforward — a blood pressure check during regular visits to the family doctor — in practice, it is more complex: Ontario family doctors often lack access to nursing staff, pediatric-specific blood pressure machines and blood pressure cuffs, and time to settle active children before taking their blood pressure.

Creating awareness about high blood pressure in children is essential, Chanchlani says.

Empowering families and caregivers to raise the issue with their primary care providers, while also educating family doctors and other health-care practitioners, will be crucial.

“This study is just one of many steps needed to improve blood pressure screening in Canadian children,” says Chanchlani.

“Now, organizations like Hypertension Canada, the Canadian Pediatric Society, and the College of Family Physicians of Canada, all need to come to the table to say, ‘Hey, this is a major problem.’ ”

Crucial donor support

Chanchlani’s study started with a $100,000 Collaborative Research Excellence (CoRE) grant, an annual seed funding initiative established by a donation to McMaster’s department of Pediatrics.

Now in its third year, the program finances high-impact research with the potential to attract more grants in the future.

Chanchlani successfully applied for the funding in 2022, the first year it was offered. “Without CoRE, this research would not have been possible,” he says.

Two years later, with multiple studies published in high-impact journals, Chanchlani is turning to the next phase of his research, which will explore whether children with hypertension are also at an increased risk of kidney conditions.

This year, the Kidney Foundation of Canada announced its support for Chanchlani’s ALERT-BP study that aims to develop a tool to predict the risk of high blood pressure in young children. This partnership represents a proof-of-concept moment for CoRE and a significant achievement for pediatric researchers at McMaster.

With several CoRE projects in the pipeline and more expected to be funded this year, pediatric research is growing, says Gita Wahi, associate chair of research in McMaster’s department of Pediatrics.

“Dr. Chanchlani’s progress demonstrates the impact of this funding tool and that McMaster is hub of research excellence in child health. I look forward to seeing what’s next.”

Chanchlani’s research is being featured at the Pediatric Academies Society Conference in Toronto on May 6.

Researcher Featured In This Story

Republish this Article

All republished articles must be attributed in the following way and contain links to both the site and original article: “This article was first published on Brighter World . Read the original article. ”

Media Enquiries

The Communications and Public Affairs Office is staffed from 8:30 a.m. to 4:30 p.m. Monday to Friday.

The University has a broadcast quality television studio to facilitate live and pre-recorded interviews with media. Learn more about our experts.

Related Stories

McMaster and University of Ottawa receive more than $115M to bolster pandemic preparedness in Canada  

New federal funding will enable the Canadian Pandemic Preparedness Hub to develop novel therapeutics, vaccines, and technologies to more effectively prevent and respond to future infectious disease threats.

Look into your heart: Engineering researchers’ cardiac imaging breakthrough 

Zahra Motamed’s lab is developing non-invasive ways for early and precise diagnosis of patients with a chronic cardiovascular disease in which the aortic valve opening narrows, restricting blood flow.

Association between HIV and treatment-resistant hypertension in Malawian adults: a protocol for a case-control study

Affiliations.

• 1 Population Health Theme, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi.
• 2 Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi.
• 3 Department of Pharmacy, Kamuzu University of Health Sciences, Blantyre, Malawi.
• 4 Population Health Theme, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi [email protected].
• PMID: 37532483
• PMCID: PMC10401204
• DOI: 10.1136/bmjopen-2022-069280

Introduction: Treatment-resistant hypertension (RH), defined as uncontrolled blood pressure (≥140/90 mm Hg) despite treatment with ≥3 medications of different classes (including diuretics) at optimal doses, is associated with poor prognosis and an elevated risk of end-organ damage. In areas where HIV is endemic, such as sub-Saharan Africa, the risk of hypertension is high in people living with HIV. It remains unknown if HIV infection further increases the risk of RH. This study seeks to determine the association between HIV and RH as well as investigate other factors associated with RH in hypertensive Malawian adults.

Methods and analysis: A case-control study will be conducted among adult hypertensive patients attending a clinic at a referral hospital in Malawi. The cases will be hypertensive patients with a confirmed diagnosis of RH. For each case, two controls (hypertensive patients without RH), frequency matched for age group and sex, will be selected from among hospital clients attending the same hypertension clinic as the case. In both groups, HIV status will be ascertained. Additionally, information on other potential risk factors of RH, such as chronic kidney disease, obesity, hypercholesteraemia, diabetes, smoking, alcohol use, antiretroviral therapy regimen and duration, will be collected in both cases and controls. For each of the potential risk factors, ORs will be calculated to quantify the strength of their association with RH. In a multivariate analysis, conditional logistic regression will be used to assess the independent association between HIV and RH as well as the influence of the other potential drivers of RH.

Ethics and dissemination: This protocol has been approved by the College of Medicine Research Ethics Committee (COMREC) in Malawi (P.05/22/3637). Findings from this study will be disseminated through a peer-reviewed publication in an open-access international journal. Furthermore, anonymised data will be available on request from the authors.

Keywords: CLINICAL PHARMACOLOGY; HIV & AIDS; Hypertension.

© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.

Publication types

• Research Support, Non-U.S. Gov't
• Case-Control Studies
• HIV Infections* / complications
• HIV Infections* / drug therapy
• HIV Infections* / epidemiology
• Hypertension* / complications
• Hypertension* / drug therapy
• Hypertension* / epidemiology
• Malawi / epidemiology
• Risk Factors

Grants and funding

• WT_/Wellcome Trust/United Kingdom

NHS Dorset ICB App Library sees 5,400 app recommendations made

NHS Dorset ICB has shared a case study on its partnership with ORCHA to develop a Dorset App Library for health apps and digital healthcare products, with the aim of providing “easy, central access to a range of digital tools” along with ensuring confidence that apps within the library meet standards across data privacy, clinical safety, interoperability, accessibility and more.

Since it was launched in 2020, the library has reportedly received “over 62k site visits and over 165k page views”, with more than 5,400 app recommendations made to users. The case study also highlights that “over 260 professionals/teams are using that library as part of their day to day working” across LiveWell Dorset, primary care, local authorities and the voluntary sector.

Assessing the impact, analysis showed that the most popular searches and downloads were apps relating to mental health; that Active Monitoring teams at Dorset Mind found the library particularly useful in supporting people during the “whilst waiting period”; and that the six webinars on the use of the app library to date have been “well received”.

Challenges outlined by the case study include cultural issues around awareness and digital readiness amongst the healthcare workforce, which the ICB aimed to overcome through onboarding and education sessions for the app library.

The ICB notes that the partnership with ORCHA ensures that health apps are reviewed prior to their introduction across the ICS and as such “health professionals are provided with awareness, accessibility, and trust to recommend the use of health apps to the population for supported self-management”.

Crystal Dennis, interim lead for digital access to service @home for Our Dorset Digital, said: “After Transformation Boards learned of what had been achieved in Dorset, everyone was unanimous in the view that it was a no-brainer to roll out an app library powered by ORCHA across the seven ICS organisations.”

The case study also sets out next steps including undertaking further reviews of impact to understand how the library is currently being used and any “unmet needs”, and raising awareness of the library across NHS Dorset.

To read the case study in full, please click here .

NHS Dorset’s search for volunteers for its Digital Public Engagement Group was one of the stories covered in one of our recent news in brief articles , with the aim of helping to develop digital health and care services across the region.

In related news, Barnsley Hospital has launched a smartphone app which offers children waiting for surgery a virtual tour of the hospital from the waiting room to the operating theatre, featuring characters such a koala nurse and a rhinoceros doctor to help children feel “comfortable” before their procedure.

• News in brief: NHS Dorset seeks digital engagement…
• Department of Health and Social Care shares recommendations…
• South West London ICB shares findings and recommendations…
• AI in research: proposals for informed consent, ChatGPT in…
• Royal College of Midwives calls for Scotland's IT systems to…
• North East and North Cumbria ICB reports on progress made in…

Patient communication and engagement learnings from across health and care

Panel discussion: considerations, approaches and learnings for healthcare cloud strategies, “if we are always successful then i’d argue we’re not being innovative at all”: panel discussion on international digital healthcare development, panel discussion: supporting the nhs workforce with digital skills and digital careers, interview: alcidion’s chief medical officer paul deffley and healthcare consultant amanda thornton on success with patient flow, feature: navigating the challenges of patient flow in clinical settings, cynerio and it health on securing patient data for safer care.

• Share full article

Advertisement

Supported by

When Is the Best Time to Work Out?

It’s an age-old question. But a few recent studies have brought us closer to an answer.

By Alexander Nazaryan

What is the best time of day to exercise?

It’s a straightforward question with a frustrating number of answers, based on research results that can be downright contradictory.

The latest piece of evidence came last month from a group of Australian researchers, who argued that evening was the healthiest time to break a sweat, at least for those who are overweight. Their study looked at 30,000 middle-aged people with obesity and found that evening exercisers were 28 percent less likely to die of any cause than those who worked out in the morning or afternoon.

“We were surprised by the gap,” said Angelo Sabag, an exercise physiologist at the University of Sydney who led the study. The team expected to see a benefit from evening workouts, but “we didn’t think the risk reduction would be as pronounced as it was.”

So does that mean that evening swimmers and night runners had the right idea all along?

“It’s not settled,” said Juleen Zierath, a physiologist at the Karolinska Institute in Sweden. “It’s an emerging area of research. We haven’t done all the experiments. We’re learning a lot every month.”

No single study can dictate when you should exercise. For many people, the choice comes down to fitness goals, work schedules and plain old preferences. That said, certain times of day may offer slight advantages, depending on what you hope to achieve.

The case for morning exercise

According to a 2022 study , morning exercise may be especially beneficial for heart health. It may also lead to better sleep .

And when it comes to weight loss, there have been good arguments made for morning workouts. Last year, a study published in the journal Obesity found that people who exercised between the hours of 7 a.m. and 9 a.m. had a lower body mass index than counterparts who exercised in the afternoon or at night, though it did not track them over time, unlike the Australian study, which followed participants for an average of eight years.

Of course, the biggest argument for morning exercise may be purely practical. “For a lot of people, the morning is more convenient,” said Shawn Youngstedt, an exercise science professor at Arizona State University. Even if rising early to work out can be challenging at first , morning exercise won’t get in the way of Zoom meetings, play dates or your latest Netflix binge.

The case for afternoon exercise

A few small studies suggest that the best workout time, at least for elite athletes, might be the least convenient for many of us.

Body temperature, which is lower in the morning but peaks in late afternoon, plays a role in athletic performance. Several recent small studies with competitive athletes suggest that lower body temperature reduces performance (though warm-ups exercises help counter that) and afternoon workouts help them play better and sleep longer .

If you have the luxury of ample time, one small New Zealand study found that it can help to nap first. As far as the rest of us are concerned, a Chinese study of 92,000 people found that the best time to exercise for your heart was between 11 a.m. and 5 p.m.

“The main difference is our population,” Dr. Sabag said. While his study was restricted to obese people, the Chinese study was not. “Individuals with obesity may be more sensitive to the time-of-day effects of exercise,” he said.

The case for evening exercise

This latest study may not settle the debate, but it certainly suggests that those struggling with obesity might benefit from a later workout.

Exercise makes insulin more effective at lowering blood sugar levels, which in turn fends off weight gain and Type 2 diabetes, a common and devastating consequence of obesity.

“In the evening, you are most insulin resistant,” Dr. Sabag said. “So if you can compensate for that natural change in insulin sensitivity by doing exercise,” he explained, you can lower your blood glucose levels, and thus help keep diabetes and cardiovascular disease at bay.

One persistent concern about evening exercise is that vigorous activity can disturb sleep. However, some experts have argued that these concerns have been overstated.

The case that it may not matter

While many of these studies are fascinating, none of them is definitive. For one thing, most are simply showing a correlation between exercise times and health benefits, not identifying them as the cause.

“The definitive study would be to actually randomize people to different times,” Dr. Youngstedt said, which would be phenomenally expensive and difficult for academics.

One thing public health experts do agree on is that most Americans are far too sedentary. And that any movement is good movement.

“Whenever you can exercise,” Dr. Sabag urged. “That is the answer.”

In a recent edition of his newsletter that discussed the Australian study, Arnold Schwarzenegger — bodybuilder, actor, former governor — seemed to agree. He cited a 2023 study suggesting that there really isn’t any difference in outcomes based on which time of day you exercise. In which case, it’s all about what works best for you.

“I will continue to train in the morning,” the former Mr. Universe wrote. “It’s automatic for me.”

Alexander Nazaryan is a science and culture writer who prefers to run in the early evening.

Let Us Help You Pick Your Next Workout

Looking for a new way to get moving we have plenty of options..

What is the best time of day to exercise? A few recent studies have brought us closer to an answer .

Sprinting, at least for short distances, can be a great way to level up your workout routine .

Cycling isn’t just fun. It can also deliver big fitness gains with the right gear and strategy.

VO2 max has become ubiquitous in fitness circles. But what does it measure  and how important is it to know yours?

Is your workout really working for you? Take our quiz to find out .

Pick the Right Equipment With Wirecutter’s Recommendations

Want to build a home gym? These five things can help you transform your space  into a fitness center.

Transform your upper-body workouts with a simple pull-up bar  and an adjustable dumbbell set .

Choosing the best  running shoes  and running gear can be tricky. These tips  make the process easier.

A comfortable sports bra can improve your overall workout experience. These are the best on the market .

Few things are more annoying than ill-fitting, hard-to-use headphones. Here are the best ones for the gym  and for runners .

Sun Singapore Case Study

Sun Singapore Picks AMD Powered AI for Smart-Parking Solution

AMD, PlanetSpark, and Aupera have teamed up with Sun Singapore to build an AI-based solution for parking structures that eases traffic congestion.

Get in touch with a business expert and find out what AMD can do for you.

Related case studies.

PlanetSpark’s AMD Based EdgeAI Box Helps Accelerate Video Analytics

May 05, 2024

Adding extra layers of protection with AMD EPYC™ processors

February 20, 2024

University of Applied Sciences Pforzheim Develops Radar Sensor System Using Vitis™ HLS in AMD Zynq™ SoC

February 13, 2024

JR Kyushu, TAI Use AMD AI to Inspect Bullet Train Tracks

February 05, 2024

Manage consent

Details cookies, important margin product information.

CFDs are complex instruments and come with a high risk of losing money rapidly due to leverage. 65% of retail investor accounts lose money when trading CFDs with this provider. You should consider whether you understand how CFDs, FX or any of our other products work and whether you can afford to take the high risk of losing your money.

Cookie policy

Our websites use cookies to offer you a better browsing experience by enabling, optimising, and analysing site operations, as well as to provide personalised ad content and allow you to connect to social media. By choosing “Accept all” you consent to the use of cookies and the related processing of personal data. Select “Manage consent” to manage your consent preferences. You can change your preferences or retract your consent at any time via the cookie policy page. Please view our cookie policy and our privacy policy .

Case study: Smartly reducing your investment while maintaining market exposure

Koen Hoorelbeke

Options Strategist

Summary:  This case study illustrates how Alex strategically employs long-term call options to both realize profits and maintain exposure to NVIDIA stock. By adjusting his holdings through these options, he secures gains while keeping potential for future growth, showcasing effective risk management and investment foresight.

Introduction:

In the dynamic world of investing, the ability to adapt strategies to changing market conditions is crucial for maximizing returns while managing risks. For buy-and-hold investors like Alex, who have seen substantial gains in certain stocks, the challenge often lies in realizing profits without losing potential future growth. This case study explores how strategic use of long-term call options can provide an innovative solution to this dilemma, allowing investors to secure gains and maintain market exposure simultaneously.

Background:

Meet Alex, an investor with a portfolio valued at $153,319, showing a profit of $44,534 from an initial investment of $108,785. His holdings include various stocks, but a significant portion of his profit comes from his investment in NVIDIA Corporation (nvda), which currently constitutes 55% of his portfolio's total value.

Alex's NVIDIA shares have appreciated significantly, and he's looking to realize some of these gains. However, he wants to maintain his market exposure to NVIDIA due to its potential for further growth.

Solution: Using a long-term call option:

To achieve his goals, Alex decides to buy a long-term call option on NVIDIA. This option will allow him to buy NVIDIA shares at a set price of $850 each anytime until the option expires in June 2025, regardless of how high the stock price goes. This option costs him $20,300 for one contract, which covers 100 shares.

Portfolio overview:

Here is a breakdown of Alex's current portfolio before any transactions:

• NVIDIA (nvda) : 100 shares at a buy price of $496, now valued at $847.2 each, totaling $84,720.
• Other holdings : Includes stocks like PayPal (pypl), Nike (nke), and Palantir (pltr), with various performances and allocations within the portfolio.

Financial mechanics simplified:

• Current stock position : Alex holds 100 shares of NVIDIA.
• Option purchase : The call option has a cost of $20,300 and provides similar market exposure to owning approximately 66 shares of NVIDIA.

How many shares can Alex sell?

By purchasing the call option, Alex can sell about 66 shares of NVIDIA without reducing his effective market exposure to NVIDIA's future price movements. This is because the option helps maintain a similar level of investment influence as the shares he plans to sell. Specifically, the call option has a delta of 0.66, which means that one contract of the option (covering 100 shares) effectively corresponds to the exposure of owning 66 shares of the stock (0.66 * 100 = 66).  

• Reduced direct investment : Alex can reduce his direct exposure by selling 66 shares, which would secure approximately $56,000 (66 shares × $847.20/share). After accounting for the cost of the option ($20,300), the net amount secured is about $35,700. This allows him to use these funds for other investment opportunities or to diversify his portfolio further.
• Maintained market exposure : The long-term option ensures that Alex still benefits from potential price increases in NVIDIA's stock.
• Flexibility and security : This strategy allows Alex to lock in profits while keeping the flexibility to participate in future growth, providing a balanced approach to managing his successful investment.

While using long-term options can offer significant advantages, there are inherent risks to consider:

• Premium cost : The initial cost of the option ($20,300) is a sunk cost, meaning it is not recoverable if the option expires worthless. This represents a fixed loss if NVIDIA's stock price does not perform as expected.
• Volatility and time decay : Options are sensitive to changes in market volatility and lose value over time as they approach expiration — a phenomenon known as time decay. If NVIDIA's stock price remains below the strike price as the expiration date nears, the value of the option could decrease significantly.

Conclusion:

This approach allows Alex to capitalize on his gains in a high-performing stock while strategically maintaining his position for future growth. By using a long-term call option, Alex smartly adjusts his portfolio to reduce risk and secure profits, demonstrating a prudent method of portfolio management in a rising market. However, it's essential for Alex to consider the risks associated with options trading and monitor his investments accordingly.

Latest Market Insights

Global Market Quick Take: Europe – 13 May 2024

Is US data finally slowing down?

China/Hong Kong Market Pulse: Barbell Tactical Trades on High Dividend and Technology Names

Weekly FX Chartbook: US CPI and US-China trade tensions on the radar

Global Market Quick Take: Asia – May 13, 2024

Global Market Quick Take: Asia – May 10, 2024

Global Market Quick Take - May 10, 2024

Global Market Quick Take: Asia – May 9, 2024

Quarterly Outlook 2024 Q2

2024: The wasted year

Macro: It’s all about elections and keeping status quo

Markets are driven by election optimism, overshadowing growing debt and liquidity concerns. The 2024 elections loom large, but economic fundamentals and debt issues warrant cautious investment.

FX: The rate cut race shifts into high gear

As US economic slowdown hints at a shift away from exceptionalism, USD faces downside with looming Fed cuts. AUD and NZD set to outperform as their rate cuts lag. JPY gains on carry unwind bets and BOJ pivot.

Equities: The AI and obesity rally is defying gravity

Amid AI and obesity drug excitement, equities see varied prospects: neutral on overvalued US stocks, negative on Japan due to JPY risks, positive on Europe. European defence stocks gain appeal.

Fixed income: Keep calm, seize the moment

With the economic slowdown, quality assets will gain favour, especially sovereign bonds up to 5 years. Central banks' potential rate cuts in Q2 suggest extending duration, despite policy and inflation concerns.

Commodities: Is the correction over?

Commodities poised for rebound. The "Year of the Metal" boosts gold and silver, copper awaits rate cuts. Grains may recover, natural gas stabilises. Gold targets $2,300-$2,500/oz, copper's breakout could signal growth.

You can access both of our platforms from a single Saxo account. Preview platform Open Account

Disclaimer The Saxo Bank Group entities each provide execution-only service and access to Analysis permitting a person to view and/or use content available on or via the website. This content is not intended to and does not change or expand on the execution-only service. Such access and use are at all times subject to (i) The Terms of Use; (ii) Full Disclaimer; (iii) The Risk Warning; (iv) the Rules of Engagement and (v) Notices applying to Saxo News & Research and/or its content in addition (where relevant) to the terms governing the use of hyperlinks on the website of a member of the Saxo Bank Group by which access to Saxo News & Research is gained. Such content is therefore provided as no more than information. In particular no advice is intended to be provided or to be relied on as provided nor endorsed by any Saxo Bank Group entity; nor is it to be construed as solicitation or an incentive provided to subscribe for or sell or purchase any financial instrument. All trading or investments you make must be pursuant to your own unprompted and informed self-directed decision. As such no Saxo Bank Group entity will have or be liable for any losses that you may sustain as a result of any investment decision made in reliance on information which is available on Saxo News & Research or as a result of the use of the Saxo News & Research. Orders given and trades effected are deemed intended to be given or effected for the account of the customer with the Saxo Bank Group entity operating in the jurisdiction in which the customer resides and/or with whom the customer opened and maintains his/her trading account. Saxo News & Research does not contain (and should not be construed as containing) financial, investment, tax or trading advice or advice of any sort offered, recommended or endorsed by Saxo Bank Group and should not be construed as a record of our trading prices, or as an offer, incentive or solicitation for the subscription, sale or purchase in any financial instrument. To the extent that any content is construed as investment research, you must note and accept that the content was not intended to and has not been prepared in accordance with legal requirements designed to promote the independence of investment research and as such, would be considered as a marketing communication under relevant laws.

Please read our disclaimers: Notification on Non-Independent Investment Research (https://www.home.saxo/legal/niird/notification) Full disclaimer (https://www.home.saxo/legal/disclaimer/saxo-disclaimer) Full disclaimer  (https://www.home.saxo/legal/saxoselect-disclaimer/disclaimer)

Your browser cannot display this website correctly.

Our website is optimised to be browsed by a system running iOS 9.X and on desktop IE 10 or newer. If you are using an older system or browser, the website may look strange. To improve your experience on our site, please update your browser or system.