Archive for the ‘Blogfinger Medical Reports’ Category

Internet cartoon.


Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups. But some relief appears to be coming, as the AMA and joins forces with some payers to fix this broken process. Read more at AMA Wire®.

This quote is from the AMA Morning Rounds:  “Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,”

Blogfinger Medical Commentary:  Paul Goldfinger, MD, FACC

Some of you may have experienced rejection of a particular prescription drug by your drug plan. But such rejections typically get reversed by enlisting your doctor’s help, and that would require his time and that of his staff to deal with the insurance company.  The process is called “prior-authorization.”

In the article above, from the AMA, they discuss the problem from the perspective of the physician, but I have experienced it myself, from the perspective of the patient.

And, without a doubt, the episodes of prior authorization have increased noticeably for patients, but, as discussed above, also for the prescribing physician and his staff.

And now we see insurance companies questioning even cheap generics or chronically used stable medications,  and the issue isn’t always the drug choice itself.

For example, I recently ran into this situation related to my use of a high blood pressure medication that is perhaps the number one or number two choice prescribed by doctors for their patients with hypertension.

In my case, I was doing very nicely with two 5 mg. tablets each morning of that drug   (10 mg per day)—lisinopril, an ACE inhibitor. However recently my doctor wanted me to increase the dose from two tabs each day to two tabs twice per day  (20 mg per day), ie 4 tabs per day instead of 2.

So I would need 360 tabs per 90 days instead of 180 tabs per 90 days—-a perfectly reasonable dose change.    I was notified that they would not send me my medication because it required the prior authorization process.     Meanwhile I was running out of medications while the plan would try to get my doctor to respond.  And the drug plan was contacting me by mail and phone messages to raise the PA alarm.

I couldn’t understand why this innocuous dose change was a problem—it’s a cheap drug with a zero  copay.  I was baffled, so I called the company, but the customer service representative couldn’t figure out why prior authorization was being applied to my prescription.  She advised me to wait for the process to play out.  This was unacceptable.

I  thought about the problem, and it dawned on me that maybe the number of pills was the issue, and not the medication itself.

Maybe the problem was the 360 tablet requirement, every 90 days.   Being a physician I was able to call and  speak to a pharmacist at the mail order plan. He verified that the number of pills was the problem, not the dose.

So I asked if we could change the tablet size from 5 mg. to 10 mg, making the daily dose two tabs each day.  He said “fine” and a few days later I received 180 of the 10 mg tabs.

But the warning letters and phone messages continued.  Finally I called the “prior authorization” department and told her that I fixed the problem myself. And she said, “Oh, when you get the letters and phone calls just ignore them until the matter is fully resolved.”

The best resolution available for most patients is to make sure that your doctor’s office staff has done their job with the paper work. It might  be easier to resolve if you buy your meds from a local pharmacy.  If you have a mail order pharmacy, as I do, and you are running out of pills, one of the local pharmacies will help you get a temporary supply, assuming that the left hand and the right hand at your drug company can resolve the problem.




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By Paul Goldfinger, MD, FACC.  Editor @Blogfinger.net.

In a NY Times piece recently a young physician argued that experience in medicine is overrated and that smart young physicians, armed with technology, can do a better job in diagnosis and treatment than silver haired professors steeped in Hippocratic values.

In 2016, I posted a piece called “The Case of the Hypokalemic High Jumper.”  (link below)  It was a difficult situation where all the technology available could not produce a diagnosis, but a careful history taken at the bedside by a physician was all that was necessary.

The case of the hypokalemic high jumper

In the New Yorker cartoon above, an alert doctor took a good look and made the diagnosis.

In medical school, in the second year, we all took a course called “Physical Diagnosis.”  It taught us how to take a proper history—very detailed, but customized to suit the needs of an individual patient.  We also learned how to conduct a sensitive physical examination—how to feel a spleen, palpate a liver and listen to the heart and lungs—in fact how to accurately assess the whole body.  We were taught that such skills  have been used by physicians going  back to the Greeks  and that we could learn so much using those basic tools.

During my cardiology residency, we were trained to be meticulous in auscultating the heart  (ie listening with a stethoscope.) We used stethoscopes with 3 heads to help sort it all out.  We made recordings of heart sounds where we could measure intervals down to fractions of a second in order to figure out how narrow a heart valve might be.  It was a source of great pride to be able to use just our ears and minds to determine if someone needed heart surgery or not and then to help a medical student who couldn’t appreciate the subtleties of the cardiac examination.

But now, I am afraid that doctors are becoming too complacent in using technology to replace the traditional tools. These skills are still helpful in assembling all the pieces of a puzzle and then following the progress of the patient at the bedside or long term in the office.  I see doctors doing a poor job in taking a history, a process which has been replaced in large part by computer check lists.  Garbage in, garbage out.  And the same concern exists for the physical examination.

I was present when a patient went to a local ER with a painful, swollen knee. The Physician Assistant took a cursory history  (he had no idea that a real doctor was observing) and ordered an X Ray.  He did not properly examine the knee.   And he never bothered to review the patient’s medication list. He was functioning like a robot via an algorithm.  If he had done a proper history, he would have learned that the patient was on a blood thinner and might have a hemarthrosis  (bleeding into the knee.)  The problem was diagnosed with a proper history and physical exam by a careful physician and corrected by aspirating the joint with a needle and adjusting the medication.

Yes, the new technologies are remarkable, but each patient is different, and the physician must use all the tools available at his disposal including his eyes, head, ears and hands.  And, experience is perhaps the best tool of all.

RUFUS WAINWRIGHT   “Heartburn.”   This is a peculiar song, but it makes the point that doctors need to remember that psychological factors can mimic heart burn or something much more serious—like a derailed roller coaster.  A doctor must take a good history to pick up on this situation.

“Is this heartbreak or is this heartburn?
Can I be spared from being so dramatic?
Gotta learn the difference when I love ya
The difference when I love ya and that derailed roller-coaster”



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Submitted by the American Medical Association on January 2, 2018.  The CDC is the Centers for Disease Control and Prevention in Atlanta.

NBC Nightly News (12/30 ) reported on Saturday that “the CDC says this flu season is already shaping up to be a lot worse than last [season’s], with widespread flu activity now being reported in dozens of states.”

NBC Nightly News reported that flu is widespread in 36 states, according to the CDC.  This is more states than last year (24.)

Modern Healthcare (12/29) reported the CDC issued an alert warning health care professionals of an uptick in cases caused by the H3N2 strain of the flu virus, “which is usually associated with a higher number of hospital admissions and flu-related deaths.”


Influenza is hitting the US very hard this season;  it is especially bad in the south, except for Florida where the snowbirds complain about 60 degree temperatures.

The CDC says that it will peak towards the end of January, and senior citizens are at the greatest risk of acquiring influenza and for getting very sick from it, including an increased mortality and hospitalization risk.  The currently most active strain, H3N2 is also the most deadly.

“If you haven’t gotten a flu shot yet,” Schaffner said, “run, don’t walk, and get yourself vaccinated. It can take up to 10 days for the vaccine’s full effects to kick in.”  (This quote is from an infectious disease specialist at Vanderbilt University School of Medicine.)

The symptoms of influenza are usually worse than with the common cold including high fever  (which may be absent,) hacking cough (which may be dry,) tightness in the chest with shortness of breath, shaking chills, marked fatigue and headache.  Complications include sinus and ear infections, pneumonia, and aggravation of asthma.

We used to gear up for the yearly peak of influenza around this time, when our hospital and ER would be swamped with patients.  It was the only time of year when we expected to have beds filled in the hallways. Stay out of the hospital if you possibly can.

Avoid crowds, avoid children or adults with respiratory infections, and wash hands often  (pick up some antibacterial liquid soap such as Dial.)   If you get sick, make sure you stay hydrated with electrolyte solutions such as Gatorade.  Chicken soup made with vegetables has medicinal value as long as a Jewish doctor suggests it.

And, if you think you have the flu, call your doctor to see if he wants to order an anti-viral medication such as Tamiflu, but do that as soon as symptoms appear.

Good luck staying out of trouble with this situation.



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The generator is under the skin. A wire is passed into a vein and into the right side of the heart (the tip is positioned in the right ventricle). This technique has stood the test of time.

Permanent pacemaker configuration.   The generator is under the skin. A wire is passed into a vein beneath the clavicle and into the right side of the heart (the tip is positioned in the right ventricle). In this example there is a second wire in the right atrium.

I saved this 1970's unit made by Cordis. The surgeon would place it into a

I saved this used 1970’s single lead unit made by Cordis in Miami.  The surgeon would place it into a “pocket” under the skin and attach it to an electrode in the heart.   Paul Goldfinger photo. ©

The opposite side of the unit shown.

The opposite side of the unit shown.  Cardiologists would go into the OR with the surgeon when a pacemaker was placed. Now, surgeons are usually no longer needed for this procedure. ©  Paul Goldfinger photo

A tiny modern version of a permanent pacemaker.

A tiny modern version of a permanent pacemaker.

Current model.

Current model.

By Paul Goldfinger, MD, FACC,  Dean at the Blogfinger  Off-shore School of Medicine .   Re-posted from Feb. 2016 on Blogfinger.net

My career spanned the remarkable history of permanent cardiac pacemakers. In the early 1970’s, those devices were as a big as a can of tuna fish. They had limited functions and a variety of technical problems. Today they are miniature electronic marvels.

The story began around 1930 when an Australian researcher found that the heart could be stimulated with a localized electrical shock delivered from a wire.

1949: The Medtronic Company, pioneers in pacemakers, was begun in a garage in Buffalo by an engineer and a physician.

1952: At the Boston Beth Israel Hospital, a patient was admitted with fainting spells due to drastic slowing of the heart. These are called Stokes-Adams attacks. This was the first case to be treated with a temporary pacemaker. A wire was attached to the external wall of his heart, while the pacemaker generator was outside his body.

1957: The first battery powered unit was developed, and, in 1958, the first permanent pacemaker was implanted in a dog, consisting of a generator under the skin and a wire attached to the outside wall of the heart.

1960: The first permanent pacemaker was implanted in a human. In 1961, the first in New Jersey was performed by heart surgeon Victor Parsonnet at Newark Beth Israel. Dr. Parsonnet is one of a core group of doctors world-wide to get credit for pioneering work in permanent pacemakers.

1973- 1980: The era when my own career began, the technology of permanent pacemakers evolved strikingly, with smaller and more complicated  “generators,” longer lasting batteries, and better electrode (wire) systems.  Medical electronics had been evolving thanks to the invention of the microprocessor.

When a patient only needed a temporary pacemaker, a cardiologist such as myself would pass a wire into the right ventricle through a vein in the arm or neck and attach it to an external pacemaker which hung from an IV pole at the bedside.  Eileen sometimes kids me by saying, “If you can put a wire into somebody’s heart, how come you can’t…….(fill in the blank)”

The permanent units could just only control slow heart rates at first, but later, more functions were developed and could be programmed (changing the settings) from without.

At first, pacemakers had to be routinely changed every two years because of battery life, but later the batteries were improved.

In the early 1970’s research with a nuclear powered pacemaker was performed by Dr. Parsonnet and his team at Newark’s Beth Israel Hospital . They were trying to increase the battery life.   That technology did not work out.

During this phase, techniques for monitoring the battery life and functions of a permanent pacemaker were developed. Eventually a patient could be followed by the use of a telephone, so hospitals throughout NJ had a setup where they could check their patients by phoning into NBIH for monitoring allowing doctors to predict when a pacemaker had to be changed and how well it was working. In-person visits to a pacemaker clinic were also required to check a variety of other functions .

In late 1970’s, at Dover (NJ) General Hospital and Medical Center, Jean Wiarda, RN ( a cardiac nurse) and myself,  with the cooperation of Medtronic, set up the first free-standing pacemaker clinic in north Jersey. After that, many other hospitals followed suit and broke away from the NBIH connection.  Later patients were able to phone in  their pacemaker signals from home  to the clinics. They also had to come for in-person evaluations intermittently depending on what we wanted to measure or program.

A major development, evolving in the 1970’s, was the transvenous lead for permanent pacemakers which eliminated the need to open the chest and sew an electrode into the heart muscle.   Instead, an electrode could be passed through a vein under the collar bone and into the right ventricular chamber, eliminating the need for heart surgery.

Now that continues to be standard, although the pacemaker generators are much smaller, and the electrodes have been refined, and sometimes more than one wire is used. Even though the generators are now tiny (you can’t even tell that someone has a unit,) they can perform all sorts of miraculous functions and are totally adjustable from without using a device called a programmer.

Surgeons used to install permanent transvenous pacemakers, but now these complex devices are placed by electrophysiologists, cardiologists who specialize in electrical diagnostics and therapeutics including implantable cardio-defibrillators.

The future of electrophysiology is huge, and progress is made every day in this field.

Around here, Jersey Shore Medical Center and Morristown Medical Center have first rate electrophysiology departments.


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FROM THE AMA:    STAT reports the flu season “is off to an early start this year” and could “peak over the holidays,” a new CDC indicates. The piece says the “wildly unpredictable” flu viruses leave experts uncertain of precisely how extensive the season will be, but the CDC’s weekly flu reports offer updated predictions and data, with the most recent report showing “that Louisiana and Oklahoma already have widespread flu activity and some nearby states are heating up too.” According to CDC influenza epidemiologist Lynnette Brammer, who leads flu reporting, “If it continues to go up like it has the last couple of weeks, yeah, we could have a fair amount of activity right at Christmas.”



From the Nov.  29, 2017  NEW ENGLAND JOURNAL OF MEDICINE:     “Seasonal influenza epidemics cause 3 million to 5 million severe cases and 300,000 to 500,000 deaths globally each year, according to the World Health Organization (WHO). The United States alone sees 140,000 to 710,000 influenza-related hospitalizations and 12,000 to 56,000 deaths each year, with the highest burden of disease affecting the very young, the very old, and people with coexisting medical conditions.  (BF bold print)

“However imperfect, though, current influenza vaccines remain a valuable public health tool, and it is always better to get vaccinated than not to get vaccinated. In this regard, the CDC estimates that influenza vaccination averted 40,000 deaths in the United States between the 2005–2006 and 2013–2014 seasons.2 Yet we can do better.”

It is difficult and unpredictable to get the virus profile to be accurate, because the profiling is done early in the year, and virus mutations can appear, leaving your flu shot to have a reduced efficacy.  Usually flu shots are 40% to 60% effective, but this year, according to the New England Journal of Medicine,  “The preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%.”  They are referring to the Southern Hemisphere  experience earlier this year in Australia.  H3N2 is the main offender so far, although there may be others emerging now.  The transmission of the influenza virus has been accelerating sharply in the US at this time.

So, if you haven’t yet had a flu shot, rush out and get one.  Most drug stores offer it.  If you are  a member of a high risk group, such older folks  (over age 65) or those with chronic illnesses, try to avoid exposure in places with many people in close contact.  And stay away from anyone who has a “cold” or, especially, has flu-like symptoms including fever, cough, chills, muscle aches, congestion, runny nose, headaches, and marked fatigue.

If you have such symptoms, your doctor may prescribe an antiviral medication, such as Tamiflu,  if you call early in the course of your illness.

And don’t forget frequent hand washing.



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Cup-a-joe at Nagle’s. Paul Goldfinger © Note the OG ads under the glass.



Reuters  (11/23)  reported researchers found that “people who drink three to four cups of coffee a day are more likely to see health benefits than harm,” according to a paper published in the British Medical Journal.

The Atlanta Journal-Constitution (11/24) reported the researchers also found that people who drink three to four cups per day appear to be at lower risk for “diabetes, liver disease, dementia and some cancers,” including endometrial, liver, prostate, and skin.

The researchers “examined 201 observational studies analyzing the health of coffee drinkers.” Forbes (11/24) reported the researchers also found that coffee consumption was linked to lower risk for Parkinson’s disease, metabolic syndrome, kidney stones, and gout.

The Telegraph (UK) (11/22) reported the researchers found that drinking up to seven cups of coffee per day was linked to a lower risk of early death.



We have posted two articles in recent years about the health aspects of coffee drinking.  The link below is good discussion. This AMA post above brings us up to  date.

My advice is, as before, do not fear coffee drinking except remember that caffeine can be addictive and can cause cardiac dysrhythmias, fast heart beat, tremors, nervousness, and insomnia.

Regarding insomnia, some people are especially sensitive, so some experts say that  they should not drink coffee after 2 PM.  And if you are a regular drinker of coffee, and then you don’t have any, consider that as a cause of an unexplained headache.  Also, coffee can increase alertness due to its effects on the brain; that is why people like me really need that morning Joe. (And I don’t mean Scarborough)

Some drink coffee to stay awake, such as during exams, driving and doing careful tasks.  Whenever I had to show up at the coronary care unit in the middle of the night, the nurses greeted me with coffee. In fact my office supplied free coffee for that unit so that they all could stay awake.  But when I got home, I could fall asleep instantly despite the caffeine.  The same was true of a phone call from the hospital while I was asleep.

BF medical article about coffee 8/15


BERTIE HIGGINS    “Key Largo”   Do you think that Bogie  (“Here’s lookin’ at you kid..”) and Bacall were drinking coffee that winter in the Keys?



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A nice array of local produce including blackberries, blueberries, broccoli,mushrooms, and radishes. Ocean Grove display. Blogfinger photo © 7/15/17  Click  book cover to enlarge the text.


By Eileen and Paul Goldfinger at  @Blogfinger.net.

Most major prevention trials have concluded that fresh fruits and vegetables will help the process due to their nutritional content of  fiber and micronutrients including vitamins, minerals and antioxidants.  This dietary approach is one of the major reasons why the Mediterranean Diet has been found to be so beneficial.

There is a reason why New Jersey is called the Garden State.  Local farms are turning out a great crop for 2017 including big, beautiful beefsteak tomatoes and a record breaking peach crop.

This is the first generation in America where we can look forward to fresh produce all year round, instead of only in season, thanks to advances in packaging and shipping.  And that includes fresh seafood.

So take advantage of using these healthful Garden State ingredients over the next couple of months.  (Hint: Point Pleasant scallops–Here is a link to Eileen’s Pt. Pleasant scallops with tomato and scallion sauce)

Pt. Pleasant scallop recipe by Eileen


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By Paul Goldfinger, MD, Editor @Blogfinger

Do you find flaws that indicate a deterioration in some aspects of our healthcare system? We often do and yesterday we stumbled on another one.

We were at a local medical group for an office visit. When we went to the desk to schedule our next visit, the face behind the glass asked for our credit card information. She assured us that they would only use the card if we had an unpaid balance, for example if there was a copay or a balance after insurance paid.

When we refused the idea that we should give them open access to our checking account  (ie a blank check), she informed us that she could not schedule our next visit without that card. In other words, they were willing to lose two patients who had no history of payment issues over this “policy.”

We were handed a statement in writing which explained that the “insurance industry makes patients responsible for high deductibles, co-payments and non-covered services.” In other words, they didn’t trust their patients to take care of outstanding balances and they hate to wait.

The statement said that if an unpaid balance exists, they would send us an email statement, and if we did not pay within 5 days, they would charge our credit card.   They also worried that we might change our credit card, so they concluded by warning that “you may cancel your credit card, but we will be unable to continue your care without an active credit card on file.”

Although we have been happy with our medical care with this group, this policy, which was willing to let us  leave without a subsequent appointment, casts a dark cloud over that medical provider.  To be honest, we were furious.  They are entitled to establish rules for collections, but this policy has a tinge of abandonment and coercion, something which is unethical among physicians.

For one thing, the policy makes our credit card available to anyone in the office who is interested in getting a new TV, for example.  It also makes it much more difficult to negotiate or discuss a billing issue once they have snatched your cash from your account.  And you need the time to do that because sometimes medical bills contain errors or even fraudulent charges.

Is this legal?  Evidently it is.  (quote below is from Cleveland.com)

“An AMA spokesman said, ‘Employers are offering health plans that require their employees to shoulder a greater share of health care costs. Total cost-sharing for the average patient from deductibles, co-payments and coinsurance has increased from $422 to $747 between 2004 and 2014, according to the Kaiser Family Foundation.’

“He said the cost-sharing trend is accelerating because of the health insurance exchanges opening up. Those often come with high-deductible plan options that people choose to keep their premiums down.

“Meanwhile, overhead for doctors’ offices has soared, he said, in part because of time spent complying with government regulations and health insurer policies.

“To lower overhead costs,” Mills said, “medical practices are focusing more on streamlining patient payment collections. Some practices do take credit card numbers for this purpose.”

“He added that the AMA does not offer guidance to doctors’ offices on this issue, except to say that doctors who do it should get advice from an expert because of the security risk of keeping this type of information on file.

“So the bottom line: If a doctor’s office won’t treat you  because you won’t give the office a credit card number to keep on file, then I’d find a new doctor. Period.”

We are not yet sure what to do, but this feels like blackmail and definitely affects our doctor-patient relationship.  The policy shows disrespect for the group’s patients, and a basic tenet of physician values is to always put the best interest of the patient first.


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This is about the Canadian Supreme Court ruling that made Teva’s sildenafil available there.



Paul Goldfinger,  MD, Editor @Blogfinger.net and Professor at the Blogfinger Off-shore School of Medicine in Ocean Grove, NJ.

Men who use Pfizer’s Viagra for erectile dysfunction know how expensive that little blue pill is. In 2012, Pfizer made over $2 billion with it.

But the FDA has now approved low cost generic Viagra (sildenafil) to be manufactured by the Israeli company Teva, but that won’t begin until December, 2017 (and maybe sooner.)

The generic version (sildenafil) has been sold in Europe since 2013, so we know that it is a viable generic. It also has been for sale in Canada since 2012.

You can actually buy sildenafil now in the U.S, under the name Revatio, which is a drug approved for a lung/heart problem.  It comes in a dose of 20 mg (unlike Viagra which is in doses of 25 mg, 50 mg, or 100mg). The generic version of Revatio has been approved recently by the FDA.

If you are considering buying that generic, you might want to have a conversation with your pharmacist first.

Or, if you are anxious to get generic Viagra pricing, you can order from a legitimate Canadian company, and there are some, but that will be your responsibility to make that contact, and  you will need a prescription.   Your doctor may or may not cooperate with you for that.  And those Canadian companies often take weeks to get your prescription to you by mail, and sometimes their drugs are made in Turkey or India or other places.  That doesn’t mean that those drugs are a problem, but you need to get all the facts.

Be careful ordering on the Internet. The price will be enticing, but only use sites that you know are legitimate; and only those which require a doctor’s prescription.   There are some fraudsters patrolling the Web.  And don’t buy those non-Viagra supplements.  They are useless.

I also want to remind you of the significant side effects and drug interactions that are part of the story. Do not try any of these forms of sildenafil without discussing your treatment in great detail with your physician.

MARISA MONTE:  (She’s from Brazil where the Viagra patent ran out in 2014)

“I know a man ain’t supposed to cry.”

Well, Marisa’s funky intro means that you need at least 30 minutes for sildenafil to take effect, so if you want to surprise someone, be sure to plan ahead.

Marisa Monte.







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By Paul Goldfinger, MD, FACC

As you may know,  blood pressure measurement consists of a top number (systolic) and a bottom number (diastolic.) Both numbers are important, but recent research trials and guidelines have been focusing on the systolic end points. The exact way to express a BP reading is 120/80 mm Hg. But for this article we will just use the number–e.g. 120/80.

Blood pressures are usually taken in the sitting position.  Some doctors ask their patients to sit for 5 minutes before taking a measurement. This will result in a number that is often about 10 points lower than an immediate office reading and may be different than readings obtained at home.

I recommend that all patients with hypertension (“high blood pressure”)  buy a device and keep track of readings at  home.  I suggest an initial reading and then another after 5 minutes.   Keep a written record for your doctor with the measurements, date, time and circumstances  (eg “just had an argument with my spouse”)   Remember that blood pressure readings do vary, so show your physician all your readings when you go for an office visit.

Experts have been disagreeing lately regarding  the “target” systolic  (top) numbers that physicians should aim for when treating older patients  (over age 60) for hypertension  (high blood pressure.)

No one disagrees that treatment should begin for readings over 170, but most physicians will begin therapy for readings averaging over 150/90. Studies show benefits of treatment even for those over age 80.    Doctors will legitimately differ in deciding when to start therapy, depending on the circumstances.   The current treatment  guideline controversies surround the question of how low to go.

The basic concept is that BP control will prevent stroke and cardiac events as well as reduce cardiac mortality rates.  In older individuals, there is a special concern regarding lowering the systolic number too much.

If the BP is caused to be too low, quality of life issues may take center stage including important problems such as fainting, dizziness, cognitive impairment, depression, hip fractures, impotence, and  fatigue.   Sometimes patients will stop their meds due to such reactions. Tell your physician if you suspect side effects.

There are a variety of  drugs that doctors use to treat hypertension and they are often utilized in combination.  If you doctor wants to use beta blockers, keep in mind that this class of drugs may not be as effective for prevention as others and may be associated with significant side effects.*

One recent discovery is that statin drugs, added to anti-hypertensive drug therapy, will improve the prognosis regardless of LDL (“bad”) cholesterol levels.

The JNC 8 (Joint National Committee) guidelines came in 2013,  after not revising the recommendations for over 10 years.   They decided to lighten up on their target systolic reading concluding that up to 150  was OK for “seniors” instead of the prior goal of 140.

But some experts would prefer to see the pressure lowered to below 140,  and even to 130 if tolerated by the patient, especially if the patient is at higher risk, such as diabetics and those with prior stroke, TIA, known heart disease or significant risk factors.

Another recent trial called Sprint advocated a target below 120 for patients 75 and older. The study found that patients with a target of 120 did better than those with 140, but that study was criticized on procedural grounds, and that goal could be risky in older patients who run a significant risk of side effects with such low readings.  Even 130  may be associated with problems. The doctor has to be very careful when aiming for those aggressive targets.

So what is the physician to do given all these disagreements?    The answer is to be knowledgeable regarding research  trials and  official guidelines, but to decide each case individually.

Dr Franz Messerli , a BP specialist and Clinical Professor of Medicine at Columbia U. School of Medicine is quoted on Medscape Cardiology  2/28/17.:    “After JNC 7, it took 11 years to get one more set of guidelines. Now we have six or seven, and they all tell a different story. It has become very confusing to the practicing clinician.

The patient in front of you never quite conforms to the patient in the trial or to the patients from whom the evidence was derived for the latest guidelines. Despite all the guidelines, you still have to be a doctor, and you have to individualize therapy and continue to learn.

Dr. Messerli concluded by saying, “Most physicians know that guidelines are more for lawyers than for doctors.”

*Prof. Messerli:  “Despite lowering blood pressure, there is no— and I repeat, no—evidence that beta-blockers reduce heart attack, stroke, or death in hypertensive patients ≥ 60 years. Ironclad evidence has been put forward that beta-blockers are not acceptable antihypertensive drugs in this age group.”  

Here is an important link from our series on treating hypertension. It is from 2013.  You can read our other posts in that series by typing “hypertension” into our search bar (above).




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