Middle_Aged_African

Introduction Strokes are the leading cause of death in the United States each year; nearly 800,000 strokes occur each year (CDC, 2013). Blood pressure has been identified by a large number of studies as the single most important variable in the prevention and treatment of strokes. It is estimated that one-fourth of all strokes could be avoided if hypertension were better controlled (Woo, 2004). Strokes occur in black middle-aged males at a significantly higher rate than that of other race or gender. The failure to control hypertension only increases the possibility of stroke occurrence. African-Americans have also been identified at an increased risk for having undiagnosed and untreated hypertension. Although this is not completely understood it remains a priority for many providers. The JNC7 (2003), guideline recommends maintaining a systolic blood pressure (SBP) below 120mmHg and a diastolic blood pressure (DBP) below 80 mmHg. Guidelines for starting anti-hypertensive medications begin at 140 and 90 respectively. After working in the Emergency Department two things concerning black males were recognized; 1) black males are unaware of their hypertensive condition, and 2) strokes can be devastating. It has been apparent that the end result for middle-aged African-American males with untreated hypertension consisted of a number of complications including stroke. Strokes often result in death or permanent disability. As primary care providers the challenge of identifying and effectively treating conditional risk factors in an effort to prevent stroke is obvious. Intervention and treatment could result in an unknown number of preventable strokes, death and permanent disability. The facts of stroke and risk factors for this devastating disease are apparent; however the specific limitations for blood pressure risk in middle-aged African-American males have not been so obvious. Does moderately increased blood pressure in African-American males place them at the same risk for stroke as do higher rates of blood pressure' Is it possible that African-Americans have other gender/race specific factors that contribute to increased rates of hypertension and stroke' Although we are not able to investigate all variables related to stroke the following PICO question will examine one aspect of incidence of strokes related to this population. Evidence Based Practice (PICO) Question The PICO question researched and covered in this paper is, “In middle aged African-American males with HTN (P) how does controlled blood pressure (<140/90) (I) compared with poorly controlled blood pressure (>140/90) (C) influence the risk of stroke (CVA) (O)”' Middle-aged African-American males were the population of focus during research. The intervention investigated was controlled blood pressure, determined to be less than SBP 140mmHG and DBP 80mmHG. In contrast, the comparison related to the population of focus was uncontrolled blood pressure, identified as a SBP and DBP greater than 140mmHg and 90mmHg respectively. The focus of outcome was on the influence of the intervention and comparison on the risk of stroke. The focus of population was limited to African-American males between the age of 45 and 65 years old; excluding males outside of these ages. Women, children, and the elderly were not considered in the focus of the focus of research. Controlled blood pressure was considered any blood pressure whether treated, untreated, diagnosed or undiagnosed to be below 140/90. Both ischemic and hemorrhagic strokes were considered and included in this investigation. Literature Search Strategy Although a very popular subject of research in the past few decades, finding articles specific to African-American or black males, hypertension and stroke in the past five years proved to be a challenge. Search limitations included males between 45 and 65 years of age. Attempts exclude women and white males proved to be challenging, therefore information specific to black males were extracted from articles that included women, white males and those less than 45 years-old. Search criteria did not include geriatric and pediatric patients. Both hemorrhagic and ischemic stroke were including in our search criteria. Many of the research articles found cited resources many years before, leading to data well over five years old. Databases searched incorporated CINHAL, OVID, Galileo, Google scholar and e-journals. Limited findings for the past five years lead to our expanding search range to 1999. Unfortunately two of our research articles lead us back to 1999 and 2004. Although not up to date, both articles provided evidence of hypertension leading to increased rates of stroke. Search criteria resulted in well over one-hundred articles of which were limited to five articles for inclusion. All five articles coincidental were found to be published in the Stroke Journal published by the AHA and American Stroke Association (ASA). Analysis of Findings Practice Recommendations Prior to the start of this study it was assumed that finding concrete evidence leading to clear results would provide a vast amount of information specific to middle-aged African-American males suffering from stroke pointing directly at hypertension. Although a significant amount of information hinted toward higher blood pressure and stroke in this population, much was left suggesting further studies more specific to this population and strokes. There are a large number of variables that need to be considered for specific results. Several factors identified during this research revolved around individualized needs of African-American males. These included awareness, treatment versus control, socio-economic status and factors unrelated to medication for treatment of hypertension. Black males are more likely to suffer a stroke at a much younger age than their white counterparts. Processes to better meet the needs of African-American males at an even earlier age should be strongly considered in an effort to thwart hypertension and its associated co-morbidities in this a naïve population. Based on findings of black males being more likely to demonstrate compliance once HTN is identified, is it likely improved screening for the general public prove to decrease the likelihood of stroke' This may be especially true concerning black middle-aged men who are otherwise healthy or symptom free. Better screening of the general public specific to middle-aged black males would increase awareness for this otherwise high risk population. Also increasing education in areas where larger populations of black males are located. In light of blood pressure control as opposed to blood pressure awareness, is it possible that African-Americans require more stringent guidelines for blood pressure control' Klungel (1999) suggests treating blood pressure as being half the battle, while controlling the blood pressure is essential to overall effectiveness and prevention of stroke. This may be indication enough to consider more closely monitored blood pressure and variables affecting blood pressure. Just as guidelines for diabetics and kidney patients are determined to be lower, it is possible that the same is true for the African-American population. A multi-modality approach with more emphasis on factors other than medications affecting blood pressure could reduce risk of stroke. Improving modifiable variables like exercise, smoking, cholesterol levels, stress and weight control would definitely eliminate the likelihood of stroke in all population, but possibly even more in this population. Further research may reveal increased sensitivity to these risk factors for black males. Lastly but definitely not least is the consideration of cost in a world where healthcare is not affordable for the uninsured and lower socioeconomic class. A large number of black men live in poverty or beneath standards capable of obtaining health insurance. Two plans of action could provide better outcomes. The first would include screening with strict guidelines for adolescent black males who are on Medicaid in an effort to identify black males at risk for hypertension. Further studies may reveal a predictive nature to hypertension at a younger age. In this case when healthcare is still available awareness may be initiated. The other method would include offering preventive screening, treatment and medications to all persons identified to have hypertension. This is a cost saving preventive measure that could easily pay for itself. Conclusion Although limitations were apparent in this research, a direct correlation with hypertension and stroke was recognized as a common theme in all articles. This finding seems to be even more obvious in the African-American male population. With hypertension’s apparent relationship to stroke, further research specific to factors contributing to hypertension in African-American males could prove essential. Findings of further research would significantly influence future treatment and guidelines for this at risk population. This may require creative thinking and diligence on behalf of researchers, providers and patients in an effort to decrease stroke and its intolerable effects. The repercussions of these efforts could only prove to positively benefit a growing number of persons suffering from this disease. References: Centers for Disease Control and Prevention (CDC). (2013). Stroke Facts. Retrieved from http://www.cdc.gov/stroke/facts.htm Howard G, Cushman M, Kissela BM, Kleindorfer DO, McClure LA, Safford MM, Rhodes JD, Soliman EZ, Moy CS, Judd SE, Howard VJ. (2011). Traditional risk factors as the underlying cause of racial disparities in stroke: lessons from the half-full (empty') glass. Stroke. (2011). Dec;42(12):3369-75. doi: 10.1161/STROKEAHA.111.625277. Howard G, Prineas R, Moy C, Cushman M, Kellum M, Temple E, Graham A, Howard V. (2006). Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study. Stroke, May; 37(5): 1171-8. DOI: 10.1161/01.STR.0000217222.09978.ce Kleindorfer, D., Lindsell, C., Alwell, K.A., Moomaw, C.J., Woo, D., Flaherty M.L., Khatri, P., Adeoye O, Ferioli S, Kissela B.M. (2012). Patients living in impoverished areas have more severe ischemic strokes. Stroke , Aug; 43(8):2055-9. DOI: 10.1161/STROKEAHA.111.649608. Epub 2012 Jul 5. 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