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Posts Tagged ‘JNC 8 guidelines for hypertension treatment’

 

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By Paul Goldfinger, MD, FACC.

After the JNC 8  guidelines were finally released in 2013, I began a series of articles about hypertension  (high blood pressure) because it is such a common condition, and there has been confusion as to how to treat the problem. Experts on the subject sometimes differ based on a variety of clinical trials, and your doctors may give you conflicting information.   Please look at the 3 links below and then drop down to our latest summary.

Background on high blood pressure

 

Misc high blood pressure topics

 

2017 BF discussion on hypertension treatment in older patients

 

In June 2017, a huge analysis of multiple trials of hypertension patients “reports that risk of cardiovascular disease and mortality was much lower in patients who attained a target systolic blood pressure  (that’s the top number) below current recommendations.”   (Medscape June 21, 2017)

They looked at 42 randomized clinical trials and more than 140,000 patients.  The work was led by a team from the SPRINT trial at Tulane University in New Orleans.

Most doctors have tried to lower systolic readings below 140 mm Hg.  But this study says that the lowest risk was at a systolic BP of 120-124 mm Hg. At the least, the authors suggest that physicians get BP readings below 130 mm Hg, if that goal can be safely achieved.

A big problem is that even with a goal of 140 mm Hg, doctors are not doing well in getting their patients there. The lead author in the SPRINT trial said, “I think 130 mm Hg is a reasonable goal.”  But he also said that their published paper in Circulation in 2016 showed that “worldwide, using 140 mm Hg as the cut point, only 17% of hypertensive patients have their blood pressure controlled. At a much lower goal of 125 mm Hg, uncontrolled blood pressure would be “huge.”

As a cardiologist who followed the idea of “evidence based practice” I pushed to achieve the guideline goals in my patients and achieved success in nearly 100%. It is doable if the doctor and the patient form a partnership and are strongly motivated  to get to target  readings. Some of my own ideas are reviewed in the links above.

Meanwhile if you have hypertension be sure to get a home BP device and follow my suggestions above.  I am not exaggerating when I tell you that hypertension can be successfully treated with few side effects and that such therapy can prevent complications like strokes and heart attacks and can reduce death rates. If you must be fearful, be afraid of the disease and not the therapy.

As newer studies and guidelines emerge, I will keep you all informed.

MUSIC  Why?  Music can be therapeutic. Stress reduction can lower your blood pressure.

ALICIA MORTON with some encouraging words from Annie:

 

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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).

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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Joint National Committee 8 hypertension guidelines just announced.

Joint National Committee 8 hypertension guidelines just announced.

By Paul Goldfinger, MD, FACC

Professor of Medicine at the Blogfinger Off-shore School of Medicine in Ocean Grove, NJ

My specialty boards are in internal medicine and cardiovascular disease. But those names are misleading. All doctors practice internal medicine, even dermatologists, because skin problems can reflect something that is more than skin deep. Even physicians who are board certified as cardiologists need to look at their certificates to recall that the word “vascular” is part of who they are. That is important for our topic, because the “vascular department” is where high blood pressure lives.

I am not Dr Chung, but I have one just like this, but it has my name: Blogfinger, MD

I am not Dr Chung, but I have one just like his—it has my name. Dr Chung’s is on the internet

There are significant differences from specialty to specialty.  In general, however, you need a certain personality to enjoy your job as a physician, depending on your chosen branch of medicine.

Surgeons tend to be more flamboyant than internists. They usually  like instant gratification.  Their motto is “When in doubt, cut it out.” But internists need to enjoy small victories; in fact they have to consciously identify their personality goals, or they could hate their jobs.

It’s  all about destinations.  If you are an internist and your goal is to prevent death, heart attacks and strokes, then you are seeking success in distant end points which you might not be able to measure.   You need to measure something to see if you are a winner or a loser—a good doctor, or not. In hypertension, we can measure the blood pressure.  The top number is systolic, while the bottom is diastolic.  They are both important.

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I have always enjoyed (yes, doctors can enjoy what they do) diagnosing and treating hypertension.  In the 1960’s, it was much more of a challenge than it is now because now we have  technology (eg echocardiograms), a wide variety of effective medications, and a major public health initiative to deal with the “silent killer.”

In 1941, FDR had a blood pressure of  188/105. We would have called that “moderate hypertension” and it could have been effectively treated with drugs if they had existed.   His doctor didn’t have much to do for it. He just took notes in his journal.

In 1944, before FDR went to Yalta, his BP was running 210/120, and then, after that arduous 14,000 mile round trip journey, he developed “malignant” hypertension with heart and kidney failure.  He returned to Georgia and had a brain hemorrhage, at which time his BP was recorded at 300/190. He died at age 63.  But now, a patient with hypertension can be treated better than the President of the United States over 60 years ago.

When I was an intern in 1966 at Mt . Sinai Hospital in New York, we did the best we could for hypertension with only a few suboptimal drugs at our disposal. It was frustrating.  We used a drug called Ismelin  (guanethidine). It was pretty powerful, but it had issues, one of which  impressed this 25 year old new doctor—it was called retrograde ejaculation. Just the name alone was enough to give any guy the willies. We’ll skip the graphic details.   As it turned out, that side effect wasn’t so bad, but it sure was startling.  It taught me to ask the right questions about medication side effects.

So fast forward to current times where we have so many great drugs for hypertension. We can pretty much get anybody’s BP down to where it belongs, and I loved monitoring that process using a simple device–a sphygmomanometer. You know it as a blood pressure machine. And watching those numbers get to the right place by doing that medication voodoo that we do so well;  I found that deeply satisfying.  The victories came in small increments, and patience was required.

Part of that pleasure was in knowing about the evidence that showed that treating hypertension can prevent heart attacks and strokes. That provided another ingredient—motivation to do a good job.   It’s  that EBM—evidence based medicine—that we have been hearing about during our Obamacare discussions.

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Which brings me to yesterday’s announcement by an expert panel from the National Institutes of Health regarding the latest guidelines (version #8 since the 1970’s) for the treatment of hypertension. Below is the NY Times article on this subject. It is very good.   We will discuss the new guidelines next in Part II.

New York Times on BP guidelines

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