Posts Tagged ‘treating high blood pressure by Paul Goldfinger’

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The CBS Evening News (11/9,) reported that “a new study that says sharply lower blood pressure leads to significantly longer lives.”

On ABC World News (11/9), Dr. Richard Besser reported, “The results were so startling, they stopped the study…early.”

The New York Times (11/10,) reports that investigators found that “among the 9,361 hypertension patients followed for an average of 3.2 years, there were 27 percent fewer deaths (155 compared with 210) and 38 percent fewer cases of heart failure (62 compared with 100) among patients who achieved the systolic pressure target of 120 than among those who achieved the current 140 target.”

Altogether, “there was a 25 percent reduction — 243 compared with 319 — in people who had a heart attack, heart failure or stroke or died from heart disease, Dr. Paul K. Whelton, a principal investigator for the study, said.” The findings were presented at the American Heart Association meeting and published in the New England Journal of Medicine.

Blogfinger Medical Commentary.   Paul Goldfinger, MD, FACC

One year ago, experts at the NIH were recommending that doctors back off  on their advice for patients with hypertension  (high blood pressure) saying that any systolic reading  (the top number) under 150 would be fine for patients over age 60, while 140 would suffice for younger people.  The 140 number had been the standard for many years.

In 2014, after years of waiting, the NIH put out their JNC 8 guidelines for treating high blood pressure. The result had cardiologists pulling their hair out over the wishy-washy results which had doctors cutting back on aggressive treatment,  and patients, especially older ones,  throwing away their pills.  This quote is from the NJC 8, 2014 guidelines:

There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion.

Now, in a large trial of over 9,000 people age 50 or older, it appears that a systolic reading of under 120 is best. The study did not include diabetics or  stroke victims.  In order to be in the trial, you needed a BP of 130-180 systolic.  The bottom number (diastolic) was not studied but it is nevertheless important, and 90 is the cutoff for diastolic readings.  And if you were younger than 75 you needed to have at least one risk factor such as heart disease or high cholesterol. in order to be in the trial.

So most people in the US with hypertension would not qualify for this trial, and the results can’t be applied to them.  The treatment phase consisted of one group who were shooting for a reading  under 140, while the more aggressive group achieved BP under 120.

The study considered drug therapy as the main way to get the systolic BP below 120 in the aggressively treated group, but no consideration was given to non-drug lifestyle therapies such as weight reduction, low salt diet, adequate sleep and exercise.

Interestingly although this academic study (done where the researchers often live in a bubble) was making believe that doctors can push readings down to 120 in older individuals, the reality, in real-life,  is that many patients can’t even get their BP under 140.  Doctors have often failed to achieve the old goals, despite an excellent array of drugs, and there are often errors made in how these patients are followed.

In the office, the BP reading is often taken in a hurry by a medical assistant whose technique is often sloppy using untrustworthy equipment.   In addition, a rushed measurement  is often misleading.  The patient should be allowed to sit quietly and then repeat the reading.  The doctor should double check it himself.

Office readings are particularly unreliable if one is interested in the blood pressure experienced by a patient throughout the day.  All my patients were recording home readings several times per day, keeping diaries of time and circumstances.  If they were stressed, or they had other issues,  they were to write it down.  They also would take readings standing and sitting. Almost every one of my patients were within scientific guidelines.

I discussed salt, nutrition, exercise, stress and weight with my patients as part of a comprehensive  prevention plan. It’s all in our book “Prevention Does Work: A guide to a healthy heart.” by Paul and Eileen Goldfinger.

It is important to point out that striving for a BP of 120 especially in the elderly, creates a risk of dizziness, fainting, falling, kidney failure and cognitive failure.   The benefits in this trial, in absolute numbers,  are not huge, despite the 24% reduction in end points such as death rates, and many experienced doctors are skeptical.  My own cardiologist is sticking to the old guidelines, and I agree, but I am inclined to want to be closer to 120 than to 140. The new guidelines are not even out yet, so don’t be too quick to play the low number game.

In 2014, I wrote a series of 4 articles “Confessions of a high blood pressure doctor.”  Part III deals with this topic of targets as of 2014. It is a good orientation piece.      Confessions Part III treatment goals 2014

Quote of the day.  In the New York Times (11/10) “Well” blog, Harlan M. Krumholz, MD, from Yale Med School, points out that this trial does not offer an absolute conclusion for clinical use at this time.

He writes, “The study opens a new option for treatment, but it is not a slam dunk that everyone who fits the eligibility criteria of the study ought to be treated.” Rather, Dr. Krumholz argues, “it is a choice that is worthy of thought and reflection.”   

And we can sure use more doctors who take the time for “thought and reflection.”

You can also search the Times for Gina Kolata’s recent essay on this subject.

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