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Confessions of a high blood pressure doctor: Part II

Posted in Blogfinger Presents, tagged , on February 28, 2019|

 

Be calm. Lower your BP.  Visit the Ocean. Paul Goldfinger photograph © California.

 

By Paul Goldfinger, MD, FACC

Part II:   What are the numbers?

Earlier this month we posted Part I where we introduced the subject of hypertension.  In that discussion we spoke about the use of guidelines for doctors to follow in diagnosing and treating this important condition. We also mentioned  that there are some disagreements among the experts world-wide regarding how to diagnose and  manage hypertension. Here is a link to Part I.

Confessions of a high blood pressure doctor. 2019.

Fifty years ago, there wasn’t much interest in the management of hypertension because there were no good studies, and doctors tended to downplay the subject.  Many thought that a  blood pressure of 150-160 or even up to 180 wasn’t so bad, and a major cardiology text said that mild hypertension didn’t require therapy.  FDR  had a blood pressure  far exceeding 200 at Yalta, and very little could be done for him. There were few drugs available that could help. He died of a complication—a stroke.

In recent years, and for a long time, the diagnosis of hypertension was made when BP exceeded 140/90.  We learned from research trials that effective treatment of high blood pressure could prevent death, strokes, cardiac events, vision loss, and chronic kidney disease.

But there have been different appraisals of this research, resulting in a variety of guidelines, largely by the Joint National Commission (JNC 8, 2014), the AHA/ACC*  (2018), the American Academy of Family Practice (2017,) and the European Society of Hypertension (2018).  The disagreements mostly revolve around how to diagnose the condition, how to treat it, when to treat it, and whether to pay attention to age or not. The Americans strive for the same treatment goal  (130/80) regardless of age, but the Europeans and the AAFP believe in seeking 140/90 as the cutoff for those over 65.

But others disagreed in a more fundamental way: 

In an  analysis in the European Heart Journal, 2018, we have some quotes:

1. “130/80 mm Hg is the new magic number as recommended by the AHA/ACC guidelines for diagnosis of hypertension.  By defining hypertension down from 140/90, the number of people in the USA said to be hypertensive increased overnight by 31 million.” 

2.  Guidelines for diagnosing systolic hypertension vary by 20 points among the various recommendations. This needs to be settled.  The measurement of blood pressure is often done inaccurately, even in doctors’ offices.

This is a quote from a research paper, “The measurement of blood pressure is likely the clinical procedure of greatest importance that is performed in the sloppiest manner.”

3. “Among those with hypertension under both old and new guidelines, only 24% were receiving anti-hypertensive treatment.  The vast majority of participants between 25 and 35 years (87%) were untreated, as were 56% of participants over age 65. And, for those begun on drug therapy, half have stopped it by 12 months.

4. “Blood pressure management needs to be individualized to minimize the likelihood of harm (side effects of treatment)  while maximizing the likelihood of benefit. 

5. Some have even doubted the wisdom of treating hypertension at all.   In 1931, in the British Medical Journal, JH Hay said, “The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it.”

You can now begin to appreciate the complexity of all this, and we will continue talking about these matters until we run out of topics:

For now, here are the American guidelines, 2017, by the *American Heart Association and the American College of Cardiology  (AHA/ACC).  The official papers are long and very involved, but here are the basics:

a. “Normal BP” is defined as less than 120/80.  If 120-129 /80, that is considered “elevated BP.”

b. Any patients with sustained readings of over 130/80 are considered to have hypertension, regardless of age.

c. Stage I hypertension is 130-139/80-89

d. Stage II hypertension is over 140/90

e. The goal of treatment is to get BP under 130/80 regardless of age.

The Europeans use 140/90 as their cutoff, and they recommend going easy with drug therapy for those over age 65.  In that case, the goal is 140, not 130. They tend to be skeptical of the aggressive American approach and they especially worry about getting too pushy with the elderly because of dangerous side effects in that age group.

I sympathize with the Europeans.  Their approach seems more practical, more possible, and less wedded to sheer numbers.

The goals and decisions about treatment depend also on whether the patient has other issues such as heart disease, coronary risk factors, congestive heart failure and other risk factors.

Here is the quote of the day from Feb 19, 2019 in the McGill University Office of Science and Society  (“Separating sense from nonsense”):

“The current hypertension guidelines controversy is in many way much ado about nothing. Given the history of controversies which we have endured with respect to blood pressure it is remarkably minor. First we had to figure out how to measure , then whether we should measure it at all, whether we should bother trying to lower it, and then now how low we should go. And given that we used to tolerate blood pressures of up to 200 mm Hg, the current argument of 130 vs 140 is a very minor disagreement indeed.  The average reader would best be served by ignoring the curent disagreement. Worry about it too much and it will inevitably raise your blood pressure.”

We will get into a variety of other  topics such as how to measure blood pressure properly, what are the risks of drug therapy, which drugs should be used, what about the elderly and their particular risks, when should treatment be started, and what about non -pharmacologic therapy?

Tune in for Part III.

KARRIN ALLISON:   Spring time will contribute to lower blood pressures:  a non pharmacologic fact of nature, with no side effects. Other such BP lowering factors include music, art, love, good sleep, happiness, faith, comfort, optimism, weight control, exercise, nutrition, and others.  Depression, anger and anxiety need to be overcome.

 

 

 

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Confessions of a high blood pressure doctor. 2019.

Posted in Blogfinger Medical Reports, Blogfinger Presents, Hypertension on Blogfinger, tagged , , on February 18, 2019| 1 Comment »

 

 

This topic is currently caught up in a tangle of controversies and guideline wars.

 

British Medical Journal. 2012.

 

By Paul Goldfinger, M.D., F.A.C.C. Board Certified cardiologist/internist, Editor of Blogfinger.net, and Dean of the Blogfinger Offshore School of Medicine in Ocean Grove, NJ.  Closed on Sunday mornings until noon.  



PART I:  WHAT ARE THE ISSUES?

 

We wrote a series of this type before, but there are some important issues to discuss now based on changes of guidelines for the diagnosis and treatment of high blood pressure, i.e. hypertension.

Hypertension is a condition which threatens huge numbers of people around the world. The prevalence among adults in the U.S. used to be quoted as 32%, but since the new guidelines came out with new definitions, the number is now estimated to be 46%. And that number goes up with age, so that 76% is the prevalence in adults ages 65-74; and rises to 82% in ages 75 and older.

The measurement of BP is obtained using an electronic or mechanical device—a sphygmomanometer. 120/80 is the classic normal, but even that is controversial. The top number is called the systolic, while the bottom is diastolic. If either number or both is consistently elevated, then a diagnosis of hypertension is obtained. But there are different degrees of severity, and the risks of the disease go up as the numbers go up.

What is clear is that bringing the blood pressure to normal will reduce the risk of devastating vascular problems such as heart attack, heart failure and stroke.

Where the guidelines differ is in the cutoffs for making the diagnosis of hypertension, cutoffs for choosing various therapeutic approaches, and cutoffs having to with target readings when therapy is established.

But the world-wide healthcare establishment has yet to agree about how to correctly diagnose and treat hypertension. And the matter has other ramifications:

a. Many people with the disease have no idea that they have a problem

b. Of those who have been diagnosed and treated, a large percent have failed to reach desirable BP goals. And many who know that they have a problem are in a state of denial and do not go for evaluation or they receive inadequate followup, or they do not reliably and correctly take their medication.

In addition, physicians often fail to deal with hypertension properly, as defined by guidelines.  In fact, some doctors ignore guidelines altogether, deciding their approach based on instinct and ignorance.

I have always thought that guidelines were a great idea since most doctors don’t have time to read all the research, so why not take the advice of experts?   But there is a caveat: The doctor-patient relationship must be preserved, and the physician must be allowed flexibility in his decisions.  However, if guidelines become inviolable laws, then doctors will rebel, and quality care will decline. In medicine, one size does not fit all.

c. There currently is a war of sorts, between the Americans and the Europeans regarding guidelines which determine how to diagnose and treat this important disease. No, it’s not like the D-Day invasion, but it is bad enough that both sides have published their own guidelines: the Americans in 2017 and the Europeans (let’s include Australia in this group) in 2018.

For years, the National Institutes of Health took on the task of issuing hypertension guidelines in the form of the Joint National Commission reports. The last time they did so  (JNC8) was in 2014, but then, probably for political reasons, they retreated to their Bethesda headquarters, turning the job over to a combined committee from the American Heart Association and the American College of Cardiology (disclosure: I am a “Fellow” of both organizations.  That title is gender neutral.) 

And the Europeans have the European Society of Cardiology and the European Society of Hypertension.

To tell the truth, I not only prefer their croissants, their wine, and their beachwear, but I also prefer their hypertension guidelines. However we will get into that later.

d . And why can’t they totally agree? It’s because there have been hundreds of credible research trials on the subject done around the world, many recently, and because there are some philosophical differences between the two sides.  And because medicine is a mixture of art and science, and no matter how much doctors try to practice “evidence based” medicine, there always is room for good judgement, style, and experience. 

And don’t forget the incursions into medical practice by the bottom-line oriented health corporations, government, “Big  Pharm,”  and insurance companies;  and by many physicians themselves who have been coerced into leaving private practice to become puppets of their employers—large hospital “health” systems.  

Along the way, some of these doctors have compromised their standards in exchange for less stress, less administrative duties, more time off, and more cookbook medicine that can torture and break the traditional doctor- patient relationship.  And the growing use of physician extenders to replace doctors introduces perhaps more efficiency and more money,  but, in my opinion, greater chances for mistakes in patient care.  As the hypertension guidelines become more complex, the involvement of physicians gets less.

I’m going to try to penetrate the layers of complexity of all this for you . You would be surprised if you knew how deep those layers go. 

 Feel free to comment by looking down and finding the comments button.

See you soon for Part II (I hope I can remember my Roman numerals.)

 

THE MARVELOUS WONDERETTES.   And if you think that medicine and music don’t mix, just walk into an OR sometime during major surgery.

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Lowering blood pressure in hypertensive older patients  (ie  those 60 and up.) —a controversial subject even with published guidelines.

Posted in Blogfinger Medical Reports, Blogfinger Presents, tagged , on March 1, 2017|

 

images

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).

https://blogfinger.net/2013/12/23/confessions-of-a-high-blood-pressure-doctor-part-ii-controversy-emerges-regarding-the-jnc8-practice-guidelines-for-hypertension/

 

 

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